- Email: [email protected]
Visual estimation of postpartum blood loss during a simulation training: A prospective study
Journal Pre-proof Visual estimation of postpartum blood loss during a simulation training: a prospective study ´ Aurelien ´ ´ Juliette Lemee, Scalabre, Celine Chauleur, Tiphaine Raia-Barjat
PII:
S2468-7847(19)30706-8
DOI:
https://doi.org/10.1016/j.jogoh.2019.101673
Reference:
JOGOH 101673
To appear in:
Journal of Gynecology Obstetrics and Human Reproduction
Received Date:
8 September 2019
Revised Date:
26 November 2019
Accepted Date:
29 November 2019
´ J, Scalabre A, Chauleur C, Raia-Barjat T, Visual estimation Please cite this article as: Lemee of postpartum blood loss during a simulation training: a prospective study, Journal of Gynecology Obstetrics and Human Reproduction (2019), doi: https://doi.org/10.1016/j.jogoh.2019.101673
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Visual estimation of postpartum blood loss during a simulation training: a prospective study.
Juliette Lemée MD1, Aurélien Scalabre2, Céline Chauleur MD, PhD1,2, Tiphaine Raia-Barjat MD, PhD1,2.
Department of Gynaecology and Obstetrics, University Hospital, Saint Etienne, France
2
Department of pediatric surgery - University Hospital – Saint-Etienne – France
3
INSERM UMR1059, University Jean Monnet, F 42023 Saint Etienne France.
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1
Corresponding author :
Tiphaine RAIA-BARJAT
-p
Department of Gynaecology and Obstetrics
Hôpital Nord, University Hospital,
re
Avenue Albert Raimond
France Phone: +33 - 4 - 77 82 86 09
na
Fax: +33 - 4 – 77 82 89 54
lP
42270 Saint Priest en Jarez
Email: [email protected]
ur
INTRODUCTION
Postpartum haemorrhage (PPH) is one of the leading causes of maternal death in the world,
Jo
before high blood pressure and sepsis according to WHO (1). In France, obstetric haemorrhages account for 24% of all direct obstetric deaths (29 deaths between 2010 and 2012)(2).
PPH is defined as blood loss greater than 500mL, whether externalized or not, within 24 hours of delivery, regardless of the mode of delivery. It is qualified as severe when the losses exceed 1000mL(3). The main causes of PPH are uterine atony (41%), uterine rupture (21%) and per caesarean wounds (21%)(2).
The diagnosis must be made quickly, it relies in practice on the visual evaluation of the losses. This method turns out to be imprecise and underestimates the losses by 30 to 50%(4,5). As a result, the incidence of PPHs increases from 5% to 10% when an accurate estimation is made (6). Other diagnostic criteria were put in place and then abandoned, such as the haematocrit and haemoglobin levels, which are not adapted to the emergency (7). Recommendations, whether national or international, advise the inclusion of clinical signs and symptoms of hypovolemia in the evaluation of PPH. (3,8). PPH requires rapid management to reduce maternal morbidity, direct consequences of hypovolemia (shock, anoxia, metabolic acidosis, coagulopathy, hypothermia)(9) and obstetric
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outcomes of the patient (uterine synechiae after selective embolization of the uterine arteries, ovarian insufficiency after ligation of the lumbar-ovarian pedicles, uterine infections after uterine padding(10), fertility consequences and complications during subsequent pregnancies after surgical management of PPH(11). An underestimation of the losses results in a delay in
-p
the care and therefore exposes to more complications.
The quickest way to quantify losses is the use of a collector bag. It allows a non-suggestive
re
quantitative visual estimation of postpartum losses. (12). Despite this, in the recommendations of the CNGOF (French National College of Gynaecologists and Obstetricians) in 2014, the
lP
systematic use of a collector bag is left to the teams' choice except in case of proven PPH (3). Other methods have been tried such as collecting sheets (with evaluation by photospectrometry)(13), they are certainly more precise in the estimation but more expensive and
na
less easy to use. Another way used in practice is the weighing of the absorbent pads (14). Simulation training can improve practices by identifying gaps in the management of PPH (15) and improving visual estimations (16).The aim of this study was to compare the visual
ur
estimation of losses (with collector bags and with absorbent pads) in postpartum with the real volume. The secondary aims were to compare the estimation between large and small
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volumes with collector bags and absorbent pads, and for the same volumes collector bags against absorbent pads. The goal of this study is to allow each professional to have a better estimate of losses in clinical practice and earlier diagnosis of PPH thanks to simulation.
METHODS This prospective study was conducted from May 23 to December 22, 2017 during 14 training sessions on the theme of postpartum haemorrhage provided by the Elena perinatal network. These days were held at the Faculty of Medicine of Saint-Etienne. Six institutions participated: university hospital of Saint Etienne, hospital of Roanne, Montbrison, Annonay, Firminy and St Chamond. The participants were midwives, paediatric auxiliaries, obstetrics and anaesthesia interns, as well as obstetrician gynaecologists, anaesthetists and nurse anaesthetists. They were recruited
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through e-mails and posters in the birth halls of the various centres so that they can register. The scenario, which was identical each day of the training, used 5 graduated collector bags (Picture 1) and 5 absorbent pads (Picture 2) filled with known volumes of fake blood (mixture of water and gouache) and clots (gelatine, mercurochrome, soluble coffee) of appearance and colour comparable to real blood. The equipment used was the same as that in the birth room
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with collector bags > 1500mL, graduated. The bags were numbered, as were the absorbent pads. Volumes were precisely measured using a measuring jug for the bags and a balance for
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the pads. Each participant went through the 10 situations of quantification of losses and recorded their estimate in millilitres on a sheet. The volumes to be estimated were in the order
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of 900mL, 1200mL, 600mL, 1800mL and 1000mL for the collector bags and 1000mL, 200mL, 600mL, 400mL and 300mL for the absorbent pads. The professionals did not have a
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ur
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predetermined order of passage or any time limit to estimate the losses.
Picture 1: Collector bags
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Picture 2: Absorbent pads
The different analyses were carried out using the XL STAT® software. The normality of the
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distribution of all the continuous variables was subject of a statistical analysis. Comparisons of means for which the normality of variable distribution was assumed were performed using
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a Student's T-test. For the others, comparisons were made using a Mann-Whitney test. The signed Wilcoxon test was used to compare the estimated volumes with the actual value
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contained. Whatever the statistical analysis considered, the significance of the result was
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ur
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accepted only for a risk of the first species (risk α) less than 5%. 1370 data were analysed.
RESULTS
Professionnels registered to the sessions n = 143 no responses n=6 Professionnels who estimated the losses n = 137
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Obstetrics team n = 112 Obstetricia n intern n=3
Midwife n = 64
Child care assistant n = 31
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Anesthesia team n = 25 Anesthesist Anesthésia Anesthesist Obstetrician nurse intern n = 14 n=7 n = 15 n=3
One hundred and forty-three professionals participated in the training days, only 6 did not
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answer, a total of 137 participants who estimated the volumes contained in 5 collector bags
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and 5 absorbent pads for a total of 1370 responses.
The means of the estimated volumes for the different volumes were significantly different
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from the real volume for all the bags (𝜌-value < 0.0001 for all volumes studied: 600mL,
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900mL, 1000mL, 1200mL, and 1800mL) (Figure 1).
1600 1400 1200 1000 800 600 400 200 0 600mL
1000mL
900mL
Real volume
1200mL
1800mL
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Differences between estimated volumes and real volume (mL)
1800
Figure 1 Box plot. Collector bags: Differences between estimated volumes and real value (absolute value) by each real volume in the collector bag. The crosses correspond to the
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means. The central horizontal bars are the medians. The lower and upper limits of the box are the first and third quartiles, respectively. Points are minimum and maximum for each
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species.For the absorbent pads, the means estimated volumes were significantly different from the real value (𝜌 − 𝑣𝑎𝑙𝑢𝑒 = 0.001, < 0.001, 0.013, 0.007 for the volumes of 200ml, 300mL, 600mL, 1000mL, respectively). For the 400mL volume, the mean of the observed volumes
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ur
na
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was not significantly different from the real value (𝜌 − 𝑣𝑎𝑙𝑢𝑒 = 0,661) (Figure 2).
1200 1000 800 600 400 200 0
200mL
400mL
300mL
Real volume
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Differences between estimated volumes and real volume (mL)
1400
600mL
1000mL
Figure 1 Box plot. Absorbent pads: Differences between estimated volumes and actual volume
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(absolute value). The crosses correspond to the means. The central horizontal bars are the medians. The lower and upper limits of the box are the first and third quartiles, respectively.
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Points are minimum and maximum for each species.
For collector bags, the estimate for small volumes (between 500 and 1000mL) is significantly
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more accurate compared to large volumes (> 1000mL) (𝜌 = 0.0002) (table 1). Error! Reference source not found.For the absorbent pads, the estimation for small volumes
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(< 500ml) is significantly more accurate than the larger volumes (between 500 and 1000mL) (𝜌 < 0.0001 )(Table 1).
In comparison, for the same volumes between 500 and 1000mL, the collector bag is
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significantly more accurate than that absorbent pads (𝜌 < 0.0001 )(Table 1).
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Considering an accurate estimate at ± 50ml of the actual volume, for volumes between 500 and 1000mL vs. > 1000mL the percentage of correct answers is 35% (145/411) vs. 30% (82/274) (𝜌= 0.14 Chi2 test) (Figure 3). Or 33% for all volumes. 57% of estimates are underestimated with collection bags, with a mean difference of 202mL for volumes between 500 and 1000mL and 256mL for volumes over 1000mL.
100%
7%
10%
90% 80%
30%
35%
70% 60% 50% 40% 30%
63%
55%
20% 10% 0% 500-1000mL exact (AV±50mL)
underestimates
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overestimates
>1000mL
Figure 3: Collector bags: Distribution of estimations function of there accuracy for volumes
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between 500mL and 1000mL vs > 1000mL
With absorbent pads, for the volumes <500mL vs. >500mL, the percentage of correct answers
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is 28% (116/411) vs. 16% (43/274). (𝜌 = 0,0001 Chi2 test) (Figure 4). Or 22% for all volumes.
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Fifty one percent of the responses are underestimated with the absorbent pads, with a mean difference of 112mL for volumes less than 500ml and 248mL for those between 500 and
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1000mL. 100% 90%
25%
70% 60% 50%
28%
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40%
ur
80%
30% 20%
27%
16%
58%
47%
10% 0%
<500mL overestimates
500-1000 mL exact (AV±50mL)
underestimates
Figure 4 Absorbent pads: Distribution of estimates < 500ml vs 500-1000mL
DISCUSSION We pointed out that the visual estimation of losses was significantly different from the actual value and that the tendency was to underestimate losses. The number of fair estimates at ± 50ml was 33% with the bags against 22% with the absorbent pads and was more accurate for small volumes and with the use of collector bags. The visual estimation of the losses with collector bag or absorbent pads is imprecise. Other studies have published similar results (17,18). However, these are old studies, where the practices were different from the current ones.
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Regarding our secondary objectives, this study allowed to compare the visual estimation of losses for small vs. large volumes with graduated bags and with absorbent pads. With the collector bags, the visual loss estimation is better for volumes between 500 and 1000mL vs. volumes greater than one liter. With absorbent pads, volumes less than 500ml are better estimated than volumes of more than 500ml. By comparing the estimates made with collector
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bags and with absorbent pads for the same volumes (between 500 and 1000mL), the collector bags are the most accurate. These results are found in the study by Buckland et al. which
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compared, during a simulation workshop, the visual estimation of losses in containers and on sheets/linings. Among the 88 participants and on 5 different situations, the losses were better
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estimated in the collector bags and for small volumes (19).
A recent study by Brooks compares estimations of blood loss in collector bags with a baby
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weight scale vs collector bag, a baby weight scale and a visual aid. Sixty-nine professionals estimated 3 volumes in each scenario during a simulation workshop. Their study shows that the addition of a visual estimator resulted in a significatively overestimation of blood loss.
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The rates of participants’ estimations were accurate at 85.5% with the collector bag and the baby weight scale with a 20% error margin (20).
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Our results highlight the fact that more than half of the estimated volumes are below the actual value of ±50mL. This is consistent with the literature review which shows that there is a tendency to underestimate the amounts of losses from 30 to 38% according to the study by Al Kadri et al. (21), Toledo et al. (22). This underestimation increases for large volumes (23). Duthie et al. Compared the visual estimation of losses vs calculated losses on 62 natural deliveries (separating multiparous from primiparous). In the first group of primiparous, the mean of the visual estimates was 260 ± 12mL and the mean of the calculated estimates of 401 ± 29mL. In the multiparous group, the mean of the visual estimates was 220 ± 10ml vs. the
mean of the calculated estimates of 319 ± 41ml. In both groups, the visual estimate of the losses was significantly lower than the calculated losses (24). Stafford et al. showed that, out of 677 subjects, the visual estimation of losses was significantly different from the calculated estimate and that there was an increasing underestimation with the increase in the volume of losses (23). Studies have confirmed the role of simulation in improving the management practices of PPH. Maslovitz et al. has shown that simulation sessions are useful for detecting errors in management and thus contribute to improving the practices (15). Mbachu et al. compared visual estimates of losses before and after theoretical training. His study focused on 144
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participants in 8 different situations. A significant improvement was noted in 6 out of 8 situations. It has thus proven that regular training sessions by simulation increase the accuracy of the visual estimation (25).
With regard to the measures using collector bags, this is an inexpensive and practical method.
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The shape of the bags is also decisive in the accuracy of the estimation. Different shapes exist, more or less flared. Legendre et al. Showed in a study conducted at the CHU of Angers, that
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there is a significant difference in the estimates of blood loss between the bags, 3 different brands were tested. Graduations only allow a clear estimate of up to 1500mL. And depending
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on how the bag is held (left hanging, straightened or both pinched at both ends), the estimate varies. The flare shape of the bag makes it possible to read precisely the losses of low volumes but after one liter the difference between two marks decreases. A non-flared bag with
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the same distance between each graduation should be considered for better estimates(26). The margin of ± 50ml of the real volume to be estimated, chosen in our study to define the
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right estimate, is not clinically relevant. We find this margin of precision in the study by Buckland et al..(19).
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Compares to other studies, we have good effectives with a mix of professionals who are all led to monitors the patients in post-partum. In addition, we have a strict threshold for the precision of the estimates compared to other studies who’s goes up to ± 500mL. One of the main limitations of our study lies in the fact that it was not a real situation, there was not the feel of the birth room with the particular obstetric context. The "sequence effect" was limited by the random order of presentation of the bags. It should also be noted that the simulation took place before the theoretical course on PPH, the results would probably have
been better afterwards. The small number of participants is a limit of our study. It is due to the small effective at each session. In this study we did not test the accuracy of the estimates according to the experience and the specialty of the participants. As shown by Toledo et al. (22), Yoong et al. (27) and Glover et al. (4) the experience and the profession had no influence on the accuracy of the estimates. Not all professionals participated in these training days.
CONCLUSION
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The simulation puts the professionals in a real situation and allowed them to realize that there was a significant difference in the estimates of blood loss with the actual value. These results highlight the importance of weighing the protections (especially in the case of delayed bleeding after reinstallation of the patient). And the use of collection bags seems more
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accurate than the visual estimation. Bags suitable for large volumes could be useful in case of severe PPH. The goal is to diagnose early PPH to avoid a delay in the care.
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Acknowledgment to the ELENA perinatal network that allowed us to use the data they
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collected.
References Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323-333.
2.
Les morts maternelles en France : mieux comprendre pour mieux prévenir. 5e rapport de l’Enquête Nationale Confidentielle sur les Morts Maternelles (ENCMM), 2010-2012. Saint-Maurice : Santé publique France, 2017. 230 p. Disponible à partir de l’URL : www.santepubliquefrance.fr. 2017.
3.
Sentilhes L, Vayssière C, Deneux-Tharaux C, Aya AG, Bayoumeu F, Bonnet M-P, et al. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). Eur J Obstet Gynecol Reprod Biol. 2016;198:12‑ 21.
4.
Glover P. Blood loss at delivery: how accurate is your estimation? Aust J Midwifery Prof J Aust Coll Midwives Inc. 2003;16:21‑ 4.
5.
Rothermel LD, Lipman JM. Estimation of blood loss is inaccurate and unreliable. Surgery. 2016;160:946‑ 53.
6.
Deneux-Tharaux C, Bonnet M-P, Tort J. [Epidemiology of post-partum haemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2014;43:936‑ 50.
7.
Rath WH. Postpartum hemorrhage--update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand. 2011;90:421‑ 8.
8.
Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, Riris S, Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016;124:e106–e149.
9.
Aya AG, Ducloy-Bouthors A-S, Rugeri L, Gris J-C. [Anesthetic management of severe or worsening postpartum hemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2014;43:1030‑ 62.
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1.
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10. Malartic C, Cagnat J, Morel O, Ricbourg A, Gayat E, Mebazaa A, et al. [Invasive conservative care in cases of severe post-partum haemorrhage: future fertility and pregnancy outcome consequences]. Gynecol Obstet Fertil. 2012;40:582‑ 90.
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11. Blanc J, Courbiere B, Desbriere R, Bretelle F, Boubli L, d’Ercole C, et al. Is uterinesparing surgical management of persistent postpartum hemorrhage truly a fertilitysparing technique? Fertil Steril. 2011;95:2503‑ 6. 12. Tourné G, Collet F, Lasnier P, Seffert P. [Usefulness of a collecting bag for the diagnosis of post-partum hemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2004;33:229‑ 34. 13. Patel A, Goudar SS, Geller SE, Kodkany BS, Edlavitch SA, Wagh K, et al. Drape estimation vs. visual assessment for estimating postpartum hemorrhage. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2006;93:220‑ 4.
14. Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health. 2010;55:20‑ 7. 15. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109:1295‑ 300. 16. Dildy GA, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. 2004;104:601‑ 6. 17. Brant HA. Precise estimation of postpartum haemorrhage: difficulties and importance. Br Med J. 1967;1(5537):398‑ 400. 18. Pritchard JA. Changes in the blood volume during pregnancy and delivery. Anesthesiology. 1965;26:393‑ 9.
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19. Buckland SS, Homer CSE. Estimating blood loss after birth: using simulated clinical examples. Women Birth J Aust Coll Midwives. 2007;20:85‑ 8. 20. Brooks, M. et al. Use of a Visual Aid in addition to a Collector Bag to Evaluate Postpartum Blood loss: A Prospective Simulation Study. Sci. Rep. 7, 46333; doi: 10.1038/srep46333 (2017).
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21. Al Kadri HMF, Al Anazi BK, Tamim HM. Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet. 2011;283:1207‑ 13.
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22. Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA. The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg. 2007; 105:1736 ‑ 40, table of contents. 23. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol. 2008;199:519.e1-7.
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24. Duthie SJ, Ven D, Yung GL, Guang DZ, Chan SY, Ma HK. Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery. Eur J Obstet Gynecol Reprod Biol. 1991;38:119‑ 24.
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25. Mbachu II, Udigwe GO, Ezeama CO, Eleje GU, Eke AC. Effect of on-site training on the accuracy of blood loss estimation in a simulated obstetrics environment. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2017;137:345‑ 9.
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26. Elodie R, Céline G. http://dune.univangers.fr/fichiers/20092006/2015MFASMA3659/fichier/3659F.pdf. :33. 27. Yoong W, Karavolos S, Damodaram M, Madgwick K, Milestone N, Al-Habib A, et al. Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals? Arch Gynecol Obstet. 2010;281:207‑ 13.
Table 1 : Comparison of actual volumes and estimated volumes for collector bags and absorbent pads.
400 5001000m L
600 1000 600
Collectors bags
5001000m L
900 1000
>1000 mL
1200 1800
500
50
800
50
1500
150
1200
30
2000
50
1200
250
1250
100
1200
60
1500
350
2000
ur
na
EV: estimated volumes ; AV : actual volume ; SD : Standard Deviation
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𝜌 value
126,4 <0,000 1
ro of
Absorbent pads
300
20
Mean of differen ces
257,9
-p
<500m L
173,3 ± 103,9 249,5 ± 150,5 428,6 ± 224,6 549,7 ± 243,8 914,7 ± 387,7 515,3 ± 115,5 836,5 ± 193,2 888,3 ± 172,6 1102,3 ± 189,1 1588,7 ± 264,3
EV max
re
200
EV min
lP
AV
Mean EV ± SD
Mean of difference s AV-EV (Absolute values) ± SD 84,2 ± 66,1 129,0 ± 91,9 166,1 ± 153,1 208,7± 134,6 307,2 ± 250,2 107,6 ± 94,4 151,5 ± 135,2 121,9 ± 165,5 139,3 ± 160,7 245,6 ± 232,5
<0,000 1
127 0,0002
192
PII:
S2468-7847(19)30706-8
DOI:
https://doi.org/10.1016/j.jogoh.2019.101673
Reference:
JOGOH 101673
To appear in:
Journal of Gynecology Obstetrics and Human Reproduction
Received Date:
8 September 2019
Revised Date:
26 November 2019
Accepted Date:
29 November 2019
´ J, Scalabre A, Chauleur C, Raia-Barjat T, Visual estimation Please cite this article as: Lemee of postpartum blood loss during a simulation training: a prospective study, Journal of Gynecology Obstetrics and Human Reproduction (2019), doi: https://doi.org/10.1016/j.jogoh.2019.101673
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier.
Visual estimation of postpartum blood loss during a simulation training: a prospective study.
Juliette Lemée MD1, Aurélien Scalabre2, Céline Chauleur MD, PhD1,2, Tiphaine Raia-Barjat MD, PhD1,2.
Department of Gynaecology and Obstetrics, University Hospital, Saint Etienne, France
2
Department of pediatric surgery - University Hospital – Saint-Etienne – France
3
INSERM UMR1059, University Jean Monnet, F 42023 Saint Etienne France.
ro of
1
Corresponding author :
Tiphaine RAIA-BARJAT
-p
Department of Gynaecology and Obstetrics
Hôpital Nord, University Hospital,
re
Avenue Albert Raimond
France Phone: +33 - 4 - 77 82 86 09
na
Fax: +33 - 4 – 77 82 89 54
lP
42270 Saint Priest en Jarez
Email: [email protected]
ur
INTRODUCTION
Postpartum haemorrhage (PPH) is one of the leading causes of maternal death in the world,
Jo
before high blood pressure and sepsis according to WHO (1). In France, obstetric haemorrhages account for 24% of all direct obstetric deaths (29 deaths between 2010 and 2012)(2).
PPH is defined as blood loss greater than 500mL, whether externalized or not, within 24 hours of delivery, regardless of the mode of delivery. It is qualified as severe when the losses exceed 1000mL(3). The main causes of PPH are uterine atony (41%), uterine rupture (21%) and per caesarean wounds (21%)(2).
The diagnosis must be made quickly, it relies in practice on the visual evaluation of the losses. This method turns out to be imprecise and underestimates the losses by 30 to 50%(4,5). As a result, the incidence of PPHs increases from 5% to 10% when an accurate estimation is made (6). Other diagnostic criteria were put in place and then abandoned, such as the haematocrit and haemoglobin levels, which are not adapted to the emergency (7). Recommendations, whether national or international, advise the inclusion of clinical signs and symptoms of hypovolemia in the evaluation of PPH. (3,8). PPH requires rapid management to reduce maternal morbidity, direct consequences of hypovolemia (shock, anoxia, metabolic acidosis, coagulopathy, hypothermia)(9) and obstetric
ro of
outcomes of the patient (uterine synechiae after selective embolization of the uterine arteries, ovarian insufficiency after ligation of the lumbar-ovarian pedicles, uterine infections after uterine padding(10), fertility consequences and complications during subsequent pregnancies after surgical management of PPH(11). An underestimation of the losses results in a delay in
-p
the care and therefore exposes to more complications.
The quickest way to quantify losses is the use of a collector bag. It allows a non-suggestive
re
quantitative visual estimation of postpartum losses. (12). Despite this, in the recommendations of the CNGOF (French National College of Gynaecologists and Obstetricians) in 2014, the
lP
systematic use of a collector bag is left to the teams' choice except in case of proven PPH (3). Other methods have been tried such as collecting sheets (with evaluation by photospectrometry)(13), they are certainly more precise in the estimation but more expensive and
na
less easy to use. Another way used in practice is the weighing of the absorbent pads (14). Simulation training can improve practices by identifying gaps in the management of PPH (15) and improving visual estimations (16).The aim of this study was to compare the visual
ur
estimation of losses (with collector bags and with absorbent pads) in postpartum with the real volume. The secondary aims were to compare the estimation between large and small
Jo
volumes with collector bags and absorbent pads, and for the same volumes collector bags against absorbent pads. The goal of this study is to allow each professional to have a better estimate of losses in clinical practice and earlier diagnosis of PPH thanks to simulation.
METHODS This prospective study was conducted from May 23 to December 22, 2017 during 14 training sessions on the theme of postpartum haemorrhage provided by the Elena perinatal network. These days were held at the Faculty of Medicine of Saint-Etienne. Six institutions participated: university hospital of Saint Etienne, hospital of Roanne, Montbrison, Annonay, Firminy and St Chamond. The participants were midwives, paediatric auxiliaries, obstetrics and anaesthesia interns, as well as obstetrician gynaecologists, anaesthetists and nurse anaesthetists. They were recruited
ro of
through e-mails and posters in the birth halls of the various centres so that they can register. The scenario, which was identical each day of the training, used 5 graduated collector bags (Picture 1) and 5 absorbent pads (Picture 2) filled with known volumes of fake blood (mixture of water and gouache) and clots (gelatine, mercurochrome, soluble coffee) of appearance and colour comparable to real blood. The equipment used was the same as that in the birth room
-p
with collector bags > 1500mL, graduated. The bags were numbered, as were the absorbent pads. Volumes were precisely measured using a measuring jug for the bags and a balance for
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the pads. Each participant went through the 10 situations of quantification of losses and recorded their estimate in millilitres on a sheet. The volumes to be estimated were in the order
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of 900mL, 1200mL, 600mL, 1800mL and 1000mL for the collector bags and 1000mL, 200mL, 600mL, 400mL and 300mL for the absorbent pads. The professionals did not have a
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predetermined order of passage or any time limit to estimate the losses.
Picture 1: Collector bags
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Picture 2: Absorbent pads
The different analyses were carried out using the XL STAT® software. The normality of the
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distribution of all the continuous variables was subject of a statistical analysis. Comparisons of means for which the normality of variable distribution was assumed were performed using
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a Student's T-test. For the others, comparisons were made using a Mann-Whitney test. The signed Wilcoxon test was used to compare the estimated volumes with the actual value
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contained. Whatever the statistical analysis considered, the significance of the result was
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accepted only for a risk of the first species (risk α) less than 5%. 1370 data were analysed.
RESULTS
Professionnels registered to the sessions n = 143 no responses n=6 Professionnels who estimated the losses n = 137
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Obstetrics team n = 112 Obstetricia n intern n=3
Midwife n = 64
Child care assistant n = 31
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Anesthesia team n = 25 Anesthesist Anesthésia Anesthesist Obstetrician nurse intern n = 14 n=7 n = 15 n=3
One hundred and forty-three professionals participated in the training days, only 6 did not
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answer, a total of 137 participants who estimated the volumes contained in 5 collector bags
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and 5 absorbent pads for a total of 1370 responses.
The means of the estimated volumes for the different volumes were significantly different
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from the real volume for all the bags (𝜌-value < 0.0001 for all volumes studied: 600mL,
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900mL, 1000mL, 1200mL, and 1800mL) (Figure 1).
1600 1400 1200 1000 800 600 400 200 0 600mL
1000mL
900mL
Real volume
1200mL
1800mL
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Differences between estimated volumes and real volume (mL)
1800
Figure 1 Box plot. Collector bags: Differences between estimated volumes and real value (absolute value) by each real volume in the collector bag. The crosses correspond to the
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means. The central horizontal bars are the medians. The lower and upper limits of the box are the first and third quartiles, respectively. Points are minimum and maximum for each
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species.For the absorbent pads, the means estimated volumes were significantly different from the real value (𝜌 − 𝑣𝑎𝑙𝑢𝑒 = 0.001, < 0.001, 0.013, 0.007 for the volumes of 200ml, 300mL, 600mL, 1000mL, respectively). For the 400mL volume, the mean of the observed volumes
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was not significantly different from the real value (𝜌 − 𝑣𝑎𝑙𝑢𝑒 = 0,661) (Figure 2).
1200 1000 800 600 400 200 0
200mL
400mL
300mL
Real volume
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Differences between estimated volumes and real volume (mL)
1400
600mL
1000mL
Figure 1 Box plot. Absorbent pads: Differences between estimated volumes and actual volume
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(absolute value). The crosses correspond to the means. The central horizontal bars are the medians. The lower and upper limits of the box are the first and third quartiles, respectively.
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Points are minimum and maximum for each species.
For collector bags, the estimate for small volumes (between 500 and 1000mL) is significantly
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more accurate compared to large volumes (> 1000mL) (𝜌 = 0.0002) (table 1). Error! Reference source not found.For the absorbent pads, the estimation for small volumes
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(< 500ml) is significantly more accurate than the larger volumes (between 500 and 1000mL) (𝜌 < 0.0001 )(Table 1).
In comparison, for the same volumes between 500 and 1000mL, the collector bag is
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significantly more accurate than that absorbent pads (𝜌 < 0.0001 )(Table 1).
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Considering an accurate estimate at ± 50ml of the actual volume, for volumes between 500 and 1000mL vs. > 1000mL the percentage of correct answers is 35% (145/411) vs. 30% (82/274) (𝜌= 0.14 Chi2 test) (Figure 3). Or 33% for all volumes. 57% of estimates are underestimated with collection bags, with a mean difference of 202mL for volumes between 500 and 1000mL and 256mL for volumes over 1000mL.
100%
7%
10%
90% 80%
30%
35%
70% 60% 50% 40% 30%
63%
55%
20% 10% 0% 500-1000mL exact (AV±50mL)
underestimates
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overestimates
>1000mL
Figure 3: Collector bags: Distribution of estimations function of there accuracy for volumes
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between 500mL and 1000mL vs > 1000mL
With absorbent pads, for the volumes <500mL vs. >500mL, the percentage of correct answers
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is 28% (116/411) vs. 16% (43/274). (𝜌 = 0,0001 Chi2 test) (Figure 4). Or 22% for all volumes.
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Fifty one percent of the responses are underestimated with the absorbent pads, with a mean difference of 112mL for volumes less than 500ml and 248mL for those between 500 and
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1000mL. 100% 90%
25%
70% 60% 50%
28%
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40%
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80%
30% 20%
27%
16%
58%
47%
10% 0%
<500mL overestimates
500-1000 mL exact (AV±50mL)
underestimates
Figure 4 Absorbent pads: Distribution of estimates < 500ml vs 500-1000mL
DISCUSSION We pointed out that the visual estimation of losses was significantly different from the actual value and that the tendency was to underestimate losses. The number of fair estimates at ± 50ml was 33% with the bags against 22% with the absorbent pads and was more accurate for small volumes and with the use of collector bags. The visual estimation of the losses with collector bag or absorbent pads is imprecise. Other studies have published similar results (17,18). However, these are old studies, where the practices were different from the current ones.
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Regarding our secondary objectives, this study allowed to compare the visual estimation of losses for small vs. large volumes with graduated bags and with absorbent pads. With the collector bags, the visual loss estimation is better for volumes between 500 and 1000mL vs. volumes greater than one liter. With absorbent pads, volumes less than 500ml are better estimated than volumes of more than 500ml. By comparing the estimates made with collector
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bags and with absorbent pads for the same volumes (between 500 and 1000mL), the collector bags are the most accurate. These results are found in the study by Buckland et al. which
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compared, during a simulation workshop, the visual estimation of losses in containers and on sheets/linings. Among the 88 participants and on 5 different situations, the losses were better
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estimated in the collector bags and for small volumes (19).
A recent study by Brooks compares estimations of blood loss in collector bags with a baby
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weight scale vs collector bag, a baby weight scale and a visual aid. Sixty-nine professionals estimated 3 volumes in each scenario during a simulation workshop. Their study shows that the addition of a visual estimator resulted in a significatively overestimation of blood loss.
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The rates of participants’ estimations were accurate at 85.5% with the collector bag and the baby weight scale with a 20% error margin (20).
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Our results highlight the fact that more than half of the estimated volumes are below the actual value of ±50mL. This is consistent with the literature review which shows that there is a tendency to underestimate the amounts of losses from 30 to 38% according to the study by Al Kadri et al. (21), Toledo et al. (22). This underestimation increases for large volumes (23). Duthie et al. Compared the visual estimation of losses vs calculated losses on 62 natural deliveries (separating multiparous from primiparous). In the first group of primiparous, the mean of the visual estimates was 260 ± 12mL and the mean of the calculated estimates of 401 ± 29mL. In the multiparous group, the mean of the visual estimates was 220 ± 10ml vs. the
mean of the calculated estimates of 319 ± 41ml. In both groups, the visual estimate of the losses was significantly lower than the calculated losses (24). Stafford et al. showed that, out of 677 subjects, the visual estimation of losses was significantly different from the calculated estimate and that there was an increasing underestimation with the increase in the volume of losses (23). Studies have confirmed the role of simulation in improving the management practices of PPH. Maslovitz et al. has shown that simulation sessions are useful for detecting errors in management and thus contribute to improving the practices (15). Mbachu et al. compared visual estimates of losses before and after theoretical training. His study focused on 144
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participants in 8 different situations. A significant improvement was noted in 6 out of 8 situations. It has thus proven that regular training sessions by simulation increase the accuracy of the visual estimation (25).
With regard to the measures using collector bags, this is an inexpensive and practical method.
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The shape of the bags is also decisive in the accuracy of the estimation. Different shapes exist, more or less flared. Legendre et al. Showed in a study conducted at the CHU of Angers, that
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there is a significant difference in the estimates of blood loss between the bags, 3 different brands were tested. Graduations only allow a clear estimate of up to 1500mL. And depending
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on how the bag is held (left hanging, straightened or both pinched at both ends), the estimate varies. The flare shape of the bag makes it possible to read precisely the losses of low volumes but after one liter the difference between two marks decreases. A non-flared bag with
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the same distance between each graduation should be considered for better estimates(26). The margin of ± 50ml of the real volume to be estimated, chosen in our study to define the
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right estimate, is not clinically relevant. We find this margin of precision in the study by Buckland et al..(19).
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Compares to other studies, we have good effectives with a mix of professionals who are all led to monitors the patients in post-partum. In addition, we have a strict threshold for the precision of the estimates compared to other studies who’s goes up to ± 500mL. One of the main limitations of our study lies in the fact that it was not a real situation, there was not the feel of the birth room with the particular obstetric context. The "sequence effect" was limited by the random order of presentation of the bags. It should also be noted that the simulation took place before the theoretical course on PPH, the results would probably have
been better afterwards. The small number of participants is a limit of our study. It is due to the small effective at each session. In this study we did not test the accuracy of the estimates according to the experience and the specialty of the participants. As shown by Toledo et al. (22), Yoong et al. (27) and Glover et al. (4) the experience and the profession had no influence on the accuracy of the estimates. Not all professionals participated in these training days.
CONCLUSION
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The simulation puts the professionals in a real situation and allowed them to realize that there was a significant difference in the estimates of blood loss with the actual value. These results highlight the importance of weighing the protections (especially in the case of delayed bleeding after reinstallation of the patient). And the use of collection bags seems more
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accurate than the visual estimation. Bags suitable for large volumes could be useful in case of severe PPH. The goal is to diagnose early PPH to avoid a delay in the care.
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Acknowledgment to the ELENA perinatal network that allowed us to use the data they
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collected.
References Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323-333.
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Les morts maternelles en France : mieux comprendre pour mieux prévenir. 5e rapport de l’Enquête Nationale Confidentielle sur les Morts Maternelles (ENCMM), 2010-2012. Saint-Maurice : Santé publique France, 2017. 230 p. Disponible à partir de l’URL : www.santepubliquefrance.fr. 2017.
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Sentilhes L, Vayssière C, Deneux-Tharaux C, Aya AG, Bayoumeu F, Bonnet M-P, et al. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). Eur J Obstet Gynecol Reprod Biol. 2016;198:12‑ 21.
4.
Glover P. Blood loss at delivery: how accurate is your estimation? Aust J Midwifery Prof J Aust Coll Midwives Inc. 2003;16:21‑ 4.
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Rothermel LD, Lipman JM. Estimation of blood loss is inaccurate and unreliable. Surgery. 2016;160:946‑ 53.
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Deneux-Tharaux C, Bonnet M-P, Tort J. [Epidemiology of post-partum haemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2014;43:936‑ 50.
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Rath WH. Postpartum hemorrhage--update on problems of definitions and diagnosis. Acta Obstet Gynecol Scand. 2011;90:421‑ 8.
8.
Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, Riris S, Thomson AJ on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016;124:e106–e149.
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Aya AG, Ducloy-Bouthors A-S, Rugeri L, Gris J-C. [Anesthetic management of severe or worsening postpartum hemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2014;43:1030‑ 62.
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10. Malartic C, Cagnat J, Morel O, Ricbourg A, Gayat E, Mebazaa A, et al. [Invasive conservative care in cases of severe post-partum haemorrhage: future fertility and pregnancy outcome consequences]. Gynecol Obstet Fertil. 2012;40:582‑ 90.
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11. Blanc J, Courbiere B, Desbriere R, Bretelle F, Boubli L, d’Ercole C, et al. Is uterinesparing surgical management of persistent postpartum hemorrhage truly a fertilitysparing technique? Fertil Steril. 2011;95:2503‑ 6. 12. Tourné G, Collet F, Lasnier P, Seffert P. [Usefulness of a collecting bag for the diagnosis of post-partum hemorrhage]. J Gynecol Obstet Biol Reprod (Paris). 2004;33:229‑ 34. 13. Patel A, Goudar SS, Geller SE, Kodkany BS, Edlavitch SA, Wagh K, et al. Drape estimation vs. visual assessment for estimating postpartum hemorrhage. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2006;93:220‑ 4.
14. Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health. 2010;55:20‑ 7. 15. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007;109:1295‑ 300. 16. Dildy GA, Paine AR, George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. 2004;104:601‑ 6. 17. Brant HA. Precise estimation of postpartum haemorrhage: difficulties and importance. Br Med J. 1967;1(5537):398‑ 400. 18. Pritchard JA. Changes in the blood volume during pregnancy and delivery. Anesthesiology. 1965;26:393‑ 9.
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19. Buckland SS, Homer CSE. Estimating blood loss after birth: using simulated clinical examples. Women Birth J Aust Coll Midwives. 2007;20:85‑ 8. 20. Brooks, M. et al. Use of a Visual Aid in addition to a Collector Bag to Evaluate Postpartum Blood loss: A Prospective Simulation Study. Sci. Rep. 7, 46333; doi: 10.1038/srep46333 (2017).
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21. Al Kadri HMF, Al Anazi BK, Tamim HM. Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Arch Gynecol Obstet. 2011;283:1207‑ 13.
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22. Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA. The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg. 2007; 105:1736 ‑ 40, table of contents. 23. Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol. 2008;199:519.e1-7.
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24. Duthie SJ, Ven D, Yung GL, Guang DZ, Chan SY, Ma HK. Discrepancy between laboratory determination and visual estimation of blood loss during normal delivery. Eur J Obstet Gynecol Reprod Biol. 1991;38:119‑ 24.
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25. Mbachu II, Udigwe GO, Ezeama CO, Eleje GU, Eke AC. Effect of on-site training on the accuracy of blood loss estimation in a simulated obstetrics environment. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2017;137:345‑ 9.
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26. Elodie R, Céline G. http://dune.univangers.fr/fichiers/20092006/2015MFASMA3659/fichier/3659F.pdf. :33. 27. Yoong W, Karavolos S, Damodaram M, Madgwick K, Milestone N, Al-Habib A, et al. Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals? Arch Gynecol Obstet. 2010;281:207‑ 13.
Table 1 : Comparison of actual volumes and estimated volumes for collector bags and absorbent pads.
400 5001000m L
600 1000 600
Collectors bags
5001000m L
900 1000
>1000 mL
1200 1800
500
50
800
50
1500
150
1200
30
2000
50
1200
250
1250
100
1200
60
1500
350
2000
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EV: estimated volumes ; AV : actual volume ; SD : Standard Deviation
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𝜌 value
126,4 <0,000 1
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Absorbent pads
300
20
Mean of differen ces
257,9
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<500m L
173,3 ± 103,9 249,5 ± 150,5 428,6 ± 224,6 549,7 ± 243,8 914,7 ± 387,7 515,3 ± 115,5 836,5 ± 193,2 888,3 ± 172,6 1102,3 ± 189,1 1588,7 ± 264,3
EV max
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200
EV min
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AV
Mean EV ± SD
Mean of difference s AV-EV (Absolute values) ± SD 84,2 ± 66,1 129,0 ± 91,9 166,1 ± 153,1 208,7± 134,6 307,2 ± 250,2 107,6 ± 94,4 151,5 ± 135,2 121,9 ± 165,5 139,3 ± 160,7 245,6 ± 232,5
<0,000 1
127 0,0002
192