Obstetric Anesthesiology

Section Editor: Cynthia A. Wong

Brief Report

The Accuracy of Blood Loss Estimation After Simulated

Vaginal Delivery
Paloma Toledo, MD
Robert J. McCarthy, PharmD
Bradley J. Hewlett, BS
Paul C. Fitzgerald, RN, MS
Cynthia A. Wong, MD
BACKGROUND: Visual blood loss estimation often underestimates blood loss. In this
study we sought to determine the effect of calibrated drape markings on blood loss
estimation in a simulated vaginal delivery.
METHODS: Subjects were randomized to estimate simulated blood loss (300, 500,
1000, and 2000 mL) in calibrated or noncalibrated vaginal delivery drapes and then
crossover.
RESULTS: Visual blood loss estimation with noncalibrated drapes underestimated
blood loss, with worsening accuracy at larger volumes (16% error at 300 mL to 41%
at 2000 mL). The calibrated drape error was ⬍15% at all volumes.
CONCLUSIONS: Calibrated vaginal delivery drapes improve blood loss estimation.
(Anesth Analg 2007;105:1736 –40)

P ostpartum hemorrhage, defined as blood loss more

than 500 mL after a vaginal delivery, is a major cause of
maternal morbidity and mortality (1,2). Delay in the
diagnosis and treatment of postpartum hemorrhage may
place the parturient at increased risk of adverse outcome.
Clinicians typically diagnose postpartum hemorrhage
by visual estimation of blood loss in the vaginal drapes
at delivery. The drapes are conical in shape and collect
blood, urine, and sponges used during the delivery.
Studies have shown that visual assessment of estimated
blood loss (EBL) can underestimate postpartum blood
loss by 33%–50% compared with the “gold standard,”
photospectrometry (3). The magnitude of underestima-
tion increases as the amount of blood loss increases;
however, previous studies have not examined volumes
⬎1000 mL (4 – 6). To our knowledge, the vaginal delivery
drapes currently marketed do not have any volume
calibrations. We hypothesized that adding calibrations
to the vaginal delivery drapes would improve visual
EBL assessment.
From the Department of Anesthesiology, Northwestern Univer-
sity Feinberg School of Medicine, Chicago, Illinois.
Accepted for publication August 6, 2007.
Dr. Cynthia A. Wong, Section Editor for Obstetric Anesthesiol-
ogy, was revised from all decisions related to this manuscript.
Bradley J. Hewlett was sponsored by the Foundation for Anes-
thesia Education and Research Medical Student Anesthesia Re-
search Fellowship.
Address correspondence and reprint requests to Cynthia A. Wong,
MD, Department of Anesthesiology, 251 E. Huron St., F5-704, Chicago,
IL 60611. Address e-mail to c-wong2@northwestern.edu.
Copyright © 2007 International Anesthesia Research Society
DOI: 10.1213/01.ane.0000286233.48111.d8
1736
METHODS
The study was approved by Northwestern University’s
IRB. Participants recruited were obstetric and anesthe-
sia attending and resident physicians, and obstetric
nurses. Written informed consent was obtained before
participation.
The study was conducted on two separate dates in
a labor and delivery room. The bed was assembled as
it would be for a vaginal delivery and the delivery
drapes were suspended from the foot of the bed (Fig.
1). There were eight study stations, each containing
one vaginal delivery drape. Two types of drapes were
used: drapes with and without volume calibrations.
Each vaginal delivery drape contained a known vol-
ume of blood, urine, and a number of surgical sponges
(Table 1). The calibrated drapes had volume markings
beginning at 500 mL with 500 mL increments to a total
of 2500 mL. Drape calibrations were made using 0.9%
saline and a 500 mL graduated cylinder (TD/TC ⫾
5%). Expired packed red blood cells were diluted with
0.9% saline to a hematocrit of 33% to simulate whole
blood. Urine was simulated with 100 mL of 0.9%
saline.
Participants were randomized in blocks, by pro-
vider type to view either the four calibrated stations or
the four noncalibrated stations, and then crossover.
The order of the volumes within each set of stations
was randomized. Subjects were not informed that the
volumes in the two groups were the same. Partici-
pants received a data card for each station on which
they wrote the volume estimate. After each station, the
data card was collected. Alterations to the estimations
were not allowed once the answers were recorded.
Vol. 105, No. 6, December 2007
 Table 2. Subject Characteristics
Noncalibrated Calibrated
first first P
Provider type 0.76
Anesthesia 22 21
Obstetrics 22 20
Nursing 9 12
Level of training 0.72
Attending 22 19
Resident 22 22
Nurse 9 12
Years of experience 0.89
⬍5 29 30
5–10 13 11
⬎10 11 12
Gender 0.69
Figure 1. Photograph of noncalibrated drape containing 500 Female 32 34
mL of blood and calibrated drape containing 1000 mL of Male 21 19
blood. In addition to blood, drapes also contained 100 mL of Data are presented as counts.
simulated urine and surgical sponges.

0.002) (Fig. 2). In addition, the accuracy of EBL wors-

Table 1. Vaginal Delivery Drape Contents
Station
1 2 3 4 5 6 7 8
Calibration ⫹ ⫹ ⫹ ⫹ ⫺ ⫺ ⫺ ⫺
markings
Simulated 300 500 1000 2000 300 500 1000 2000
blood (mL)
Urine (mL) 100 100 100 100 100 100 100 100
Sponges (no.) 5 5 10 15 5 5 10 15
The primary outcome variable was accuracy of EBL
in the calibrated versus noncalibrated drapes. Second-
ary outcome variables were the effects of provider
type, level of training, and number of years of expe-
rience. The study sample (n ⫽ 100) was estimated to
achieve 90% power to detect an intraclass correlation
of 0.90 under the alternative hypothesis and, assuming
four observations per subject when the intraclass
correlation under the null hypothesis is 0.70, using an
F-test with ␣ ⫽ 0.05.
The difference between the visual EBL and the actual
blood volume was compared between the groups that
initially estimated calibrated versus the noncalibrated
drapes using ANOVA with repeated measures. The type
of provider, level of training, and years of experience
were covariates. Post hoc analysis was conducted using
Bonferroni adjustment. Bland and Altman analysis
curves were constructed by comparison of the differ-
ences of the estimated versus the actual blood volume.
P ⬍ 0.05 was used to reject the null hypothesis.
RESULTS
One hundred six subjects participated. There were
no differences in gender, level of training, or years of
experience between groups (Table 2). The differences
in EBL from actual volumes were larger in subjects
viewing noncalibrated drapes compared with the sub-
jects who viewed the calibrated drapes first (P ⫽
ened with increasing blood volume in the former
group (P ⬍ 0.05).
The accuracy of the EBL in the second four stations
viewed by each group is shown in Figure 3. The error
in the EBL was reduced to ⬍15% at all volumes when
the group that saw noncalibrated drapes first viewed
the calibrated drapes. The overall error in EBL was
⬍15% at all volumes when noncalibrated drapes were
viewed second.
There was no difference in accuracy of EBL be-
tween groups based on provider type, level of train-
ing, or years of experience. Marginal mean differences
adjusted for covariates are shown in Table 3.
DISCUSSION
The important finding of this study was that the
addition of calibration markings significantly im-
proved the accuracy of EBL in conical vaginal delivery
drapes. We also found EBL underestimation was
proportional to the volume and was as high as 41% at
2000 mL with noncalibrated drapes, but was reduced
to between 9% and 11% at this volume with calibrated
drapes. Our study confirmed the findings of previous
investigators who have demonstrated in actual vagi-
nal deliveries that visual estimation of blood loss is
inaccurate when compared with quantitative methods
(3,6). This has important clinical implications as de-
layed diagnosis and treatment of postpartum hemor-
rhage may contribute to maternal deaths (1,2).
There are several quantitative methods to estimate
blood loss; however, most are impractical in the
delivery suite. The gold standard of photospectrom-
etry, which has a 10% error rate, requires special
equipment (7). A reference blood standard is prepared
by mixing the patient’s blood with 5% sodium hydrox-
ide solution. The contents of the drapes, including
sponges, are soaked in sodium hydroxide solution
and then the blended material is filtered and the
filtrate is again diluted. Finally, the standard and

Vol. 105, No. 6, December 2007 © 2007 International Anesthesia Research Society 1737

sample solutions are read using a spectrophotometer
and blood loss is calculated using a standard equation.
Radioisotope dilution, which also has an error rate of
approximately 10%, is technically difficult and re-
quires special equipment and disposal (8). Gravimet-
ric methods require weighing all materials and may
take many hours to complete (9). Hence, clinicians
estimate blood loss based on visual assessment of the
contents of the vaginal delivery drapes.
The use of calibrated drapes as a means of
improving blood loss estimates after vaginal deliv-
eries has been shown to correlate (r ⫽ 0.92) with
blood loss measured by photospectrometry (3). The
use of calibrated drapes resulted in EBL volumes
33% more than those obtained by visual estimation.
In the aforementioned study, however, blood loss
1738 Brief Report
Figure 2. Accuracy of visual blood loss
estimations in subjects that viewed non-
calibrated (top) and calibrated (bottom)
conical shaped vaginal delivery drapes
first. Each circle represents a single partici-
pant. Slope and intercept of regression
lines are ⫺0.46 and 166 for noncalibrated
drapes and ⫺0.09 and 11 for the calibrated
drapes.
determinations by photospectrometry were made
only in 10 of the 163 patients studied. In addition,
the range of blood loss volume and absolute vol-
umes were small (93–285 mL). No previous clinical
study has compared blood loss volumes consistent
with hemorrhage to standardized methods of blood
loss estimation or compared calibrated drapes to
noncalibrated drapes.
One interesting finding of this study was that there
was no difference between providers (anesthesiolo-
gists, obstetricians, or nurses) in the accuracy of blood
loss estimation, nor was there an association between
accuracy and years of training or experience. In a
study examining blood loss estimation using simu-
lated clinical scenarios, Bose et al. (5) found that
anesthesiologists more accurately estimated blood loss
ANESTHESIA & ANALGESIA
Figure 3. Accuracy of visual blood loss
estimations in subjects that viewed cali-
brated (top) and noncalibrated (bottom)
conical shaped vaginal delivery drapes
second. Each circle represents a single
participant. Slope and intercept of re-
gression lines are ⫺0.11 and 25 for cali-
brated drapes and ⫺0.15 and 98 for the
noncalibrated drapes. There were no dif-
ferences between the groups.
(median overestimate of 4%) compared to other health
care providers, all of whom underestimated blood loss
(median estimate ⫺11% to ⫺32%). However, only a
small number of obstetric anesthesiologists partici-
pated in the study (9 of 103 participants). In the
scenarios where there was blood spilled onto the floor,
both the anesthesiologists and the other obstetric
team members underestimated blood loss by
35%–50%, similar to the errors in estimation found
at large volumes in our study. These investigators
did not examine the level of experience of the
participants.
We found that there was a learning effect in that,
participants who viewed the calibrated drapes, made
better estimations of EBL in the noncalibrated drapes.
Our study was not designed to test the long-term
Vol. 105, No. 6, December 2007
retention of this information. A limitation to our study
is that we asked participants to estimate blood loss
based on inspection of the conical drape only. We did
not ask them to estimate blood loss in hidden places,
e.g., blood spills on the bed, sheets, or floor. In the
situation where there is hidden blood loss, experi-
enced clinicians may be more accurate at blood loss
estimation. An additional limitation of this study is
that this was not an actual delivery. We did, however,
include common distractors, such as urine and surgi-
cal sponges in the drape, but did not include amniotic
fluid. As there was no associated clinical scenario in
our study, it is not clear whether knowledge of
commonly available clinical clues (e.g., vital signs,
inspection of the perineum) would have improved the
accuracy of blood loss estimation.
© 2007 International Anesthesia Research Society 1739
Table 3. Accuracy of Visual Blood Loss Estimates: Calibrated significant volumes of blood loss. Our study demon-
and Noncalibrated Drapes strated that the addition of calibrations to vaginal
Mean error Percent delivery drapes can improve the accuracy of EBL, to
(mL) error an extent similar to other quantifying methods such as
photospectrometry, without the added cost or limita-
Calibrated drapes
Calibrated first tions. Further study is warranted to determine whether
300 mL ⫺20.8 (⫺56.8, 15.1) 7 the use of calibrated vaginal delivery drapes could
500 mL ⫺53.5 (⫺100.6, ⫺6.4) 11 prevent delay in diagnosis and treatment of postpartum
1000 mL ⫺32.8 (⫺150.3, 84.6) 3 hemorrhage.
2000 mL ⫺178 (⫺328.0, ⫺28.4) 9
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1740 Brief Report ANESTHESIA & ANALGESIA