How Close Are We In Blood Loss Estimation Following Delivery?

BYDR DUNSIN TAIWO

Introduction

• Primary PPH remains a leading killer of women worldwide.• Haemorrhage accounts for 27% of maternal death worldwide.

(WHO 2014).• It accounts for 34% of maternal death in Africa, 31% in Asia,

21% in Latin America and 13% in developed countries. (AbouZahr 2003)

• Preventing PPH is the best approach to mitigating its role in maternal mortality.

• In particular, the ability to accurately estimate the level of blood loss is a veritable aspect of a careful plan to manage PPH.

• Visual estimation of blood loss at delivery is unreliable, resulting in underestimation by 30-50%. (Starr 1997), (Glazener 2001).

Introduction

• Significant differences between clinical estimation and actual measurement have been consistently demonstrated in previous studies. (Arulkumaran 2003), (Dildy 2004).

• Shock index has been advocated to further compliment visually estimated blood loss.(Gharoro 2013). The question remains, HOW CLOSE ARE WE IN ESTIMATING BLOOD LOSS AT DELIVERY?

• The present study was designed to stimulate our interest in making efforts to accurately estimate blood loss by visual assessment.

Methodology

• This was a cross-sectional study conducted among doctors and nurses at various meetings in Benin City. They included those attending a clinical meeting at the department of O&G, UBTH, members of Association of Private General Practitioners in Benin during their monthly meeting, and doctors attending Midwest sector SOGON meeting in UBTH, Benin City.

Methodology

The participants at these different meetings were invited to visually estimate the volume of blood simulators put in 4 different kidney dishes. Various volumes were represented in the dishes bearing in mind that the average documented blood loss following vaginal delivery in UBTH was 200ml (Gharoro 2009). The represented volumes were designed to assess free blood, blood clot as well as blood-soaked gauze or towel.

Methodology

• An error margin of 20% was accepted for each volume.• The estimated volumes by each participant were

recorded by them on a form provided and submitted immediately.

• The participants’ age, sex, profession, designation and years of practice were also documented on the form.

• The information retrieved was coded and used to generate a database for analysis done with SPSS. Univariate analysis was done with Chi square or Fisher Exact test as appropriate, while cross tabulation was conducted for associations.

Results

• There were 54 respondents in the study made up of 13 consultant obstetricians, 26 obstetric residents, 12 private medical practitioners and 3 midwives.

• Two residents were younger than 30 years of age; 37 respondents were aged 30 to 49 years while 10 were over 50 years.

• Only one respondent accurately assessed all 4 volumes of blood. Eight (14.8%) of them got 3 volumes correct, fifteen (27.8%) correctly estimated 2 volumes, nineteen respondents (35.2%) got only one volume correct, while eleven (20.4%) failed to correctly estimate any of the 4 volumes.

Results

• The average performance for the entire group of respondents was 35.2%.

• The consultants got an average performance of 38.5%, the residents were 35.6% correct, the private practitioners were 33.3% correct, while the midwives were 16.7% correct.

• The respondents were 4% more likely to underestimate the blood volumes (34.7% versus 30.1%).

Results

• Free blood was more accurately assessed than clotted or gauze/towel-soaked blood (75.9% vs 64.8%).

• Accuracy of estimation was poorer after 30 years of practice for both free and clotted blood. GPs and residents estimated free blood better but clotted blood poorer than obstetricians.

TablesTable 1: Sociodemographic characteristics of respondentsVariables Frequency Percentage Age (Year)20-2930-49>50

23710

4.1%75.5%20.4%

SexMale Female

4113

75.9%24.1%

DesignationObstetric ResidentConsultant ObstetricianPrivate Medical PractitionerMidwives

2613123

48.1%24.1%22.2%5.6%

Years of Practice (Year)<55-1516-30>30

201683

42.6%34.0%17.0%6.4%

Table 2: Accuracy of Visual Assessment Based on Designation

Variable Residents Obstetrician Private Practitioner

Midwives P-value

DISH ICorrectIncorrect

15(57.7)11(42.3)

4(30.8)9(69.2)

5(41.7)7(58.3)

0(0)3(100)

0.153

DISH IICorrectIncorrect

7(26.9)19(73.1)

2(15.4)11(84.6)

8(66.7)3(33.3)

0(0)3(100)

0.018

DISH IIICorrectIncorrect

13(50.0)13(50.0)

6(46.2)7(53.8)

3(25.0)9(75.0)

2(66.7)1(33.3)

0.043

DISH IVCorrectIncorrect

4(15.4)22(84.6)

5(38.5)8(61.5)

2(16.7)10(83.3)

0(0)3(100)

0.274

Table 3: Accuracy of Visual Assessment Based on Years of Practice

Variable <5 years 5-15 years 16-30 years >30 years P-value

DISH ICorrectIncorrect

11(55.0)9(45.0)

8(50.0)8(50.0)

3(37.5)5(62.5)

0(0)3(100)

0.358

DISH IICorrectIncorrect

6(30.0)14(70.0)

5(31.3)11(68.7)

3(37.5)5(62.5)

1(33.3)2(66.7)

0.138

DISH IIICorrectIncorrect

8(40.0)12(60.0)

11(68.7)5(31.3)

3(37.5)5(62.5)

0(0)3(100)

0.230

DISH IVCorrectIncorrect

5(25.0)15(75.0)

4(25.0)12(75.0)

2(25.0)6(75.0)

0(0)3(100)

0.535

Discussion

• The performance of the respondents in this study suggests a trend toward poor visual estimation of blood loss with an overall accuracy rate of only 35.2%.

• This observation is rather worrisome considering the key role played by primary postpartum hemorrhage in our alarming rates of maternal mortality.

Discussion

• Consultants had the best performance (38.5%), likely due to their experience. Similar to previous study. (Meiser 2001). Moreover, the only respondent that got all the 4 dishes correctly was a consultant.

• The accuracy based on years of practice was not significant, similar to previous studies (Grant 1997), (Patton 2001), (Dildy 2004).

Discussion

• Small volumes of free blood were better assessed, while gauze-soaked blood was more likely to be overestimated and clotted blood more likely to be underestimated. 44.4%, 42.6% and 59.3% respectively. Similar to finding from previous study. (Brant 1967)

Limitations

• The small number of respondents makes it difficult to generalize the findings.

Recommendation

• We therefore recommend a larger scale study to identify those most deficient in visual assessment of blood loss and promote a training programme for all those involved in obstetric care.

• We are also recommending that this visual estimation evaluation should be made a routine drill in all centres where obstetric services are rendered.

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