KAILUA KONA, HAWAII — By the time you detect changes in maternal blood pressure or heart rate suggesting postpartum hemorrhage, the woman already has lost a third of her blood volume, Dr. George R. Saade said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.
“Do not wait to start seeing signs and symptoms. As soon as you start estimating that the patient is losing a lot of blood, you have to start acting right then and there,” said Dr. Saade, professor of obstetrics and gynecology at the University of Texas Medical Branch, Galveston.
Orthostatic hypotension would tell you that the patient has lost 20%–25% of her blood, but if she is sitting or lying down on the delivery table, you're unlikely to detect that symptom. Hypotension reflects a loss of 30%–35% of blood volume. “Do not wait for hypotension” to treat for postpartum hemorrhage, he said at the meeting sponsored by Boston University. Clinicians typically underestimate postpartum blood loss by 30%–50%, studies suggest. On average, women lose about 500 cc in a vaginal delivery, 1,000 cc in a cesarean section, and 1,500 cc in a cesarean hysterectomy.
Dr. Garry Feinstadt, a general practitioner in Vancouver, B.C., said during a question-and-answer session that his work on quality assurance committees has convinced him that clinicians commonly record blood loss using inaccurately low numbers. “How can we teach people to accurately and honestly record blood loss?” he asked.
Dr. Saade suggested instituting a system of weighing uterine packs and learning how weights correlate with blood loss, then following a protocol of actions triggered by the weights.
Dr. Michael A. Belfort commented that his institution, St. Mark's Hospital in Salt Lake City, recently initiated a program to train nurses to estimate blood loss based on work done by Dr. Gary A. Dildy III, also of the hospital. A standard operating lap sponge soaked in blood, for example, will contain about 75 cc of blood. If it's dripping, it has absorbed about 100 cc of blood. The training sessions include photographs and evaluation of lap sponges and other materials soaked with blood.
“The critical area where you want to estimate blood loss is over 2,000 cc, and we almost always underestimate that,” he said. By that point, the patient has hypotension, has significant tachycardia, and is in shock.
Perhaps the easiest method of estimating is to picture a soda can, which would hold about 350 cc of blood. When you look at blood clots or blood in a canister, estimate how many cans of soda are represented, and you'll be close to blood volume lost. “The principle is to recognize volume,” Dr. Belfort said.
St. Mark's Hospital keeps scales in delivery rooms to weigh lap sponges and other materials to estimate blood loss. If a patient bleeds more than 1,000 cc, hospital policy mandates that a physician be there to evaluate blood loss. If more than 1,500 cc of blood is lost, two physicians must be on hand to manage the patient.
Consider organizing drills for your clinical staff on managing postpartum hemorrhage, Kimberly D. Baker, J.D., suggested in a commentary session on legal issues surrounding postpartum hemorrhage. Have the proper tools and instruments that you might need handy in delivery rooms.
Even women who develop early postpartum hemorrhage may be home before the bleeding starts, in part because they don't want to stay in the hospital any longer than they have to, noted Ms. Baker, a defense attorney in Seattle who also holds a BS in nursing. “If you are a provider who is involved with early discharge or home delivery, I can't emphasize strongly enough that you need to provide additional education to the patient to make sure that she really understands [what to do in case of bleeding]. … Educate her before delivery, not after,” she said.
'As soon as you start estimating that the patient is losing a lot of blood, you have to start acting.' DR. SAADE