1. POSTPARTUM BLOOD LOSS 1
Labor & Delivery Nurses Perceptions of Postpartum Blood Loss
Barbara DeVito, Matthew Medina, and Jennifer Orlando
Endicott College
3. POSTPARTUM BLOOD LOSS 3
Abstract
Globally, maternal mortality rates continue to be a concern. Postpartum
hemorrhage (PPH) has been identified as a key-contributing factor to maternal morbidity.
Most often this is a preventable occurrence. Research has determined that when
estimating blood loss (EBL) there is a tendency to underestimate blood loss by
approximately 30%, thereby causing delays in treatment. Precise measurement of blood
loss is an important ability necessary to prevent maternal mortality associated with
obstetric hemorrhage. Labor and delivery nurses are positioned to play a central role in
the initial recognition of a PPH. The accurate interpretation of blood loss and the
identification of PPH will translate into a more rapid team response to patient care,
improving maternal outcomes.
This study seeks to consider nurses perceptions of the application of evidence
based practice as recommended by the Association of Women’s Health, Obstetric and
Neonatal Nurses (AWHONN) regarding the use of quantified measurement of blood loss
(QBL) as the standard of care when measuring postpartum blood loss; as opposed to
estimated blood loss (EBL) after birth. QBL involves the weighing of all chucks, pads,
and under buttocks drapes to determine an accurate measurement of blood loss.
Currently, this surveyed group’s practice has been the estimation of blood loss,
determined by visualizing and estimating blood loss.
Methods
A mixed method approach was utilized in surveying 30 labor and delivery nurses
from a small community hospital north of a large metropolitan city. Participants were
4. POSTPARTUM BLOOD LOSS 4
invited to complete an anonymous survey via an Internet survey tool. A short clip
describing AWHONN’s standard of care of QBL was described to participants. The
survey consisted of ten closed-ended questions and three open-ended questions. IRB
approval was obtained from both the educational institution and the participating medical
facility. Participant’s privacy was protected through anonymous survey. Results were
shared with all participating parties. The survey tool “Survey Monkey” was utilized as
both questionnaire and data collector. Quantitative data was analyzed via the survey tool.
This study was enriched by the qualitative component. Data was obtained thru the open-
ended questions; which the researchers examined. Recurring themes were identified and
recognized.
Results
A 90% participation rate was achieved (n=27). All participants were female.
Ninety-six percent of participants acknowledge that their current practice for measuring
postpartum blood loss is EBL. Prior to the AWHONN informational clip, 51% of
participants were not aware of the practice of QBL. After seeing the informational clip,
95% of participants felt that QBL provided a more accurate measurement of blood loss
than EBL.
Emerging themes revealed participants believed that the practice of QBL
produced a more accurate measurement of postpartum blood loss, improved maternal
outcomes, and provided faster response to postpartum hemorrhage. Participants perceived
barriers to implementing the practice of QBL to be lack of education, inadequate staffing,
lack of appropriate equipment and insufficient time to complete the task of measuring
blood loss. When asked what suggestions could be made for removing these barriers
5. POSTPARTUM BLOOD LOSS 5
respondents replied: increased education, increased staffing, policy/practice change, and
the limitation of visitors.
Conclusions
The group surveyed recognizes the practice of quantified measurement of blood
loss (QBL) as being the optimal practice in promptly recognizing postpartum
hemorrhage. Barriers were identified that currently prohibit this practice from being
initiated in this facility at this time.
Keywords: Postpartum hemorrhage, estimated blood loss, quantified measurement
of blood loss
6. POSTPARTUM BLOOD LOSS 6
Chapter 1: Introduction
Globally, maternal mortality rates are concerning. Statistics vary, however, more
than 500,000 women die annually worldwide from causes that are related to pregnancy
and/or childbirth. Inarguably, that staggering statistic merits review and a plan of action
to address the needs of pregnant and laboring women worldwide. The World Health
Organization (WHO) includes improving maternal health as one of several Millennium
Development Goals (MDG’s) with highlighted foci of reducing the global maternal
mortality rate by 75 percent in addition to universal reproductive healthcare access by
2015. As highlighted by Callister and Edwards (2010), causes of maternal mortality may
include hypertensive disorders of pregnancy, pulmonary thromboembolism,
anaphylactoid syndrome of pregnancy, cardiac disease, and/or obstetric hemorrhage.
Obstetric hemorrhage is generalized to include blood loss of greater than 500 mL
in a vaginal delivery and/or 1000ml (1L) in a Cesarean delivery (Oyelese & Ananth,
2010). Obstetric hemorrhage occurs as a result of one or more of several factors. These
factors may include uterine atony, genital tract trauma such as laceration or from an
episiotomy at delivery, retained placenta and/or chorion/amnion membranes, abnormal
placentation sites, or underlying coagulopathies. Since “postpartum hemorrhage (PPH) is
considered the leading cause of pregnancy-related deaths worldwide” (p. 147), reduction
and early recognition of complications should result in improvements in maternal
mortality. Gabel and Weeber (2012) posit, “nurses are positioned to improve the accuracy
of quantifying blood loss, improve communication, initiate early diagnosis of obstetric
hemorrhage, and mobilize a team response” (p.557). To meet the global needs of
maternal mortality rate improvements, nursing staff should advocate for childbearing
7. POSTPARTUM BLOOD LOSS 7
women by implementing methods to address obstetric hemorrhage. Accurate
measurements of estimated blood loss, team emergency scenario drills, and access to
appropriate emergency care are the best methods to address obstetric hemorrhage leading
to progress toward the Millennium Development Goal. In addition, advancing
interdisciplinary research such as pharmaceutical interventions should be further
explored.
ResearchQuestion
For this study, there were two research questions. First, can the method nurses
currently utilize to measure postpartum blood loss affect the accuracy of the
measurement? Second, is the method currently used by nurses optimal for promptly
recognizing postpartum hemorrhage?
Hypothesis
Our hypothesis was that obstetrical nurses would acknowledge the need for
evidence-based practice change for blood loss management, which leads to safer
postpartum care and optimize patient outcomes.
Problem Statement
The problem researched was the lack of standardized measurements for
postpartum blood loss, possibly leading to inaccurate estimation of blood loss in patients.
8. POSTPARTUM BLOOD LOSS 8
Chapter 2: Literature Review
In Ambardekar, Shochet, Bracken, Coyaji, and Winikoff (2014), a randomized
control trial in Pune, India found that measurement of blood loss by weighing was more
precise than by calibrated measurement alone. This study looked at 900 women who
delivered a newborn vaginally. 450 had postpartum blood loss measured through use of
calibrated drapes, referred to as direct measurement and the other 450 participants were
measured by gravimetric method with a digital scale, referred to as indirect measurement.
Bateman, Berman, Riley, and Leffert (2010) looked retrospectively at postpartum
hemorrhage data from 1995-2004. The purpose of their study was to “assess trends in the
incidence of PPH in the US and to ascertain the incidence, risk factors, and sequela of
PPH in a contemporary sample of obstetric admissions (p. 1368). Their research found
that of roughly 875,000 hospital admissions for delivery, 25,654, or 2.93 per 100
deliveries were diagnosed as postpartum hemorrhage of which 79% were attributable to
uterine atony. This study demonstrates that there is an increasing incidence of PPH with
causality though secondary to an increase in rates of uterine atony.
Bingham (2012a) published an editorial in JOGNN: (the) Journal of Obstetric,
Gynecologic & Neonatal Nursing outlining the need to eliminate preventable maternal
morbidity and mortality. As the Vice President of Research, Education, and Publications
for AWHONN, she is one of the most appropriate clinicians to discuss quality
improvement in maternal mortality and morbidity initiatives. In her editorial she points
out that the major factor in maternal death is in fact clinician error. She further identifies
that:
9. POSTPARTUM BLOOD LOSS 9
The first step toward eliminating preventable maternal mortality and morbidity is
to realize that improvements are needed and are possible. Complacency or the
willingness to continue to do things the way we always have done things must be
overcome. Unless changes are made we will continue to get the same results. The
next steps are to decide to take action, learn what others have done that was
successful, thoroughly assess the situation using data from multiple sources
including mortality reviews, make a plan, try out the plan, adjust the plan as
needed, track progress using data, and work until all preventable deaths and
injuries are eliminated in the United States. (p. 530)
Al-Kadri, Al Anazi, and Tamim (2011), found that there was a significant
difference between the gravimetric calculated blood loss and both health-care providers'
estimation with a tendency to underestimate the loss by about 30% in their prospective
cohort study that took place in Saudi Arabia.
In a qualitative study by Gabel and Weeber (2012), the authors sought to seek out
the opinion of obstetrical nurses in California where quantified measurement of blood
loss (QBL) had become a standard of care over estimated blood loss (EBL). 39
participants responded to a ten-question electronic questionnaire. Important themes that
emerged from the data were that “visual estimation led to gross underestimation of the
amount of blood loss and to delays in treatment” (p.553) and that “nurses believe that
quantifying blood loss led to earlier intervention and improved patient outcomes”
(p.553). Furthermore, the authors believe firmly that nurses have the ability to improve
the quantification of blood loss and to initiate early diagnosis mobilizing a team response.
10. POSTPARTUM BLOOD LOSS 10
Another study by a team including two authors above, Al-Kadri et al., (2014)
utilized a non –randomized observational study to educate 123 health care providers on
postpartum blood loss estimation. Similar to results in other studies, providers were found
to underestimate between 30 and 50 percent of actual blood loss. In this study,
participants progressed through 30 different simulated blood loss stations. Educational
sessions were planned and provided to ensure consistent training. The results of the study
confirmed that providers were underestimating blood loss. After education, estimations
improved with training and thus it is the suggestion of this study that a practical
education program with clinical vignette be implemented to enhance accuracy of
measuring blood loss after postpartum hemorrhage.
In Bingham (2012b), the author examines the use of an established research-based
framework, the generic error modeling system (GEMS) theoretical model and applying it
to obstetric hemorrhage quality improvement. The GEMS model identifies three types of
errors, each with two subsets of active and latent. The three types of errors are those
which are skill-based, rule-based, and knowledge-based. Bingham identifies that “active
errors are made by the clinician at the time of the obstetric emergency” while “latent
errors occur within the system where the clinician performs his/her work” (p. 541). Skill-
based errors in obstetric hemmorhages occur when a clinician fails to recognize, and
therefore fails to act, that a woman is hemmorhaging. Bingham notes that when a
clinician fails to recognize the seriousness of a hemorrhage and underestimates blood
loss, “the repsonse is too little, too late” (p.542). Rule based errors in obstetric
hemmorhage occur when a plan is executed. Methods of avoiding or eliminating these
errors are by implementing drills. Drills allow the entire team to assess, make
11. POSTPARTUM BLOOD LOSS 11
adjustmetnts, and practice the organizational policies and procedures that will be utilized
during a true obstetric emergency. Knowledge-based errors are those based on the
knowledge of the individual(s) involved as opposed to pre-estabished routines.
Debriefings are an excellent tool that allow a team to reflect in a group setting on what
went well and what needed improvement. Utilizing debriefings will help to improve the
response in future emergencies.
Davis, Baddock, Pairman, Hunter, Benn, Anderson, Dixon, & Herbison (2012)
looked retrospectively at births in New Zealand that were complicated by postpartum
hemmorhage. The purpose of their study was to look at both the effect of the place of
birth (i.e. hospital, home, etc.,) on the risk of postpartum hemmorhage as well as the
mode of managing third stage labor on the severity of postpartum hemmorhage. The
study looked at the low-risk births in New Zealand from 2006-2007 with a sample size of
16,210 women. The results revealed that place of birth did not contribute to a risk of
blood loss greater than 1000 mL as only 1.32 percent of the cohort experienced blood
loss greater than the 1000 mL benchmark. However, when the mode of third-stage labor
management was reviewed, active management as opposed to physiologic management
doubled the risk of postpartum hemmorhage. Active management of third-stage labor
includes a uterotonic drug administered as soon after birth as possible, umbilical cord
cutting and clamping as soon after birth as possible, and birth of the placenta by maternal
pushing efforts or controlled cord traction, or both. Physiologic management of third-
stage labor includes no routine utertonic administration, no cord traction, delayed cord
clamping, maintaining warmth of mother, encouraging breastfeeding, and finally, with
signs of placental seperation, mother is to be encouraged to change position (squat) and
12. POSTPARTUM BLOOD LOSS 12
push to birth the placenta. The study concludes appropriately that “interventions are
driven by clincal need, used judiciously, and demonstrate benefit to the mother and/or her
baby” (p. 104).
Bingham and Jones (2012) looked critically at retrospective national maternal
mortality data. The stated purpose of their article was twofold. First, prevalence, etiology,
and prevention data of obstetric hemorrhage is described and discussed. Second, the
article addressed and discussed the growing need for “enhanced data collection, case
review, and data reporting methods to better support nurses’ ability to scrutinize the
effect their practices have on the women under their care and to guide quality
improvement initiatives” (p. 531). As described in the abstract, the data gap between data
collection and publication is three to seven years. Closing that gap will allow for swifter
initiation of quality improvement efforts and in turn, a decrease in maternal mortality
rates in our country.
Chichester, Hall, Wyatt, & Pomilla (2014) illustrated that participation in
simulation training is noted to allow clinicians to practice and polish skills for the
provision of quality care in which no one can be harmed. Furthermore, “the Joint
Commission recommends that perinatal departments conduct team training, clinical
drills, and debriefings as a maternal and neonatal death prevention strategy” (p. 502).
Given that emergency situations in reality are addressed and managed by an
interdisciplinary team of nurses, physicians, anesthesiologists, respiratory therapists, and
pharmacists, simulation as such will improve competency. The authors describe a
simulation drill that was similar to a “mega-code”. The simulation started as a shoulder
dystocia resulting in a neonatal code and progressed to an obstetric hemorrhage.
13. POSTPARTUM BLOOD LOSS 13
Participants in their simulation noted high levels of satisfaction and 100 percent of staff
reported feeling confident in their practice as a result of the simulation. Implementing
simulation training for all facilities that provide specialty obstetric care will improve staff
competency and confidence. Team members who are experienced will be able to
implement appropriate interventions immediately upon recognition of a concern.
In Callister & Edwards (2010), the authors highlight various examples of
improvements and inequities in global maternal health, mortality, and morbidity. They
identify that maternal mortality prevention should be managed on three levels. Primary
prevention could include family planning and preconception health care. Secondary
prevention includes the prevention of pregnancy and childbirth complications such as
obstetric hemorrhage. Finally, tertiary prevention includes preventing maternal mortality
when faced with obstetric complication(s).
15. POSTPARTUM BLOOD LOSS 15
Population, Sample, & Setting
Approximately 30 labor and delivery nurses consisting of all women, working at a
small community hospital north of a large metropolitan city have been chosen as the
population to be studied for this research. This hospital is centered in a minority
community with a high acuity population. The labor and delivery unit services this
community and has approximately 1,600 births per year. This purposive sample is most
appropriate since labor and delivery nurses have experience with postpartum blood loss.
Two of the student researchers are labor and delivery nurses on the unit, which allows the
sample to be highly accessible. They work alternating shifts and days, allowing the
collection of data to be more feasible over a relatively short period of time.
All labor and delivery nurses are eligible to participate with the exclusion of
nurses who work in a management role, as they do not routinely participate in bedside
care. All participants will partake in both components of the study demonstrating an
identical relationship. Due to the small sample size, 90 percent participatory rate is
desired.
Data Analysis Techniques
The surveys were analyzed both quantitatively and qualitatively. The analysis of
quantitative data will be measured using descriptive statistics such as means, medians,
and modes. Qualitative data will be analyzed to extrapolate themes related to the barriers
reported by the sample population.
16. POSTPARTUM BLOOD LOSS 16
Assumptions, Limitations, and Delimitations
A major limitation of this study was time. The limited amount of time led to the
small purposive sample of labor and delivery nurses working from a small community
hospital. Therefore, the findings of this study cannot be generalized to all labor and
delivery nurses. The logistics and structure of the unit may differ from other hospital
organizations, which could result in different qualitative results. The results may differ
depending on education nurses have received and how care is delivered among different
units. The purposive sample suggests that labor and delivery room nurses have
experience with postpartum blood loss, which limits the possibility of postpartum nurses
experience with postpartum blood loss.
The purpose of the study was to identify nurses’ knowledge and current practices
regarding measuring postpartum blood loss. Limiting the scope of the research was
essential for time constraints and to determine the basis for identifying the need for
practice change.
With anonymity of the survey, it was assumed that nurses would answer the
survey truthfully. However, since nurses within the unit knew two of the researchers this
may have created results influenced by Hawthorne effect. Nurses may have answered the
survey with answers they thought were correct rather than answers they believed to be
true.
17. POSTPARTUM BLOOD LOSS 17
Chapter 4: Results, Data Analysis, & Discussion
Data Analysis
The survey was completed by 27 labor and delivery nurses (n=27), the total years
of nursing experience is as follows: Of the 27 nurses, 7.41% had less than 5 years
experience (n=2), 7.41% had 6-10 years experience (n=2), 14.81% had 11-15 years
experience (n=4), 33.33% had 16-20 years experience (n=9), 37.04% had 21 or more
years of experience (n=10). See figure 1.
The percentage of these nurses in labor and delivery/postpartum experience is
14.81%, (n=4) had less than 5 years experience, 11.11%, (n=3), had 6-10 years
experience, 22.22%, (n=6), had 11-15 years experience, 29.63, (n=8), had 16-20 years
experience, and 22.22, (n=6), had greater than 21 years experience. See figure 2. All of
the nurses surveyed 100%, (n=27), were female gender.
The following questions involved professional membership involvement and
certification of participants. Of the 27 nurses 48.15% were members of the Association of
Women’s Health, Obstetrical, and Neonatal Nurses (AWHONN), (n=13), 51.85%, of
nurses were not members of AWHONN, (n=14). Of the 27 nurses 66.67%, did not earn
any specific specialty certifications. Of these nurses, 14.81% reported inpatient obstetric
certification (RNC-OB) (n=4), 22.22% had electronic fetal monitoring certification (C-
EFM) (n=6). See figure 3.
The following questions involved nurse’s clinical judgment regarding postpartum
blood loss, current practice of measurement, knowledge of recommended standards for
measurement, and their perceptions of accuracy of measurement. When answering the
18. POSTPARTUM BLOOD LOSS 18
clinical judgment question regarding what they considered as excessive blood loss after a
vaginal delivery, 3.7%, reported 250ml (n=1), 3.7% reported 400ml (n=1), 59.26%,
reported 500ml (n=16), and 33.33%, reported 800ml (n=9). See figure 4. When
answering the clinical judgment question regarding what they considered excessive blood
loss after cesarean delivery, 7.41% reported 500ml (n=2), 11.11% reported 750ml (n=3),
48.15% reported 1000ml (n=13), and 33.33% reported 1250ml (n=9) as excessive. When
reporting current practice of assessment of blood loss measurement, 96.3% reported
visual estimation (n=26), 3.7%, reported QBL, (n=1). See figure 5.
The following questions regarded the participants awareness of the AWHONN
standards surrounding the quantification of postpartum blood loss, 48.15% report they are
aware of AWHONN standards, (n=13), 51.85% report they are not aware of current
AWHONN standards of postpartum blood loss measurement (n=14). After considering
AWHONN standards of care for postpartum blood loss measurement, 95.65% report they
agree QBL is more accurate (n=22), 4.35% report they do not agree QBL is more
accurate (n=1).
As an enhancement to the quantitative data collected above, the addition of
qualitative data was included. Of the 27 respondents 85% of the nurses responded to the
qualitative questions (n=23). Three qualitative questions were added to gain further incite
as to the potential advantages of implementing this standard of care, of recognizing
barriers that may prohibit the implementation of new practice and the suggestions for
alleviating the barriers. Emerging themes were revealed with the question regarding
nurses’ perceived advantages of implementing the AWHONN standard on their unit.
Improved accuracy was perceived to be an advantage by 43% of the respondents (n=10).
19. POSTPARTUM BLOOD LOSS 19
Improved care was perceived to be an advantage by 26% of the respondents (n=6). Faster
intervention was perceived to be an advantage by 34% of the respondents (n=8).
Standardization was perceived to be an advantage by 8% of the respondents (n=2).
The second qualitative question revealed themes regarding the nurses’ perceived
barriers prohibiting the implementation of the AWHONN standard, with some
respondents offering more than one barrier as a potential problem. Workflow was
perceived as a barrier by 39% of respondents (n=9). Staffing was perceived as a barrier
by 34% of respondents (n=8). Time was perceived as a barrier by 30% of respondents
(n=7). Equipment was perceived as a barrier by 30% of respondents (n=7). Education
was perceived as a barrier by 26% of respondents (n=6).
The third qualitative question presented a chance for respondents to offer
suggestions for removing the perceived barriers that limited the practice of this standard
of care. Improved staffing was suggested by 39% of respondents (n=9). Education was
suggested by 30% of respondents (n=7). Practice/policy change was suggested by 17% of
respondents (n=4). Limiting visitors was suggested by 13% of the respondents.
20. POSTPARTUM BLOOD LOSS 20
Figure 1. Years of Nursing Experience
< 5 years
6-10 years
11-15 years
16-20 years
21 years or more
Figure 2. Years of L&D and/or PP Nursing
Experience
< 5 years
6-10 years
11-15 years
16-20 years
21 years or more
21. POSTPARTUM BLOOD LOSS 21
Figure 3. Nursing Certification
RNC-OB
C-EFM
Other
Not currently certified
Figure 4. Clinical Judgement: Blood loss
after vaginal delivery
250 mL
400 mL
500 mL
750 mL
22. POSTPARTUM BLOOD LOSS 22
Limitations
The most significant limitation of this study was time. This study was completed
over a nine-month period. We were unable to find an applicable questionnaire regarding
knowledge and perceptions of postpartum blood loss, therefore one needed to be created.
It was recommended by the Endicott IRB that our questionnaire be piloted. Time played
a factor in the development of our questionnaire. Due to time constraints we were unable
to pilot our questionnaire. In hindsight, after reviewing the data analysis it was
recognized that piloting the questionnaire may have helped to clarify the details of some
of the questions.
Another potential limitation of this study is the possibility of the Hawthorne
Effect. The questions regarding clinical judgment of estimated blood loss may not be
accurate. It has been statistically recognized that the estimation of blood loss is repeatedly
Figure 5. Clinical Judgement: Blood loss
after Cesareandelivery
500 mL
750 mL
1000 mL
1250 mL
23. POSTPARTUM BLOOD LOSS 23
underestimated, therefore, nurses may have answered what they thought was the desired
response versus what they believed to be true according to their clinical judgment.
Conclusions
The data results of this study support the hypothesis that obstetrical nurses will
acknowledge the need for evidence-based practice change for blood loss management.
The survey revealed that 95.6% of the respondents felt that the QBL method is more
accurate.
Several emerging qualitative themes further support this hypothesis. These themes
revealed participants believed that the practice of QBL produced a more accurate
measurement of postpartum blood loss, improved maternal outcomes, and provided faster
response to postpartum hemorrhage, which all lead to safer care and optimal patient
outcomes.
The data also demonstrated a parallel between professional membership and the
awareness of the evidence-based standard for measuring postpartum blood loss. A total of
48.15% were members of AWHONN (n=13) and coincidently 48.15% of the nurses
reported their awareness of AWHONN’s evidence based standard (n=13).
This data also demonstrated the need for practice change. Since 96.3% of
participants identified their current assessment of blood loss measurement to be visual
estimation (n=26), this supports the need for evidence based practice change. This
coincides with the findings by Gabel and Weeber (2012) discussed in the review of
literature “visual estimation led to gross underestimation of the amount of blood loss and
to gross underestimation of the amount of blood loss and to delays in treatment” (p. 553).
24. POSTPARTUM BLOOD LOSS 24
This study also provides information regarding the nurse’s current knowledge
base regarding measurement of postpartum blood loss awareness. Statistically this was
supported by only 33.33% of the nurses answering the clinical judgment questions
regarding excessive blood loss correctly (n=9). Identifying that the majority 66.67% was
unable to correctly identify what is considered excessive (n=18). These numbers support
the need for education. The need for education was a repeated theme in the qualitative
data identified by 30% of the nurses (n=9).
The findings of this study support our hypothesis, the need for practice change,
and the need for education, which will lead to safer care and optimal patient outcomes.
This is consistent with the finding in the review of literature.
Recommendations for Future Research
This study further enhances previous research findings that support the need for
quantitative blood loss measurement during the postpartum period. Once practice change
is implemented, future research concentrating on postpartum hemorrhage outcomes
would be interesting. Research containing a larger sample may identify more emerging
themes, which may in turn be more generalizable in its use. On the smaller scale this
study lays the groundwork for practice change to be established within a particular unit,
which may in turn strengthen further the application of this standard of care at more
facilities.
25. POSTPARTUM BLOOD LOSS 25
References
Al-Kadri, H. M., Dahlawi, H., Airan, M. A., Elsherif, E., Tawfeeq, N., Mokhele, Y.,
Brown, D., & Tamim, H. M. (2014). Effect of education and clinical assessment
on the accuracy of postpartum blood loss estimation. BMC Pregnancy &
Childbirth, 14(1), 1-16. doi:10.1186/1471-2393-14-110
Al Kadri, H., Al Anazi, B., & Tamim, H. (2011). Visual estimation versus gravimetric
measurement of postpartum blood loss: a prospective cohort study. Archives Of
Gynecology & Obstetrics, 283(6), 1207-1213. doi:10.1007/s00404-010-1522-1
Ambardekar, S., Shochet, T., Bracken, H., Coyaji, K., & Winikoff, B. (2014). Calibrated
delivery drape versus indirect gravimetric technique for the measurement of blood
loss after delivery: a randomized trial. BMC Pregnancy & Childbirth, 14(1), 276.
doi:10.1186/1471-2393-14-276
Bateman, B., Berman, M., Riley, L., & Leffert, L. (2010). The Epidemiology of
Postpartum Hemorrhage in a Large, Nationwide Sample of Deliveries. Anesthesia
& Analgesia, 110 (5), 1368-1373.
Bingham, D. (2012a). Eliminating Preventable, Hemorrhage-Related Maternal Mortality
and Morbidity. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing,
41(4), 529-530. doi:10.1111/j.1552-6909.2012.01371.x
Bingham, D. (2012b). Applying the generic errors modeling system to obstetric
hemorrhage quality improvement efforts. Journal Of Obstetric, Gynecologic, And
26. POSTPARTUM BLOOD LOSS 26
Neonatal Nursing: JOGNN / NAACOG, 41(4), 540-548. doi:10.1111/j.1552-
6909.2012.01373.x
Bingham, D., & Jones, R. (2012). Maternal Death from Obstetric Hemorrhage.
JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 41(4),
531-539. doi:10.1111/j.1552-6909.2012.01372.x
Callister, L., & Edwards, J. (2010). Achieving Millennium Development Goal 5, the
improvement of maternal health. JOGNN: Journal of Obstetric, Gynecologic &
Neonatal Nursing, 39(5), 590-599. doi:10.1111/j.1552-6909.2010.01161.x
Chichester, M., Hall, N. J., Wyatt, T. L., & Pomilla, R. (2014). A cost-effective approach
to simulation-based team training in obstetrics. Nursing For Women's Health,
18(6), 500-507. doi:10.1111/1751-486X.12162
Davis, D., Baddock, S., Pairman, S., Hunter, M., Benn, C., Anderson, J., & ... Herbison,
P. (2012). Risk of Severe Postpartum Hemorrhage in Low-Risk Childbearing
Women in New Zealand: Exploring the Effect of Place of Birth and Comparing
Third Stage Management of Labor. Birth: Issues In Perinatal Care, 39(2), 98-105
8p. doi:10.1111/j.1523-536X.2012.00531.x
Gabel, K. T., & Weeber, T. A. (2012). Measuring and Communicating Blood Loss
During Obstetric Hemorrhage. JOGNN: Journal of Obstetric, Gynecologic &
Neonatal Nursing, 41(4), 551-558. doi:10.1111/j.1552-6909.2012.01375.x
27. POSTPARTUM BLOOD LOSS 27
Oyelese, Y., & Ananth, C. V. (2010). Postpartum hemorrhage: epidemiology, risk
factors, and causes. Clinical Obstetrics and Gynecology, 53(1), 147-156.
doi:10.1097/GRF.0b013e3181cc406d
Appendix I- Informed Consent
29. POSTPARTUM BLOOD LOSS 29
Labor & Delivery Nurse’s Perceptions of Postpartum Blood Loss
Please read the questions below and answer by either filling in the blank or circling the
appropriate response.
1) How many years have you been licensed as a nurse?
2) How many years have you worked as a nurse in Labor & Delivery and/or Postpartum?
3) Have you earned specialty certification in this specialty? Select all that apply
a) Inpatient Obstetrics (RNC-OB) b) Maternal Newborn Nursing (RNC-MNN
c) High Risk Obstetrics (RNC-HRO) d) EFM (C-EFM)
e) Women’s Health NP (WHNP) f) Nurse Midwife (CNM)
g) Other h) Not currently certified
4) Are you a member of the Association of Women’s Health, Obstetrical, and Neonatal
Nurses (AWHONN), our professional nursing organization? (Yes / No)
5) Gender
6) Utilizing your clinical judgment, what do you consider to be excessive blood loss after
a vaginal delivery?
a) 250 mL b) 400 mL c) 500 mL d) 800 mL
30. POSTPARTUM BLOOD LOSS 30
7) Utilizing your clinical judgment, what do you consider to be excessive blood loss after
a cesarean delivery?
a) 500 mL b) 750 mL c) 1000 mL d) 1250 mL
8) What is your current practice in assessment of blood loss measurement?
a) Measured by weight (QBL) b) Visual Estimation (EBL)
9) Are you aware of AWHONN’s standards of care surrounding the quantification of
postpartum blood loss? (Yes / No)
The AWHONN standard of care in regards to postpartum blood loss states that
cumulative blood loss should be formally measured or quantified (one gram per mL of
blood) after every birth. Citing evidence based studies, AWHONN identifies that
quantifying blood loss reduces the likelihood that clinicians will underestimate the
volume of blood lost and delay early recognition and treatment (AWHONN, 2014). The
AWHONN Practice Brief can be accessed by clicking the link to the right: AWHONN
Practice Brief: Quantification of Blood Loss
31. POSTPARTUM BLOOD LOSS 31
10) Considering the AWHONN standards of care listed above for the measurement of
postpartum blood loss, do you feel this method is more accurate? (Yes / No)
11) What are the perceived advantages to implementing these AWHONN standards of
care on your unit?
12) What do you perceive as being barriers to implementing these AWHONN standards
of care on your unit?
13) What are your suggestions for removing these barriers?
