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Conference Abstract

Title: Empowering Nurses to Quantify Blood Loss in Obstetrical Hemorrhage

Presented by: Mary Smith RNC-OB, BSN

Labor & Delivery Unit

Northwell Health - Northern Westchester Hospital

Learning Outcomes

At the conclusion of this session, participants will be able to:

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

blood loss (QBL).

2. Utilize the Blood Loss Reference Guide to visual quantification blood loss during vaginal

or cesarean delivery to more accurately determine quantity.

3. Direct the activation of obstetrical hemorrhage protocol (i.e. blood transfusion) more

rapidly by detecting and reporting excessive blood loss earlier.

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

postpartum hemorrhage (PPH) and a delay in treatment.


Nurse Education Focus: Evidence-based Pedagogy

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

from a separate 100 deliveries.

Podium Presentation Abstract

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


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

intervening occur early.

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

important for early recognition and management of obstetrical hemorrhage.


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

delivery to determine blood content. Graduated under-buttocks drapes will be showcased as a

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

table and stretcher scales.

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

measurement to objective practices.

Instructional Methods

 Case Study from Northwell Health

 Demonstration of new tools
 Lecture
 Question and Answer
 Simulation


Alvarez-Ramirez, P., Trial, J. L., Hoff, B., & Scott, A. (2015). Quantifying blood loss at birth

saves lives...Proceedings of the 2015 AWHONN Convention. JOGNN: Journal of

Obstetric, Gynecologic & Neonatal Nursing, 44S45. doi:10.1111/1552-6909.12603

American College of Obstetricians and Gynecologists. (2006). ACOG practice bulletin: Clinical

management guidelines for obstetrician-gynecologists number 76, October 2006:

Postpartum hemorrhage. Obstetrics & Gynecology 108(4):1039-47. Retrieved from


Gabel, K. T., & Weeber, T. A. (2012). Measuring and communicating blood loss during obstetric

hemorrhage. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(4),

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

estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative

review of the literature. BMC Pregnancy & Childbirth, 15(1), 1-9. doi:10.1186/s12884-


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