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Learning Outcomes
1. Advocate for accurate blood loss calculation by teaching obstetricians and midwives
about the discrepancy among unguided visual estimation of blood loss and actual blood
loss to facilitate a unit change in practice from estimated blood loss (EBL) to quantified
Gap in Practice
Current standard practice for measuring intra- and postpartum blood loss is based on
visual estimation. This process is highly subjective and inaccurate, often significantly
underestimating the amount of blood lost. This gap in practice leads under diagnosis of
Based on a recent case study from Northwell Health, the session will present
retrospective EBL data collected from 100 deliveries in 2017, compared with QBL data collected
The goal of this program is to empower nursing staff to recognize significant post- and
intrapartum hemorrhage early to implement timely interventions based on QBL references and
tools.
The average EBL during a vaginal delivery is 500 ml and 1000 ml during a cesarean
section. Postpartum hemorrhage (PPH) is defined as EBL exceeding these amounts. According
to the American College of Obstetricians and Gynecologists (2006), PPH is the leading cause of
maternal death in the U.S., accounting for about 25%. PPH is treatable if diagnosis and
Visual estimations have been shown to underestimate blood loss by as much as 88%
(Hancock, Weeks & Lavender, 2015). Underestimation in blood loss can determine the decision
not to treat a hemorrhage, putting the patient at further risk. Some practices strictly use
postpartum complete blood count as laboratory evaluation of blood loss following delivery. The
problem with lab data is the delay in treatment and skewed results related to IV fluid intake and
time between delivery and blood draw (Stafford, Dildy, Clark & Belfort, 2008).
As a supplement to active management of the third stage of labor using uterotonic drugs,
controlled delayed cord clamping, and vigorous fundal massage, quantification of blood loss is
Educational Showcase
During this session, participants will be introduced to several tools that have been shown
to improve accuracy in determining blood loss following a delivery. The QBL Reference Guide
is a graphic poster showing different levels of saturation of delivery materials, like laps, 4x4
sponges, peripads and chucks, in order to assist the nurse in determining blood quantity. The
session will teach participates how to accurately weigh delivery materials before and after
further measurement tool, and participated will be trained on how to account for other fluids,
such as amniotic fluid, urine, and irrigation liquids. Additionally, the session will teach how to
determine blood concentration related to clot size with the use of posters. Finally, new
technology in QBL will be discussed, highlighting the suction canisters with automated
measurements, hands-free applications for measurement of blood on towels and sponges, and OR
Equipped with data and training in using these tools, participants will be able to return to
their units and recommend a change in practice to move from subjective methods of blood loss
Instructional Methods
References
Alvarez-Ramirez, P., Trial, J. L., Hoff, B., & Scott, A. (2015). Quantifying blood loss at birth
American College of Obstetricians and Gynecologists. (2006). ACOG practice bulletin: Clinical
http://www.ncbi.nlm.nih.gov/pubmed/17012482
Gabel, K. T., & Weeber, T. A. (2012). Measuring and communicating blood loss during obstetric
551-558. doi:10.1111/j.1552-6909.2012.01375.x
Hancock, A., Weeks, A. D., & Lavender, D. T. (2015). Is accurate and reliable blood loss
review of the literature. BMC Pregnancy & Childbirth, 15(1), 1-9. doi:10.1186/s12884-
015-0653-6
Stafford, I., Dildy, G., Clark, S., & Belfort, M. (2008). Visually estimated and calculated blood
loss in vaginal and cesarean delivery. American Journal of Obstetrics & Gynecology,
199(5),519. doi:10.1016/j.ajog2008.04.049