Download How Close Are We In Blood Loss Estimation Following delivery

How Close Are We In Blood Loss
Estimation Following Delivery?
BY
DR 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 bloodsoaked 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.
Tables
Table 1: Sociodemographic characteristics of respondents
Variables
Frequency
Percentage
Age (Year)
20-29
30-49
>50
2
37
10
4.1%
75.5%
20.4%
Sex
Male
Female
41
13
75.9%
24.1%
Designation
Obstetric Resident
Consultant Obstetrician
Private Medical Practitioner
Midwives
26
13
12
3
48.1%
24.1%
22.2%
5.6%
Years of Practice (Year)
<5
5-15
16-30
>30
20
16
8
3
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 I
Correct
Incorrect
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 II
Correct
Incorrect
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 III
Correct
Incorrect
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 IV
Correct
Incorrect
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 I
Correct
Incorrect
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 II
Correct
Incorrect
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 III
Correct
Incorrect
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 IV
Correct
Incorrect
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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•THANK YOU ALL FOR
YOUR
ATTENTION!!!!!!!!!