TAGEDENS E M I N A R S I N P E R I N A T O L O G Y 43 (2019) 11 17

Available online at www.sciencedirect.com

Seminars in Perinatology
www.seminperinat.com

Postpartum hemorrhage: early identification

challenges
Maria Andrikopoulou*, and Mary E. D’Alton
Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY

A R T I C L E I N F O AB STR ACT

Postpartum hemorrhage is the leading cause of maternal morbidity and mortality world-
wide. The majority of maternal deaths associated with hemorrhage could be preventable.
The accurate assessment of blood loss, identification of risk factors and timely recognition
of postpartum hemorrhage remain major challenges in obstetrics. It is important to review
available modalities for estimation and quantification of peripartum blood loss, the value
of risk assessment tools as well as the challenges in early recognition of clinical signs and
symptoms of postpartum hemorrhage.
Ó 2018 Elsevier Inc. All rights reserved.

treatments with associated emotional and economic costs.

Introduction
Postpartum hemorrhage (PPH) is the leading cause of maternal
morbidity and mortality worldwide, and affects up to 10% of all
deliveries.1 Although historically many definitions have been
used, the American College of Obstetricians and Gynecologists’
reVITALize program, in an effort to standardize clinical defini-
tions in obstetrics, defines postpartum hemorrhage as blood
loss greater than or equal to 1000 mL or blood loss with signs or
symptoms of hypovolemia within 24 h of delivery whether
cesarean section or vaginal birth.2
Postpartum hemorrhage can lead to maternal deaths, the
majority of which could be preventable.3 However, the accu-
rate assessment of blood loss still remains a major challenge
in the care of women in labor and delivery. Depending on the
clinical circumstance, clinicians are prone to either underesti-
mate or overestimate maternal blood loss. Underestimation is
particularly problematic as it results in delayed recognition of
postpartum hemorrhage, delayed initiation of therapy leading
to increased maternal morbidity and mortality. On the other
hand, overestimating blood loss leads to unnecessary
Thus, early, timely and precise identification of PPH is vital,
although limited due to lack of accurate methods to measure
blood loss.
Estimated blood loss
“Estimated blood loss” is perhaps the most common method
used to assess blood loss at the time of delivery. Also known
as “eyeball” estimation, estimated blood loss (EBL) mainly
relies on a physician’s opinion based on clinical experience
and use of visual aids such as sponges, kidney dishes and
sanitary pads. Despite the widespread utilization of estimated
blood loss, there have been inaccuracies and controversy in
the literature described for many years on the utility and pre-
cision of visual aids. Buckland and Homer reported that visual
aids such as kidney dishes or smaller containers were associ-
ated with more accurate estimation of blood loss than estima-
tion of blood when soaked into linen or pads.4 On the other
hand, the prospective simulation study by Brooks et al.

* Corresponding author: Columbia University Irving Medical Center, 622 West 168th Street, New York 10032 USA.
E-mail address: ma3659@cumc.columbia.edu (M. Andrikopoulou).

https://doi.org/10.1053/j.semperi.2018.11.003
0146-0005/Ó 2018 Elsevier Inc. All rights reserved.
12 S E M I N A R S I N P E R I N A T O L O G Y
showed that the addition of visual aid led to overestimation of
blood loss compared to just the use of a collector bag and baby
scale.5 Larson and colleagues reported that standard estima-
tion of blood loss with visual aids, pads, swabs and diapers
have been proven to be imprecise and inaccurate both for
vaginal delivery and cesarean section.6 Visual estimation is
thought to be inaccurate amongst health care professionals
and does not correlate with years of training and experience.7
Simulation, teaching sessions and clinical reconstructions
have been widely used in the clinical setting in an effort to
improve clinical blood loss estimation skills.8 11 However, the
long-term benefit of such teaching tools has not been proven
yet. A study by Toledo et al. included 44 participants who
underwent web-based training of blood loss estimation. The
post-training test, which was repeated 9 months later,
showed a decline and inaccuracy of blood loss estimation
skills remote from the didactic training.12 Simulation exer-
cises increase the vigilance and accuracy of health care pro-
fessionals initially, however education does not produce
sustainable improvements in blood loss estimation.
Different specialties and disciplines have also reached to
similar conclusions on the challenges of accurately estimating
blood loss. A prospective blinded cross sectional study among
emergency medical services (EMS) personnel, showed that
EMS professionals were also inconsistent with the amount of
blood loss.13 There was no correlation between accuracy and
level of training. The conclusion was that time is better to be
spent attending to patient rather than visually estimating
blood loss given poor estimates of bleeding. Similarly, a study
on anesthesia providers, showed comparable results, with
accuracy of estimated blood loss not related to provider train-
ing, years of education, years of experience, gender, or ethnic-
ity.14 These results are reinforced by the report of Rothermel
and Lipman who showed that visual estimation of operative
blood loss is unreliable and inaccurate amongst anesthesia
providers, surgeons, nurses and practitioners.15
Quantitative blood loss
Given that estimation has been shown to be inaccurate in the
evaluation of blood loss, an effort has been made for quantifica-
tion of blood loss during labor. The California Maternal Quality
Care Collaborative (CMQCC) developed an obstetric hemorrhage
toolkit which emphasizes the need for cumulative quantitative
assessment of blood loss.16 Under-buttock drapes during vagi-
nal deliveries and gram scales to weigh blood soaked materials
have been proposed to quantitate blood loss more precisely.16 It
is speculated that quantitative blood loss (QBL) has multiple
advantages in comparison to EBL. It is believed that it leads to
earlier interventions and improves the culture of drawing atten-
tion to blood loss. Objective data can help the nurse mobilize
the obstetrical team and additional resources earlier. Propo-
nents highlight that even though resource needs for quantita-
tive blood loss measurement are higher than EBL, the use of
under buttock drapes or newborn scales to weight the soaked
material are overall economic and cost effective measures
which offer an advantage to labor and delivery units.17
Multiple studies have evaluated the role of QBL in labor and
delivery. A study by Toledo et al., where 106 obstetrics and
43 (2019) 11 17
anesthesia providers were randomized to estimate simulated
blood loss in calibrated or noncalibrated vaginal delivery drapes,
showed that the use of calibrated drapes improved the accuracy
of EBL compared to noncalibrated drapes, with error of <15%.18
Visual estimation of blood loss was inaccurate compared to
quantitative methods, irrespective of experience, level of train-
ing or specialty. The discrepancy was higher with increasing
blood volume. A randomized controlled trial by Patel et al. has
also reported superiority of QBL.19 In this study, women were
randomized to visual or drape estimation of blood loss at the
time of delivery. EBL was shown to underestimate postpartum
blood loss by 33% when compared to QBL. Additionally, the
authors performed spectrometry in 10 patients and found a
high correlation between blood loss and QBL. Similarly, a pro-
spective study by Kadri et al., which included 150 women who
had a vaginal delivery compared visual assessment of blood
loss versus gravimetric measurement via measurement of
weight of soaked materials. Health care providers underesti-
mated blood loss by 30%, when visually calculating blood loss
compared to gravimetric measurement.20
However, other studies have questioned whether QBL can
actually reduce risk associated with postpartum hemorrhage. A
cluster randomized trial in 13 European countries investigated
the use of plastic collector bag in the measurement of blood
loss.21 Maternity units were randomized to use a collector bag
versus visual estimation of blood. The collector bag failed to
reduce postpartum hemorrhage. Similarly, Hackock et al.
reviewed 36 studies on blood loss during delivery and provided
no evidence that blood loss measurement led to improved PPH
diagnosis, prevented progression to severe PPH or was corre-
lated to improved maternal outcomes.22 Additionally, when
QBL was used as a predictor of hemoglobin, it did not improve
the prediction of hemoglobin 12 h postpartum in deliveries with
average blood loss and it was proven to be time and resource
intensive, requiring specific protocols and providers’ educa-
tion.23 The poor sensitivity of weighted blood loss to detect PPH
compared to hemoglobin drop was also reported by Atukunda
et al., however, that study underlined that weighted blood loss
could be valuable in areas with high PPH prevalence when labo-
ratory measurements cannot be promptly accessed.24
Given the challenges of existing techniques to accurately cal-
culate the measurement of blood loss, recently, both in vitro
and clinical studies in obstetrics and also other surgical fields
have investigated Triton, a novel mobile monitoring sys-
tem.25 28 It measures hemoglobin loss absorbed by surgical
sponges using a platform. Images of blood soaked sponges are
captured and transferred to a remote server. Feature Extraction
Technology is used to provide an accurate and precise measure-
ment of blood loss.25 26 It is speculated that it provides precise
measurement of hemoglobin on surgical sponges compared to
manual rinsing measurements and is more accurate than gravi-
metric evaluation.26 However, further studies, in a larger set of
patients, are needed to better evaluate the clinical use of this
new technology and the role of Triton in labor and delivery.
Risk assessment
Both estimated and quantitative blood loss can be inaccurate
and cannot predict or reduce the risk of PPH. Thus, early
 TAGEDENS E M I N A R S
identification of risk factors for postpartum hemorrhage can
lead to both awareness and preparedness for high blood
loss.29 Risk assessments should be undertaken during prena-
tal visits, antepartum care, admission to labor and delivery,
during the labor and postpartum course, as risk factors can
change or evolve during labor course.29 Identifying the risk
factors in each case provides the team the opportunity to
prepare, confirm that supplies and blood products are avail-
able for use, get appropriate specialties involved in the care
of patients and possibly transfer high risk patients to other
Table 1 – Risk assessment tools to help providers identify women at high risk for hemorrhage.31
I N P E R I N A T O L O G Y 43 (2019) 11 17 13
facilities in a timely fashion. Women with pregnancy com-
plications that are at risk for hemorrhage such as placenta-
tion anomalies, should be transferred to centers that
specialize in the management of such pregnancy complica-
tions with the help of a multidisciplinary team.29 Even
though there are multiple validated risk assessment tools
available to help providers identify women at high risk,30 31
(Table 1) these tools can only be used as a guidance, as they
identify only a fraction of women who will develop postpar-
tum hemorrhage.
14 S E M I N A R S I N P E R I N A T O L O G Y 43 (2019) 11 17

Table 2 – Obstetric hemorrhage checklists: initial steps, medication use, blood transfusion and actions in dif-
ferent stages of hemorrhage.43

(continued on next page)

 TAGEDENS E M I N A R S I N
Table 2 (continued.)
Vital signs and symptoms of hemorrhage
In addition to meticulous estimation of blood loss in cases of
postpartum hemorrhage, careful observation of clinical signs
is also vital. Low systolic blood pressure, tachycardia, and
raised respiratory rate have been historically used as signs of
hypovolemia. According to the Advance Trauma Life Support
(ATLS) calcification, tachycardia with heart rate over 100 beats
per minute (bpm), decreased pulse pressure and respiratory
P E R I N A T O L O G Y 43 (2019) 11 17 15
rate (RR) 20 30 correlates with 15% of blood volume loss,
whereas decreased blood pressure, tachycardia over 120 bpm
and RR 30 40 correlates with 30 40% of blood volume loss.32
Many studies have challenged the use of vital signs cut offs
in the setting of hemorrhage. Brasel et al. in a study which
included the records of more than 10,000 trauma patients,
reported that increased heart rate over 100 bpm, did not pre-
dict the need for immediate intervention in trauma patients.33
Similarly, Victorino et al. also showed that tachycardia is not a
16 S E M I N A R S I N P E R I N A T O L O G Y
reliable sign of hypovolemia in surgical trauma patients.34
Even though it is independently associated with hypotension,
absence of tachycardia is not indicative of absence of signifi-
cant blood loss. Other studies have also questioned the validity
of vital signs in trauma patients, showing that an association
exists between tachycardia, lower systolic blood pressure and
raised RR, but not to the degree reported in ATLS guidelines.35
A systematic review including 30 studies on the association of
blood loss with clinical signs and symptoms reported a signifi-
cant variability between blood loss and clinical signs.36 Thus, it
can be very challenging to establish specific cut off points for
vital signs which could alert providers and trigger an expedited
team response and action.
Most studies in the literature include mainly surgical patients
and are not focused on the obstetric population. Changes in
maternal physiology such as increase in maternal blood volume
and cardiac output, could affect the role of vital signs as a surro-
gate for blood loss in pregnancy. Case reviews of maternal deaths
led to the proposed Maternal Early Warning Criteria, which indi-
cate vital sign parameters that should trigger prompt patient
evaluation and management such as systolic and diastolic blood
pressure, heart rate, respiratory rate, oxygen saturation, oliguria,
maternal agitation, confusion or unresponsiveness.37 However,
this list of parameters only provides guidelines to help alert pro-
viders and prevent delay in recognition of severe hemorrhage or
other emergencies.37
Since change of vital signs does not always correlate with
the amount of blood loss, other clinical signs that could have
a predictive value in the setting of postpartum hemorrhage
have been studied. The shock index (SI) is calculated as the
heart rate divided by the systolic blood pressure and can
be an accurate predictor of cardiovascular changes secondary
to blood loss even in patients who otherwise would be consid-
ered normotensive.36 The SI represents a more reliable indi-
cator of hemodynamic changes secondary to blood loss.
Values over 0.9 have been associated with higher bleeding
and mortality in trauma patients.38 39An elevated SI greater
than 0.9 has been shown to be associated with massive trans-
fusion,40 and is a strong predictor of ICU admissions41 and
adverse outcomes in women with PP hemorrhage.42 Further
prospective studies are needed to validate the role of SI in
obstetric population, but it is a promising index that could be
combined with the Maternal Early Warning Criteria and thus
lead to earlier intervention and action.
Ultimately, even in the setting of normal vital signs, initiation
of treatment for suspected or evolving PPH should not be
delayed. When a clinically significant hemorrhage is identified,
even without change in vital signs, medical management with
uterotonic medications should be initiated, adequate intrave-
nous access should be established and transfusion should be
promptly started. With continued bleeding or abnormal vital
signs, aggressive escalation of therapy should be undertaken
including massive transfusion protocol and transfer to the oper-
ating room for surgical interventions (Table 2).43
Conclusion
In conclusion, postpartum hemorrhage is a complicated, mul-
tifactorial process. Accurate quantification of blood loss is
43 (2019) 11 17
vital but should not be the only focus for the management of
postpartum hemorrhage. Other factors such as the rate of
blood loss, clinical signs, patient symptoms, the shock index,
and the physiological response to hemorrhage are crucial to
early recognition of a high risk situation which may help pro-
mote optimal management.22
Disclosure
Dr. Andrikopoulou has no conflict of interest to disclose. Dr.
D’Alton is acting as the Studywide Principal Investigator for a
Prospective, Single Arm, Pivotal Clinical Trial Designed to Assess
the Safety and Effectiveness of the InPress Device In Treating Pri-
mary Postpartum Hemorrhage with InPress Technoligies, Inc.
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