Postpartum hemorrhage (PPH) is the main cause of maternal mortality and morbidity worldwide [1, 2]. Decreasing the incidence of severe PPH remains a major challenge in modern obstetrics. Traditionally, blood loss in the third stage of labor is visually estimated; however, several studies have shown that this method is highly inaccurate [3, 4], with blood loss overestimated at volumes <250 mL and underestimated at volumes >2000 mL. Delay in diagnosis and initial treatment of PPH causes most lethal and non-lethal maternal complications [5, 6]. Although objective measurements using collector bags have been shown to increase the accuracy of assessing postpartum blood loss compared with visual estimation [7–10], a recent cluster randomized trial in 13 European countries that included 11,037 births reported that the rate of severe PPH was not reduced significantly via routine use of a drape (1.71%) versus visual blood-loss estimation (2.06%) . These findings cast into doubt the benefit of using collector bags in the delivery suite. However, this trial lacked specific guidelines and action plans for women undergoing massive PPH.
The aim of our study was to evaluate the incidences of PPH and severe PPH via routine use of a calibrated pelvic plastic bag to objectively measure postpartum blood loss after vaginal delivery in connection with a stepwise PPH management protocol. Further, we correlated measured blood loss with differences between prepartal and postpartal maternal hemoglobin levels.
This investigation was a prospective, observational study. We recruited women who were admitted for a planned vaginal delivery at the Department of Obstetrics, Charité University Hospital, Berlin, Germany, a tertiary care center, from December 2011 to May 2013. The study protocol was approved by the local Ethical Committee (EA2/118/11). Informed consent was obtained from all patients. The inclusion criterion was a live singleton pregnancy after 37 weeks (estimated from the last menstrual period and confirmed by sonographic measurement of crown-rump length in the first trimester) in cephalic presentation. Women who were delivered via cesarean section in labor were excluded from the study.
We measured serum maternal hemoglobin levels just on admission for delivery in all enrolled patients. A calibrated transparent collecting drape (Brenner Medical GmbH, Putzbrunn, Germany) (Figure 1) was placed under the pelvis of each laboring woman as soon as the baby was born and before delivery of the placenta. All women prophylactically received a 3 IE oxytocin bolus via intravenous injection in the third stage of labor. The bag was left in situ until the birth attendant was no longer concerned about blood loss or the mother was transfered to the ward. In general, mothers were observed postpartum for 2 h in the delivery suite. Providers examined the drape and recorded the level indicated. In accordance with World Health Organization guidelines, we defined PPH as blood loss ≥500 mL and severe PPH as blood loss ≥1000 mL . In case of PPH, the staff used the stepwise management protocol established by a consensus group from Germany, Austria and Switzerland . Serum maternal hemoglobin content was again assessed routinely at the first postpartum day. The difference between levels on admission at term labor and those after birth were calculated and correlated with measured blood loss. Women who suffered from severe PPH and received red blood cell transfusions were exluded from the correlation analysis. Basic patient data and medical information were collected (maternal age, gravity, parity, induction of labor, mode of delivery, episiotomy and birthweight).
Descriptive analyses were conducted. Results are presented as raw numbers, rates, medians, or means±standard deviation when a normal distribution was confirmed via the Kolomogorov-Smirnov test. The incidences of PPH and severe PPH were the primary study outcome. Simple linear regression and Pearson’s correlation were used to evaluate the relationship between blood loss measured during vaginal delivery and decreases in maternal hemoglobin levels. P-values <0.05 were considered statistically significant. All statistical analyses were performed with IBM SPSS Statistics, version 22 (SPSS, Inc., Chicago, IL, USA).
Between December 2011 and May 2013, there were 4950 deliveries at the study hospital. During this period, 1019 patients were initially enrolled in the current investigation. Table 1 summarizes the demographic and clinical characteristics of patients in the study group. Of the patients, 210 patients (20%) underwent cesarean delivery in labor and were exluded from the final analysis. The mean gestational age at delivery was 39.5 weeks. The average maternal age of participants was 29 years, the median gravidity was 2 (range: 1–13) and the median parity was 1 (range 1–8). The mean birth weight was 3420±465 g for term newborns. Data on postpartum blood loss were collected for 739/809 women who underwent vaginal delivery (Table 2). Direct measurement using a calibrated collecting bag revealed a median blood loss of 250 mL (range 50–4100 mL). Of the included patients, 108 (15%) had blood loss ≥500 mL; 25 (3%) of those women had blood loss ≥1000 mL. Five women suffering from severe PPH were transfused with red-cell concentrates. No maternal deaths due to severe bleeding occured in our cohort. The mean maternal hemoglobin content at admission was 11.9±1.1 g/dL (n=801). In 759 women, the hemoglobin level was measured at the first postpartum day for an average of 10.9±1.4 g/dL. The mean hemoglobin drop was 1.0±1.1 g/dL. We found that measured blood loss after vaginal delivery significantly correlated with the actual change in maternal hemoglobin level (Figure 2) (P<0.01, r=0.47).
In this large, single-center, prospective study in the clinic, we evaluated the incidence of PPH and severe PPH by directly and accurately measuring blood loss after vaginal delivery. PPH occured in 15% of our cohort. This figure is lower than those reported by Biguzzi et al. (24%)  and by Bais et al. (19%) . In contrast to our study design, Bais and coworkers  retrospectively evaluated blood loss during labor based on measurements from a basin, weighing of used swabs and visual estimates. Our study design is more comparable with that of Biguzzi et al. , who placed a calibrated collecting bag under the pelvis of each laboring woman to determine blood loss in the third stage of vaginal birth. In a small, randomized trial, Patel and coworkers  compared visual estimation of postpartum blood loss with blood loss measured with a collecting drape. They determined a mean blood loss in the “drape group” (n=62) of 302 mL. This result is slightly higher than our value (Table 2), but the PPH incidence in their cohort was not reported. Tixier and coworkers  used a graduated underbuttocks pouch to evaluate blood loss in 122 laboring women; comparable with our observations, they reported a mean blood volume of 233 mL and a PPH occurred in 14.5% . Recently, a large French observational study stated the distribution of the volume of blood loss during vaginal deliveries , they evaluated 6134 women after 24 weeks of gestation and found a mean and median volume of bleeding of 180 mL and 100 mL, respectively. In contrast to this study, the authors used a collector bag combined with weighing of used swabs.
Biguzzi et al.  and Prasertcharoensuk et al.  reported incidences of severe PPH of 4.8% and 3.5%, respectively. Our observations are consistent with these data. Unfortunately, Zhang and coworkers , who conducted the largest study of measured blood loss in labor, defined severe PPH as a composite of all women who experienced one or more blood transfusions, intravenous plasma expansions, arterial embolizations, surgical procedures, admission to an intensive care unit, treatment with recombinant factor VII and death. These differences in study design complicate comparisons with the results of the present investigation.
In general, previous population-based data that relied on the visual estimation of blood loss at childbirth indicated a PPH incidence between 2.9% [17, 18] and 6% . However, peripartum blood loss is often not measured, and therefore the true rate of PPH is significantly underestimated. Birth attendants can expect blood loss of at least 500 mL in 15%–20% of all vaginal deliveries; 3%–5% of all laboring women will suffer severe PPH. Prevention of PPH would benefit from the identification of prenatal maternal and fetal risk factors for peripartum bleeding, but this identification is outside the scope of the present study.
Correlation of postpartal blood loss and changes in maternal hemoglobin levels
In 1532 women who underwent vaginal delivery, a previous regression analysis uncovered a significant negative non-linear correlation between maternal hematocrit change (from intrapartum to 48 h postpartum) and visual estimates of blood loss after labor (r=−0.549, P<10−4) in the absence of PPH, most parturients [53.4%] experienced either no change or an increase in postpartum hematocrit . In contrast to that study, here we evaluated maternal hemoglobin content. As expected, we found that more blood loss led to a greater decrease in maternal hemoglobin levels (Figure 2). However, 113 of our patients (14.8%) had a higher hemoglobin level in comparison to the value measured before birth. None of these patients experienced PPH or severe PPH. It is noteworthy that antepartum hemoconcentration or physiological diuresis after delivery may substantially influence maternal blood counts before and after birth. In addition, laboring patients receive various amounts of intravenous hydration, which may affect postpartum hemoglobin and hematocrit levels.
PPH management protocol
Previous studies of maternal mortality demonstrated that most deaths due to PPH involved delayed and substandard care in the diagnosis and management of peripartal bleeding (“too little is done too late”) . While healthy laboring women can usually tolerate acute blood loss of up to 1000 mL without significant hemodynamic problems , it should be kept in mind that physiological compensatory mechanisms begin to fail at blood losses of 1500 mL. Timely, accurate diagnosis of PPH is essential to initiate appropiate interventions and to improve outcomes. Delays in PPH diagnosis and treatment may result from a lack of a consensus definition, underestimation of blood-loss volume at delivery, failure to adequately manage the condition, poor communication and deficiencies in organization . To date, interest has focused on care processes, as they are potentially amenable to change . The management of PPH is multidisciplinary and requires care by several teams within the hospital, such as obstetricians, midwives, nurses, anesthesiologists, blood-bank personnel and interventional radiologists. Three studies reported succesful interventions to implement changes in the management of women with postpartal bleeding [25–27].
Since 2008, our department has used a guideline for the early management of PPH. This protocol for stepwise diagnosis and treatment of peripartum bleeding was formulated by an interdisciplinary expert committee with members from Germany, Austria and Switzerland . Several other international PPH-related clinical guidelines have been developed. A recent comparison of four national (United States, Canada, Great Britain, Australia/New Zealand) guidelines revealed substantial variations in the definition of PPH and in recommendations for active management of the third stage of labor . However, none of these guidelines contain a clear statement that promotes the use of a blood-collection drape to quantify blood lost during peripartal bleeding.
Strength and limitations
The strengths of our research were the large number of cases, with more than 1000 participants, and the uniform study methodology that was implemented at a single referral university center. To our knowledge, this is the first investigation to measure blood loss after vaginal delivery and to correlate these measurements with decreases in maternal hemoglobin levels postpartum. Our study also encompassed a standardized PPH management protocol for this large number of cases.
Our study has some limitations. We excluded 20% of the initial enrolled women due to cesarean section in labor, and in 70 patients, the postpartal blood sample was not available. Possible explanations for the loss to follow-up are early discharge after delivery and declined or failed maternal blood sampling. Direct measurement of blood loss is widely accepted to be the most accurate methode for determining blood loss. However, values could be falsely higher if other types of fluid, such as amniotic fluid or urine, are also collected in the pouch. Vice versa, systematically lower values may occur in this study population because weighing of used swabs was not taken into account in the total calculation of bleeding. Further, primary PPH is defined as blood loss ≥500 mL in the first 24 h after birth. In our setting, all blood lost during the third stage of labor and up to 2 h after delivery was collected. We may have missed peripartal bleeding that started after the women left the delivery suite.
Underbuttocks drapes with a graduated collection pouch are a simple, objective and rapid tool for diagnosing PPH in the delivery suite. Recognizing that a mother has bled or is bleeding significantly after childbirth warrants timely intervention. As stated in the guidelines for Germany, Austria and Switzerland, birth attendents should adhere to their protocol for the systematic quantification of blood loss if PPH is suspected.
Further work is needed to establish consensus across national guidelines, including a standard definition of PPH. This consensus should reflect evidence-based medicine strategies for the management of peripartal bleeding, and the implementation of these protocols in daily clinical practice.
None of the authors have a conflict of interest. The author’s laboratory and study group received grants from CSL Behring.
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The authors stated that there are no conflicts of interest regarding the publication of this article.
About the article
Published Online: 2015-09-03
Published in Print: 2016-05-01