2nd International Conference on Applied Science and Health

Research for Better Society: Developing Science and Technology to Improve

Health and Well-being

ICASH-A06
METHODS OF POSTPARTUM BLOOD LOSS MEASUREMENT IN
INDONESIA SHOULD BE MODIFIED FOR BETTER ACCURACY: A
LITERATURE REVIEW
Siska Febrina Fauziah*, Melyana Nurul Widyawati,
Tecky Afifah Santy Amartha

Postgraduate Applied Science Program in Midwifery,

Poltekkes Kemenkes Semarang, Semarang, Indonesia,

Corresponding author’s e-mail: [email protected]

ABSTRACT

Backgrounds: Assessment of blood loss after delivery is important because intervention in the “golden
hour” is crucial to prevent maternal morbidity and mortality. In fact, the biggest obstacle in overcoming
postpartum blood loss are symptom recognition, accuracy, and timely diagnosis.
Aims: The objective of this study was to analyze the strengths and weaknesses between visual
estimation and quantification of blood loss measurements.
Methods: Literature review was conducted using the electronic databases Science Direct, Pubmed, and
Google Scholar. Measurement of blood loss and postpartum hemorrhage was used as keywords in
searching strategy. A total of 23 from 17.200 of publications range from 2010 until May 2017 and
presented in English language were included in this review.
Results: Many studies show that quantification of blood loss method is better than visual estimation.
Visual estimation of blood loss was imprecise, tend to underestimate blood loss, and thus to delay
diagnosis of PPH, whilst quantification of blood loss more accurate and objective. Nonetheless,
quantification methods not used routinely due to their unavailability, more time consuming,
complicated, costly, and analyst workload increases.
Conclusions: Modified measurement method and its existing protocol needed to overcome blood loss
during postpartum.

Keywords : Blood loss, postpartum hemorrhage, measurement

INTRODUCTION
Postpartum hemorrhage (PPH) is the leading direct obstetric cause of maternal mortality worldwide. It
occurs in nearly 14 million births and is responsible for approximately 140,000 maternal deaths each
year[1]. World Health Organization (WHO) stated that nearly three-fourth of obstetric hemorrhage
occured in postpartum period[2]. This pattern was similar with the condition in Indonesia.
In 2015, maternal mortality rate in Indonesia was 305 per 100,000 live births[3] and 30% of it is caused
by obstetric hemorrhage[4]. In the smaller region, Central Java, maternal mortalilty rate was 109.65 per
100,000 live births and obstetric hemorrhages were responsible for 20.26% maternal deaths in 2016[5].
Ika Fibriana analyzed the causes of maternal mortality in Cilacap, a district in Central Java. It was found
that obstetric hemorrhage was the leading direct of maternal mortality and 88.2% of it occured in
postpartum period[6]. Immediate postpartum hemorrhage is defined as exessive blood loss more over
or equal with 500 mL after normal delivery[7-9]. Assessment of blood loss after delivery is important
because active intervention in the “golden hour” is crucial to prevent maternal morbidity and

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

mortality[10]. But in fact, the largest bariers in treating postpartum hemorrhage are symptom
recognition and accurate, timely diagnosis[11, 12].
There are many ways to estimate the blood loss after delivery. In practice, clinicians can rely on several
methods of quantification – subjective (visual estimate) or objective (collector bag, weighing
compresses or sanitary pads, or laboratory analysis). However, in Indonesia, there is no standardized
protocols for estimating blood loss following a vaginal delivery[8]. Although the ideal measurement of
postpartum blood loss involves the use of objective tools, visual estimation is still the most commonly
used in dialy obstetric practices[12].
The objective of this study was to analyze the measurement of blood loss methods either subjective or
objective approach. So that we could choose the best option for measuring the blood loss or get the
useful point to modify the method that appropriate in Indonesia.

METHODS
The research articles were reviewed from electronic databases including Science Direct, Pubmed,
Google Scholar and any other related websites. The number of keywords were used including
“Measurement of Blood Loss” and “Postpartum Hemorrhage”. A total 23 from 17,200 of publications
range from 2010 until May 2017, which were discussed about measurement of blood loss method and
presented in English language, were included in this review. In addition, relevant chapters of textbooks
and current guidelines were examined to capture any further information or additional reports not
identified in the electronic search.

RESULTS
The methods used to measure blood loss are categorized into visual estimation of blood loss and
quantification of blood loss. Visual estimation is subjective method that measured the amount of blood
loss visually. Meanwhile quantification of blood loss is objective method that measured the amount of
blood loss by using certain calculation[11]. There are three types of quantification of blood loss
methods: gravimetric, utilization of under-buttocks drapes, and laboratory analysis. In this section, the
method will be described based on the result of reviewed previous studies.
Visual Estimation
Half of total publications reviewed in this review discussed about visual estimation of blood loss.
Parayre et al[13] and Yoong et al[14] evaluated the accuracy of visual estimation by asking health
providers to estimate simulated blood loss visually. Both of the studies showed that visual estimation
was inaccurate and tend to overestimate the large volume and underestimate the small volume. Parayre
et al[13] suggested that the accuracy of visual estimation was 35.34%.
Lertbunnaphong et al[15] compared visual estimation to utilization of a novel birthing drape.
immediately after delivery, a birth attendant inserted the drape under the patient’s buttocks. Postpartum
blood loss was measured by visual estimation and then the blood from the drape was poured into a
standard cylinder and measured objectively. Visual estimation was found to be inaccurate, resulting
underestimation, with low correspondence and poor aggrement compared to objective measurement
using the birthing drape. Two-third of immediate PPH cases were misdiagnosed using visual estimation.
Al Kadri et al[16] compared visual estimation and gravimetric measurement. There was a significant
difference between the gravimetric calculated blood loss and health care providers’ estimation with
percentage of error by about 30%. This study suggest the better accuracy of visual estimation from
previous study. Golmakini et al[17] confirmed the result of this study.
Withanathantrige et al[18] assessed the agreement between visual estimation, gravimetric method and
calculation based on hemoglobin levels. They found that visual estimation had tendency to be
underestimated when blood loss > 500 mL and to be overestimated when blood loss < 500 mL compared

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

to gravimetric method. The visual estimation had also less aggreement than gravimetric method
compared to calculation based on hemoglobin levels.
Ram et al[19] compared the accuracy of visual estimation with actual blood loss which was calculated
based on haematocrit value. When the average of blood loss is small, the accuracy rate of blood loss
estimation is high. In contrast, when the average of blood loss exceeds 500 mL, the accuracy decreases
significantly. This suggests that clinical estimation is inaccurate as the blood loss increases.
Beside of low accuracy, many studies suggested that the visual estimation of blood loss among various
members of medical team could be different[14, 20-23]. This discrepancy may lead to a conflict with
treatment decision and delay the treatment that should be given[21]. The right time for giving
rescucitation is very important and late recognition of significant blood loss may delay intervention
until hemorrhage has occured[23]. To overcome these problems, many studies tried to modify visual
estimation by utilizing visual aid, conducting estimation training, or creating a novel tool that can be
used to measure blood loss as follow descriptions.
Zuckerwise et al[23] designed a pocket card containing images of blood on common obstetric materials
to serve as visual aid. They also created six stations with known volumes of artificial blood using
materials from standard delivery kits and asked participants to estimate blood loss visually across a
variety of volumes and materials before and after recieving the visual aid. The result showed that
visual estimation was inaccurate and tend to overestimate the small volumes and underestimate the
larger volume. However, the visual aid were effective to improve the accuracy of blood volume
estimation as much as 34.9%. Clinical background and years of experience did not affect the accuracy
of health providers’ estimation[14, 16, 20, 22, 23].
Toledo et al[22], Al Kadri et al[20] and Khaldikar et al[21] assessed the impact of educational session
on the accuracy of visual estimation. Participants of the studies were asked to estimate the simulated
blood loss before and after training. In the pre-test, participants’ assessment were inaccurate which
tended to overestimate the large volume and underestimate the small volume. However, the accuracy
were improved significantly after training. Toledo et al[22] suggested that educational session improved
the accuracy of visual estimation by 34%. This indicated the beneficial impact of training on visual
assessment. In the other study, Toledo et al[24] conducted the research to evaluate retention of blood
loss estimation skills after training. They found that decay in blood loss estimation skills occured by 9
months after training. So that the training should be given routinely to maintain the skills.
Wilcox et al[25] conducted the trial of special designed underpad. Visual estimation of blood loss was
calculated by multiplying the number of blood-saturated squares or partial squares by 50 mL. The visual
estimation blood loss then compared with the actual blood loss calculated based on Mat weight before
and after use (volume of blood loss). The accuracy of this method was 69% of the time within 100 mL
and 97% at the time within 200 mL. Meanwhile the mean discrepancy was 80,91 mL compared to actual
blood loss.
Other study lead by Sharareh[26] utilized the sophistication of technology by using Triton tablet system.
The amount of blood loss and hemoglobin level could be determined by snapshotting the absorbed
blood only. Measures of surgical sponge estimated blood loss from the Triton tablet system were
compared to photometric analysis. The result showed a significant positive correlation between Triton
tablet system and photometric analysis with respect to intra-operative haemoglobin and blood loss at
0.92 and 0.91, respectively. It is the best accuracy for visual estimation method that had ever studied.
Aside from the inaccuracy which more be discussed in the previous studies, it should be realized that
the major advantage of visual estimation is that this method is a real time assessment and enables the
birth attendants to correlate findings, on an individualized basis, with the clinical presentation[27]. The
accuracy could be improved by utilization of visual aid, routine training and modification of the tool
that used to measure the blood loss. This method is also the most frequently practiced method in

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

obstetric practices[12]. It is because this method is relatively straightforward and requires no

expenditure[27]. It should be kept in mind that over 99% of maternal mortalities take place in the low
resource settings[28]. The method should not only be accurate, but should also be practical, affordable,
and able to be implemented in daily practices.
Quantification of Blood Loss
Gravimetric
The gravimetric method is one of the objective method in calculating postpartum blood loss. It
constitutes the weighing of collected blood lost during delivery as well as materials such as soaked pads
on a sensitive scale and subtracting the known dry weights of these materials to determine the actual
blood loss[27]. The difference in weight provides a rough estimate of blood loss; 1 gram equals 1
mL[11].
Vitello et al[29] conducted validation study of the gravimetric method of measuring intraoperative
blood loss. As much as 50 μL of whole blood was weighed from eighteen rats. A distilled water control
was weighed for each blood sample. This study confirmed that the measure density of blood is similar
to water. So that, this helps verify the use of gravimetric method to convert 1 gram of blood to 1 mL of
blood.
Lilley et al[30] conducted a research to validate the accuracy of gravimetric method to measure the
blood loss. For validation exercise, in a simulated PPH scenarios using known volumes of artificial
blood, the accuracy of gravimetric measurement was compared with visual estimation made by delivery
suit staff. It was confirmed that visual estimation is inaccurate which the mean error was 34,7%. In
contrast, using gravimetric method in the same scenarios, the volume could be accurately measured
with a mean error of 4%. Meanwhile in the clinical observation study, they found that gravimetric
measurement of blood loss is correlated with the fall in hemoglobin.
Atukunda et al[31] compared gravimetric method to a reference standard of hemoglobin decrease of
>10% to validate the accuracy of the method. The result showed that gravimetric method generally had
a poor sensitivity (<75%) for detection PPH. Although this method will possible to miss few cases of
PPH because of its poor sensitivity, the specificity and the positive predictive value (PPV) which were
> 90% make it a reasonable option as a means of identifying PPH in certain settings where laboratory
test is unavailable.
The gravimetric method requires no more resources than a baby weighing scale and basic mathematical
ability, and could be thaught routinely and used in all maternity services[30]. A variety of scales from
elaborate ones that hang to small, household, digital scale that measure in grams can be placed in each
labor and operating room[32, 33]. However, quantifying the blood loss using gravimetric method is
realized substanstially increases the workload of clinicians because it is complicated and time-
consuming to use, especially in a busy clinical setting[15]. Inaccuracies can arise at several steps in this
procedure, especially when collecting the blood[27].
Utilization of Under-buttocks Drape
Under-buttock drape is used to collect the blood loss after delivery[11]. There are two ways to measure
the blood loss by using the drape. The first, the blood is collected into the drape or collector bag then
poured into calibrated container or weighted with the soaked gauze or underpad[11, 15, 34]. Meanwhile
in the second way, the blood loss was measured directly by using calibrated drape[35, 36].
Brooks et al[34] conducted a prospective simulated study by asking participants to measure the blood
loss by using under-buttocks drape and baby scale. Following the first test, they recieved visual aid as
additional tool to measure the blood loss by using under-buttocks drape. The estimation of blood loss
from both of the tests were compared to the actual blood loss that known by researchers. The use of
visual aid in addition to a collector bag did not improve the health providers’ estimation and resulted
more frequent overestimation when estimating the blood loss.

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Health and Well-being

Different to previous study, Legendre et al[35] conducted simulation training by creating six different
scenarios of vaginal delivery. The participants were asked to estimate the blood loss by using calibrated
drape. The accuracy of estimated blood loss using the calibrated drape was more than 96%. Tixier et
al[36] cconducted a prospective cohort study of 122 patients. The measurement of blood loss using
calibrated drape compared to decreased level of hemoglobin and hematocrit. By using the calibrated
drape, clinicians could estimate the blood loss directly without the need to weigh or pour the blood into
other graduated container to measure the blood loss. For a threshold of 300 mL, calibrated drape had
high sensitivity and spesificity which were 88.9% and 82.7%, respectively.
By utilizing underbuttocks-drape, especially when using the second way measurement as described
above, it is only required the calibrated drape to measure the blood loss. This drape should be inserted
under the buttocks of the mother immediately after delivery and the blood loss could be measured
directly. The error in estimating blood loss can arise from failure to avoid contaminated blood with
amniotic fluid or note all the blood in the stained linen[12]. The cost of this drape was 0.86 €[36].
Laboratory Analysis
Several studies used laboratory analysis as the golden standard to evaluate the accuracy of measurement
of blood loss. By using this method, off course it is needed the blood samples that were taken before
and after the birth. Based on hemoglobin and/or hematocrit level, PPH was diagnosed when the delta
for the hemoglobin was > 3 g/dL and/or when the delta for hematocrit was > 10 points which the blood
samples were taken after admission and 2 – 3 days after the birth[16, 30, 36]. Meanwhile Atukunda et
al adapted reference that could be adapted is the incidence of more than 10% decrease in hemoglobin
level from blood samples that were taken immediately after admission and 24 hours after the birth[31].
Beside of hemoglobin and hematocrit level, other studies suggest that fibrinogen level was useful early
biomarker for predicting pregression of PPH [37-39]. Cortet et al[37] compared fibrinongen levels in
patients whose PPH worsened and became severe and those whose PPH remained non-severe. The
result showed that fibrinogen level was associated with PPH severity independently of other laboratory
factors. When the fibrinogen level was < 2 g/L, the risk of severe PPH increased 12 times. A fibrinogen
level between 2 and 3 g/L, usually considered normal, is also associated with a nearly doubled risk of
severe PPH. Collins et al[38] confirmed the result of this study and they also found that Fibtem as
effective as fibrinogen could be made as biomarker for progression of PPH.
De Lloyd et al[39] showed the similar finding about the utility of fibrinogen level for predicting PPH.
They also found that the fibrinogen level fell progresively as the estimated blood loss increase.
Nontheless, the fall of hemoglobin level was still useable as good predictor of PPH when the blood loss
was < 3000 mL.
Laboratory analysis is the most accurate method for measuring the blood loss after delivery because
this method is able to monitor the biomarker that can represent the amount of blood loss[12]. So that,
whole blood check, including hemoglobin, hematocrit, fibrinogen and fibtem, as routine intervention
will be advantageous in postpartum hemorrhage management[37-39]. Unfortunately, laboratory
analysis is impractical because this method should be practiced by expertise and need special
equipements to give the best result[33]. This method is also time consuming because the result of
laboratory analysis can be achieved at least after 24 hours or after 2-3 days postpartum to distinguish
the physiological changes and blood loss confirmation[12, 33]. It means when the patient confirmed
has bled or is bleeding, the intervention will be too late to do if the diagnosis is only rely on this method.

DISCUSSION
In this section, the methods were compared to be analyzed the strengths and weaknesses of each method
based on it’s accuracy, simplicity and availability. The method was accurate when the error rate was
less than 20% because it is just 20% for overestimation or underestimation was considered to be the
maximum individual difference that could be tolerated without interfering with patient

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Health and Well-being

management[40]. Meanwhile the simplicity and availability of the method defined by authors as ease
to practice by midwives and required tool for measurements was available in Indonesia.
Based on the result of previous studies that reviewed in this review, the most accurate method was
laboratory analysis which commonly used as gold standard for other measurements[12, 18, 19, 30, 31,
36]; followed by utilization of calibrated drape with 88.9% and 82.7% for the sensitivity and specificity,
respectively[36]; then gravimetric method which had poor sensitivity but had high specificity and
positive predictive value (>90%)[31], and the least accurate was visual estimation (33.3% – 70%)[13,
15-17].
The inaccuracy of each method has the chance to arise[12, 27]. However, visual estimation training and
the use of visual aid had been proved can improve health care provider’s accuracy in estimating blood
loss and decrease the error although it will not eliminate it and still remains overestimation or
underestimation[20-23]. When visual aids or visual estimation training were offered, the accuracy of
visual estimation improve significantly by 34% and 34.9% for utilization of visual aid and visual
estimation training, respectively[22, 23]. It seems that visual estimation of blood loss can be used in
labour and delivery suits if appropriate training and education are implemented[20-22].
Based on the simplicity of the method, the most simple method is visual estimation followed by
utilization of calibrated drape, gravimetric method, and laboratory analysis. The visual estimation could
provide real-time assessment and required no expenditure because the assessment is only depend on the
eyesight[27]. The same as visual estimation, the utilization of calibrated drape, could also provide a
real-time assessment but it certainly need that sepecial tool to measure the blood loss and clinicians
sould be careful when collected the blood[35, 36].
Beside needs special equipments, gravimetric method and laboratory analysis were relatively time-
consuming because of the procedure[12]. By using gravimetric method, clinicians should weigh all of
materials that used to absorbe the blood before and after the birth. The blood loss was known by
subtracting the wet weight of materials with the dry weight[11, 16, 27]. Meanwhile laboratory analysis
off course ideally should perform in laboratory by expertise to examine the blood sample which were
taken before and after the birth. There was also standard time for taking the blood sample after birth to
avoid the bias from physiological changes at least 24 hours[16, 31, 36].
The last is about the availability of required tool to measure the blood loss. As mentioned earlier, visual
estimation does not require any other tools beside midwive’s eyesight[27]. So that visual estimation can
be performed anywhere and anytime. Gravimetric method needs digital baby weigh scale that can be
placed in each labor room[16, 17, 31-33]. The cost of digital baby scale was vary but it is relatively not
expensive for reusable tool. In contrast, the cost of calibrated drape was 0.86 €[36] or equal to IDR
13,523.5 which three times more expensive than commonly used underpad for disposable use. It has
also not available yet in Indonesia. It needs high cost to provide laboratory analysis as method to
measure the blood loss because the needs of special equipments which relatively expensive and the
needs of expertise to do this method properly[12]. The examination also needs blood sample before and
after birth which automatically doubled the price.
Based on the description above and realizing that Indonesia is one of developing countries, visual
estimation is still the the most appropriate method for measuring the blood loss after delivery in
Indonesia. Although many studies suggested that visual estimation was not recommended anymore[12,
14, 15, 30], we believe that midwives still have to retain this skill, morover the objective method
application in developing countries still have to be strived. But certainly, it needs to be modified to give
the better accuracy.
Wilcox et al[25], Sharareh et al[26], Tixier et al[36] and Legendre et al[35] modified visual estimation
by combining visual estimation principle and quantification method principle. The blood loss could be
assessed directly and visually according to standard measurement as the reference to do the estimation,

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Research for Better Society: Developing Science and Technology to Improve
Health and Well-being

and it resulted the better accuracy. The strenghth of visual estimation provide a real-time assessment
and the strength of quantification method improve the accuracy of the modified method. It indicates
that by combining the principle of the methods, the two methods will reduce the weaknesses and
increase the strengths each other. So that it resulted the better performence.
The study that lead by Zuckerwise et al[23] showed that visual aid could improve the estimation by
34.9% because the participants of the study estimate the blood loss from the same materials provided.
In Indonesia, the utilization of visual aid had been used in daily practices. For example, the midwives
estimated the blood loss by interpreting that full soaked of sanitary pad as 100 mL, half soaked of
sanitary pad as 50 mL, half filled of kidney dish as 250 mL, completely full of kidney dish as 500 mL,
half soaked of sarong as 400 mL, and fully soaked sarong as 700 mL[10].
Contrary to the research setting, it should be realized that there are various sanitary pads and sarongs
which could have different capacity[27]. The perception of half soaked could also different for one to
the others because the absorbed blood on the sanitary pad or sarong had irregular shape[21]. So, for
getting the same benefit as this study, those materials that were used in visual aid should be materials
that were used in real clinical settings. It is very possible that every labor rooms have their own visual
aid according to materials that they used. Beside the size of materials and the capacity of absorbed
blood, visual aid should also inform about the absorptive capacity of the materials which had been
measured.
To minimize the overestimation or underestimation, by adapting Wilcox’s study[25], it could be drawn
the line scale on the visual aid surface, so that it had several squares. The estimated volume of each
square should be tested in order this calibrated visual aid could be used as the reference standard
measurement when estimating the blood loss. This modification should be strengthen by routine visual
estimation training to improve the estimation and maintain the skills[20-22, 24]. As the Toledo’s
study[22], the model of the training could be applied as live or web-based training without reduce the
effectivity. By this way, it is expected that the percentage of error of visual estimation would not be
more than 20% .
Beside of the method, the other important thing to reach the successful of postpartum hemorrhage
management is the needs of health policy formed as protocol or guideliness comprehensively[33, 41,
42]. But in fact, in Indonesia, there is no standardized protocol for estimating blood loss following a
vaginal delivery[8]. Efforts should be made to unify the assessment and management of PPH patients
through education and standardization as mentioned earlier. The policy should not concern about the
clinical procedure only but also have to regulate the availability of required tools to measure the blood
loss.

CONCLUSIONS
Blood loss during childbirth has been and continues to be a significant issue. Methods to accurately
determine blood loss that are simple and costless are deseparately needed. Visual estimation is still the
most appropriate method for measuring the blood loss after delivery in Indonesia. The weakness of
visual estimation is only about its accuracy that could be improved in various ways. Modifying the
visual estimation by making the principle of quantification methods as integrated part of this method
would provide a real-time assessment and improve the accuracy. The use of materials with known
absorptive capacity that performed together with calibrated visual aid and supported by routine visual
estimation training and it’s existing protocol will result the better accuracy in diagnosing postpartum
blood loss in Indonesia. This modification suggested that visual estimation still proper to be used
especially in low resource settings.

CONFLICT OF INTEREST
There is no conflict of interest.

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