Despite the numerous interventions adopted in maternal child health units, postpartum hemorrhage (PPH) is the leading cause of preventable maternal morbidity and mortality. Visual estimation of blood loss (EBL) during birth is commonly used by providers. This visual method is prone to errors, resulting in overestimation of blood loss and unnecessary treatments or underestimation of blood loss, resulting in delayed interventions. The article, Effect of Quantification of Blood Loss on Activation of a Postpartum Hemorrhage Protocol and Use of resources, discussed a study to determine if the use of quantification blood loss (QBL) would result in fewer activation’s of postpartum hemorrhage over visual estimation. The study was performed at a tertiary academic medical center’s labor and delivery unit in Chicago. Case criteria were full term pregnant women with a median age of 35 and weight 80.1kg. Cesarean sections were performed on all cases where the anesthesia provider visually estimated blood loss to be greater than 1,000 ml. Because the American College of Obstetricians and Gynecologists defines PPH as blood loss of greater than 1,000 ml, a PPH protocol was activated in these cases. A member of the study team, who was not involved in the case, collected data on the cases using the Triton L&D system to calculate QBL. The system used a tablet computer with a camera to measure hemoglobin mass on laparotomy sponges. The system also calculated hemoglobin content in suction canisters and had a scale via blue tooth to weigh actual blood weight on towels, pads and other materials that absorbed blood. The results of the study based on the provider’s visual estimation blood loss was 1,275 ml and 948 ml based on the study teams QBL. Limitations of the study included data collected after the procedure was performed and the patient left the operating room. Also, the setting was in a controlled operating room with all blood loss contained in canisters and sponges which is much different than in real time. The study found that with visual estimation, the blood loss was overestimated by an average of 300 ml compared with QBL. The study confirmed the use of QBL during cesarean section births would have reduced the number of identified PPH’s by more than 50% over visual estimation and reduced the resources and unnecessary interventions that are involved with a PPH protocol.
Hire, M. G., Lange, E.S., Vaidyanathan, M., Armour, K.L., & Toledo, P. (2020). Effect of Quantification of Blood Loss on Activation of a Postpartum Hemorrhage Protocol and Use of Resources. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(2), 137–143. doi:10.1016/j.jogn.2020.01.002.
The hospital I work at switched to QBL quite sometime ago. QBL measurements are significantly less than EBL. I can’t believe we worked with such an inaccurate way of measuring blood loss for so many years before the QBL was initiated. I will agree with the study results that EBL was overestimated by at least 300ml and caused initiation of protocols for postpartum hemorrhages. I work in the postpartum area and now can appreciate the accuracy of the quantification of blood loss. I read another study on effectiveness of education on the QBL process with a ten minute educational presentation. A data analysis survey showed an 89% compliance rate with the QBL process for the time studied. The QBL method of measuring blood loss should be the standard of care in order to prevent maternal morbidity and mortality. I thought your fishbone outline was clear on the processes required for staff to manage potential hemorrhages.
Ladouceur, M., Goldbort, J. (2019). A Proactive Approach to Quantification of Blood Loss in the Perinatal Setting. Nursing for Women’s Health 23(6), 471-477. DOI: https:?/doi.org/10.1016/j.nwh.2019.09.007
Christine, I think that when your unit gets used to the QBL, then the hospital will want to make QBL a standard for all deliveries. My hospital started QBL with just C-sections also. Today I took care of a twin 38week C-section patient that had a QBL of 325! I think the EBL would have been estimated at triple that amount! I just work in postpartum, so I bet you can estimate EBL better than I. Every time we have NOEl our manakin that always has a hemorrhage visit our education fair, I underestimate blood loss by quite a bit. So glad to do this class with you as I understand your journey.
We just started to implement QBL into only our c/s”s a couple of months ago . After researching this topic and knowing how serious accurate EBL is for maternal safety I am so surprised that my facility is very late in the game. When it was first introduced,many of the nurses did not like the change and thought it was ” more work” for us to do and did not know how to incorporate another task into our very busy OR team. After only a few cases it was clear that there are major discrepancies in estimating EBL. With the amount of blood shortages you wonder had many transfusions were implemented unnecessarily.
Christine, I certainly understand more work and change is hard. I think nurses are always needing to embrace change as it makes for safer and more efficient nursing care. I am glad your OR team is seeing what a big difference QBL makes. Another area in this process that I have now mastered but at first took way to much time is scanning blood into a transfusion form in EPIC. The computer works as a second nurse check and the process of giving non-emergent blood is so much faster now but it sure was not when we first started the process! Looking forwards to your poster!
Thank you for your post. I am glad to hear that your facility initiated QBL a while ago. I am disappointed that my hospital is behind times and just began introducing it into our cesarean section patients. I have been working L&D for many years and the “standard” EBL from providers is almost always 800ml. As we begin to initiate quantitative blood loss(QBL) into practice it is amazing to see the discrepancy. Most of the times the QBL is much lower than the visual EBL. Delays the diagnosis and treatment of postpartum hemorrhage due to misinterpretation of blood loss leads to complications such as coagulopathy, resulting in increased morbidity and mortality.
Hancock, A., Weeks, A. D., & Lavender, D. T. (2015). Is accurate and reliable blood loss estimation the ‘crucial step’ in early detection of postpartum haemorrhage: an integrative review of the literature. BMC pregnancy and childbirth, 15, 230. https://doi.org/10.1186/s12884-015-0653-6n
Very interesting article. I have not worked in labor and delivery or postpartum so this was not something that I was familiar with. It does seem to be logical to accept the QBL instead of a visual estimate. I think the interventions on your fishbone were very detailed and very practical interventions. I look forward to learning more on this subject. Thank you for sharing.
E. Powell, D. James, R. Collis, P. W. Collins, P. Pallmann & S. Bell (2020) Introduction of standardized, cumulative quantitative measurement of blood loss into routine maternity care, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1759534
Your summary of the study was very informative. I am not a L&D nurse, but having mostly worked in the PACU, it makes me wonder why this was not used in certain other cases. Spine and orthopedic surgeries can have significant blood loss, but it was always EBL and not QBL. Even GYN surgeries used EBL. In searching for QBL used for other surgeries I could not find anything. Now I wonder is it only applicable in birth because of postpartum hemorrhage and needing an accurate reading to initiate treatment? Blood loss in excess usually calls for treatment in any type of surgery, so it doesn’t quite make sense to me that this would only be used in delivery. Maybe a research topic to be addressed?
My facilities main operating rooms has been using QBL prior to implementing it into L&D. I researched an article on a study that was approved by the IRB where the Triton tablet system was used to calculated blood loss on joint antroplasty cases. Results of the tablet showed superior as real-time measurements to accurately quantify intraoperative blood loss. The system is quite costly, that maybe why it hasn’t been introduced yet. Maybe ask anesthesia what was the QBL? and see how they respond.
Sharareh, B., Woolwine, S., Satish, S., Abraham, P., & Schwarzkopf, R. (2015). Real Time Intraoperative Monitoring of Blood Loss with a Novel Tablet Application. The open orthopaedics journal, 9, 422–426. https://doi.org/10.2174/1874325001509010422
Thanks for the article. In addition to costliness, it also looks to be more time consuming which could be a factor. It has been 5 years since I worked in PACU, so it is possible that the hospital has now implemented this system…
Postpartum Hemorrhage is not an area I am familiar with, so I learned a lot of new information form your article and this discussion. EBL is used in the surgical world in general. It is interesting to read a report about post procedure bleeding and having to open the patient back up, but the immediate post-op notes have an EBL of 30ml? However, with PPH, it is important to be as accurate with blood loss measurements as possible, to avoid those unnecessary PPH protocols. The QBL protocol has a few more steps and procedures than an EBL, but it does seem to be more accurate, according to the study you provided.
The American Collage of Obstetricians and Geynocologists. (2019). Quantitative Blood Loss in Obstetric Hemorrhage. ACOG. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/12/quantitative-blood-loss-in-obstetric-hemorrhage.
This is a complicated and not often easily diagnosed complication after surgery. It is unfortunate that many of these complications end in a emergency hysterectomy. This is a life saving procedure and the mother is already hemodynamically compromised. Treatment of this is again, more surgery, increased risk of infection and further blood loss and need for replacement. Recognition of this happening is incredibly important to treatment but sometimes the first recognizable symptoms are those of hypovolemic shock (Escobar et al, 2017).
Escobar, M. F., Füchtner, C. E., Carvajal, J. A., Nieto, A. J., Messa, A., Escobar, S. S., Monroy, A. M., Forero, A. M., Casallas, J. D., Granados, M., & Miller, S. (2017). Experience in the use of non-pneumatic anti-shock garment (NASG) in the management of postpartum haemorrhage with hypovolemic shock in the Fundación Valle Del Lili, Cali, Colombia. Reproductive Health, 14, 1–8. https://doi-org.ezproxy.fhsu.edu/10.1186/s12978-017-0325-2
I learned a lot from reading your article. I did not realize that so many areas that deal with blood loss did so with estimation as a measurement. I can see how interventions would be delayed or overused if estimating was used as your data point. Especially is estimation was off by an average of 300 mls. I am happy to hear that hospitals are looking into having a more accurate way of measurement.