The Need to Quantify Postpartum Blood Loss

How Much Blood Did She Lose?

Troy Brown, RN


December 22, 2017

Postpartum Hemorrhage: A Growing Problem in Obstetric Care

Preparedness and quantification of blood loss for every obstetric patient are crucial for the early identification and treatment of obstetric hemorrhage, according to numerous professional groups including the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).

Common causes of postpartum hemorrhage include uterine atony, genital tract lacerations, retained placental tissue, and, less frequently, placental abruption, acquired or inherited coagulopathy, amniotic fluid embolism, placenta accreta, and uterine inversion.

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality in the United States, with a rate of postpartum hemorrhage requiring procedures to control bleeding climbing from 4.3 per 10,000 delivery hospitalizations in 1993 to 21.2 in 2014 and rising more sharply in recent years, the US Centers for Disease Control and Prevention reports.[1] The rate of postpartum hemorrhage requiring blood transfusions more than quadrupled during this time, rising from 7.9 per 10,000 delivery hospitalizations in 1993 to 39.7 in 2014.[1]

ACOG released an updated practice bulletin on postpartum hemorrhage online September 21 and in the October issue of Obstetrics & Gynecology,[2] as reported by Medscape Medical News.

"Hospitals should consider adopting a system to implement key elements in four categories: (1) readiness to respond to a maternal hemorrhage; (2) recognition and prevention measures in place for all patients; (3) a multidisciplinary response to excessive maternal bleeding; and (4) a systems-based quality improvement process to improve responsiveness through reporting and system learning," writes ACOG's Committee on Practice Bulletins—Obstetrics, in collaboration with Laurence E. Shields, MD; Dena Goffman, MD; and Aaron B. Caughey, MD, PhD.[2]

Readiness Is the Key

"Rapid recognition and treatment are necessary to prevent progression of hemorrhage, because women can lose large volumes of blood very quickly due to the physiologic changes of pregnancy. However, obstetric hemorrhage is also a low-volume, high-risk event for any given birth facility: without advance planning the probability of mounting a rapid, coordinated response is low," according to the California Maternal Quality Care Collaborative (CMQCC) OB Hemorrhage Toolkit. "Indeed, maternal mortality reviews have consistently revealed problems with recognition, communication, and effective application of interventions as contributory factors in deaths from maternal hemorrhage."[3] Furthermore, the CMQCC toolkit recommends that:

  • All obstetric units need an emergency hemorrhage cart with supplies, appropriate checklists, instruction cards, and posters. Hemorrhage medications should be immediately available in a kit or similar arrangement.[3]

  • Units should have an established response team and massive and emergency-release transfusion protocols/policies (type O negative/uncrossmatched).[3]

  • Employees should participate in education on processes and unit-based drills that include post-drill debriefing on a regular basis.[3]

The CMQCC toolkit provides an obstetric hemorrhage emergency management plan with pocket cards; checklists for obstetric hemorrhage carts, medication kits, and hemorrhage trays; recommendations for simulation drills and debriefing; and recommendations for active management of the third stage of labor. The toolkit also includes information for small and rural hospitals.[3]

Quantification of Blood Loss During Delivery

Failure to recognize excessive blood loss during childbirth is a major factor in maternal morbidity and mortality. Clinicians often visually estimate the amount of blood loss, but this method is notoriously unreliable at a time when accuracy is vital and a patient's condition can deteriorate quickly. Research shows that training improves visual estimation skills, but this ability wanes within 9 months after training.[4] Estimation accuracy is not associated with clinician age or experience, and visual estimation accuracy declines with increasing volumes of blood loss.[4]

Quantification of blood loss does not aim to provide an "exact" number because of the degree of imprecision inherent in the measurement of blood loss.[3] The goal is to promote early recognition of large-volume blood loss as part of an overall strategy to facilitate effective response to hemorrhage.[3]

The CMQCC recommends using formal methods to quantify blood loss, including graduated containers, visual comparisons, and weighing blood-soaked items, with 1 g being equivalent to 1 mL.[3]

AWHONN provides detailed guidelines in its practice brief on quantification of blood loss.[4]

A key element of the protocol offered by AWHONN is founded on the recognition that maternal blood is lost primarily after delivery of the placenta. During a vaginal delivery, fluid collected before the placenta is delivered comprises mainly amniotic fluid, urine, and feces, all of which, along with any irrigation fluid used, must be subtracted from the post-placenta fluid collection. This result is added to the blood loss measured by weighing blood-soaked materials and clots to determine the final quantification of blood loss. (The procedure for a Cesarean delivery differs slightly owing to the use of suction to collect fluid, including irrigation fluid, from the abdominal cavity).[4]

Calibrated under-buttocks drapes, which have an attached plastic pouch with measurement markings, should be used. Scales to weigh blood-soaked materials should be available in every labor and operating room as well as the postpartum unit. Hospitals can save costs by using the same scales that are used to weigh newborns. Each scale should have a laminated dry weight card attached that includes dry weights of common materials that may become saturated with blood during or after birth.[4] Formulas can be inserted into the electronic charting system to automatically subtract dry weights from wet weights of standard items such as disposable pads.[4]

Gauss Surgical, Inc., is one company that is working to simplify the quantification of blood loss in operating rooms and obstetric units. Its Triton system uses a mobile app to capture images of surgical sponges and suction canisters on an iPad and processes them "using cloud-based computer vision and machine learning algorithms to rapidly estimate blood loss," the company explained in a news release.[5]

"Features new to the second-generation system include automatic sponge-capture via an infrared 3-D sensor that attaches to the iPad and a Bluetooth scale that enables the weighing of additional blood loss components."[5]


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