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Quantification of Blood Loss: AWHONN Practice …

AWHONN PRACTICEBRIEFQ uantification of Blood loss : AWHONN Practice Brief Number 1An official Practice brieffrom the Association ofWomen s Health, Obstetricand Neonatal NursesAWHONN 2000 L Street,NW, Suite 740,Washington, DC 20036,(800) 673 8499 AWHONN periodicallyupdates Practice briefs. Forthe latest version go information herein isdesigned to aid nurses inproviding evidenced basedcare to women andnewborns. Theserecommendations shouldnot be construed asdictating an exclusivecourse of treatment orprocedure. Variations inpractice may be warrantedbased on the needs of theindividual patient,resources, and limitationsunique to the institution ortype of recommends that cumulative Blood loss be formally measured or quantified after every of the Problem A leading cause of maternal morbidity andmortality is failure to recognize excessiveblood loss during childbirth (The Joint Com-mission, 2010).

AWHONN PRACTICEB RIEF Quantification of Blood Loss: AWHONN Practice Brief Number 1 An official practice brief from the Association of Women’s Health, Obstetric

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Transcription of Quantification of Blood Loss: AWHONN Practice …

1 AWHONN PRACTICEBRIEFQ uantification of Blood loss : AWHONN Practice Brief Number 1An official Practice brieffrom the Association ofWomen s Health, Obstetricand Neonatal NursesAWHONN 2000 L Street,NW, Suite 740,Washington, DC 20036,(800) 673 8499 AWHONN periodicallyupdates Practice briefs. Forthe latest version go information herein isdesigned to aid nurses inproviding evidenced basedcare to women andnewborns. Theserecommendations shouldnot be construed asdictating an exclusivecourse of treatment orprocedure. Variations inpractice may be warrantedbased on the needs of theindividual patient,resources, and limitationsunique to the institution ortype of recommends that cumulative Blood loss be formally measured or quantified after every of the Problem A leading cause of maternal morbidity andmortality is failure to recognize excessiveblood loss during childbirth (The Joint Com-mission, 2010).

2 Women die from obstetric hemorrhagebecause effective interventions are not initi-ated early enough (Berg et al., 2005; DellaTorre et al., 2011). New York State Department of Health (2004,2009) issued health advisories informinghealth care providers to prevent maternaldeaths by improving recognition of andresponse to of Visual Estimation ofObstetric-Related Blood loss orEstimated Blood loss (EBL)Visual estimation of Blood loss (EBL) is commonpractice in obstetrics ; however, the inaccuracy ofEBL has been well established: As early as the 1960s, researchers demon-strated that visual EBL resulted in under-estimation and overestimation (Brant, 1967;Pritchard, 1965). Visual EBL most commonly results in errorsof underestimation (AI Kadri, Anazi, & Tamim,2011; Brant, 1967; Duthie et al.)

3 , 1990; Patelet al., 2006; Pritchard,1965). Visual EBL consistently resulted in underesti-mation of large volumes (Brant, 1967; Duthieet al., 1990; Stafford, Dildy, Clark, & Belfort,2008) of greater than 1000 ml (Stafford et al.,2008). With smaller volumes, EBL resulted inoverestimation compared to direct measure-ment (Dildy et al., 2004). The use of visual EBL can result in underesti-mation of Blood loss by 33 50% (Patel et al.,2006). With training, clinicians initially improvedaccuracy with visual EBL (Dildy et al.,2004) but experienced skill decay withinnine months of training completion (Toledo,Eosakul, Goetz, Wong, & Grobman, 2012). Provider specialty, age, or years of expe-rience were not related to accuracy of vi-sual EBL (Al Kadri et al., 2011; Toledo, Mc-Carthy, Hewlett, Fitzgerald, & Wong, 2007),and medical students as well as experiencedclinicians made similar errors (Dildy et al.

4 ,2004).Implications of InaccurateEvaluation of Blood loss Accurate and timely recognition of excessiveblood loss by clinicians is crucial becauseit leads to the initiation of Blood transfusionsand other maternal resuscitative efforts. Many clinicians rely on the flawed, imprecisemethod of visual EBL. Inaccurate measurement of postpartumblood loss has the following implications: Overestimation can lead to costly, inva-sive, and unnecessary treatments such asblood transfusions that expose women tounnecessary risks. Underestimation can lead to delay in deliv-ering lifesaving hemorrhage of Blood loss (QBL) QBL is an objective method used to evaluateexcessive , 00, 1 3; : 2014 AWHONN , the Association of Women s Health, Obstetric and Neonatal Nurses1 AWHONN Practice BriefTable 1: Tips for Quantification of BloodLoss (QBL) Quantification of maternal Blood loss is a team Create a list of dry weights for delivery items that maybecome Blood -soaked with directions on how tocalculate Blood Begin QBL immediately after the infant s birth (prior todelivery of the placenta) and assess and record theamount of fluid collected in a calibrated under-buttocksdrape or suction canister.

5 Keep in mind that most of thefluid collected prior to birth of the placenta is amnioticfluid, urine, and feces. If irrigation is used, deduct theamount of irrigation from the total fluid that Record the total volume of fluid collected in theunder-buttocks drape or suction Subtract the pre-placenta fluid volume from thepost-placenta fluid volume to more accuratelydetermine the actual Blood lost. Keep in mind that mostof the fluid collected after the birth of the placenta Add the fluid volume collected in the drapes andcanister to the Blood volume measured by weighingsoaked items to determine the cumulative volume ofblood loss or Weigh all Blood -soaked materials and clots todetermine cumulative gram weight=1milliliter Blood loss volume7. The equation used when calculating Blood loss of ablood soaked item is WETItem Gram Weight DRYItem Gram Weight=Milliliters of Blood within the a gram is a unit of mass and a milliliter is a unit ofvolume, the conversion from one to the other is simple.

6 Methods to quantify Blood loss , such asweighing, are significantly more accuratethan EBL (AI Kadri et al., 2011). The use ofa calibrated drape had an error rate of lessthan 15% (Toledo et al., 2007). QBL reduces the likelihood that clinicians willunderestimate the volume of Blood lost anddelay early recognition and treatment. SeeTables 1 and Equipment Calibrated under-buttocks drapes to mea-sure Blood loss Dry weight card, laminated and attached toall scales, for measurement of items that maybecome Blood -soaked when a woman is inlabor or after giving birthTable 2: Tips for Quantification of BloodLoss (QBL) During Cesarean Births1. Begin the process of QBL when the amnioticmembranes are ruptured or after the infant is Suction and measure all amniotic fluid within thesuction canister of collected fluid before delivery of After delivery of the placenta, measure the amount ofblood lost in the suction canister and drapes.

7 At thispoint, most of the Blood will be accounted for. Notify theteam and document the amount of Blood lost Prior to adding irrigation fluid, ensure that the scrubteam communicates when irrigation is that some of the normal saline will beabsorbed into the tissues. For this reason, not all of thefluid will be suctioned out of the abdomen andaccounted One of two methods can be used to suction theirrigation fluid: Continue to suction into the samecanister and measure the amount of irrigation fluid ORProvide another suction tube to collect the irrigationseparately into another Weigh all Blood -soaked materials and clots. Calculatethe weight and convert to At the conclusion of the surgery, add the volume ofquantified Blood calculated by weight with the volumeof quantified Blood in the suction canister to determinetotal Note that lap pads dampened with normal salinecontain minimal fluid.

8 When they become saturatedwith Blood , weigh them as you would a dry lap QBL will never be exact. However, it is more accurateto do some measurements than to rely solely on visualestimates. Scales to weigh Blood -soaked items placedideally in every labor and operating room andon the postpartum unit; save costs by usingthe scales used to weigh newborns Formulas inserted into the electronic chartingsystem that automatically deduct dry weightsfrom wet weights of standard supplies suchas chux and peri-padsREFERENCESAl Kadri, H. M., Anazi, B. K., & Tamim, H. M. (2011). Visual estimationversus gravimetric measurement of postpartum Blood loss : A2 AWHONN Practice Briefprospective cohort of Gynecology and Obstet-rics,283(6), 1207 , C. J., Harper, M. A., Atkinson, S. M., Bell, E.

9 A.,Brown, H. L., Hage, M. L.,.. Callaghan, W. M. (2005).Preventability of pregnancy-related deaths: Results of astatewide & Gynecology,106(6), 1228 , H. A. (1967). Precise estimation of postpartum hemorrhage: Dif-ficulties and Medical Journal,1(5537), 398 Torre, M., Kilpatrick, , Hibbard, , Simonson, L., Scott, S.,Koch, A.,.. Geller, S. E. (2011). Assessing preventability forobstetric Journal of Perinatology,28(10),753 760. 0031 1280856 Dildy, G. A., 3rd, Paine, A. R., George, N. C., & Velasco, C.(2004). Estimating Blood loss : Can teaching significantly im-prove visual estimation? obstetrics & Gynecology,104(3), 601 , S., Ven, D., Yung, G., Guang, D., Chan, S., & Ma, H. (1990).Discrepancy between laboratory determination and visual esti-mation of Blood loss during normal Journalof obstetrics & Gynecology and Reproductive Biology,38,119 York State Department of Health.

10 (2004).Health advisory: Pre-vention of maternal deaths through improved management ofhemorrhage. New York, NY: Author. Retrieved York State Department of Health. (2009).Health advisory: Pre-vention of maternal deaths through improved management ofhemorrhage. New York, NY: Author. Retrieved , A., Goudar, S. S., Geller, S. E., Kodkany, B. S., Edlavitch, ,Wagh, K.,.. Derman, R. J. (2006). Drape estimation vs. vi-sual assessment for estimating postpartum Journal of Gynaecology & obstetrics ,93(3), 220 , J. (1965). Changes in the Blood volume during pregnancyand ,26(4), 393 Joint Commission. (2010). Preventing maternal Alert,44, 1 4. Retrieved , I., Dildy, G., Clark, S.,& Belfort, M. (2008).Visually estimatedand calculated Blood loss in vaginal and cesarean Journal of obstetrics & Gynecology,199, , P.


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