How Indonesian midwives assess blood loss during labor?

ORIGINAL ARTICLE How Indonesian Midwives assess blood loss during labor? ROSMARIA1, INDRAYANI2, YETTY ANGGRAINI3, BAIQ C. LESTARI4, SRI L. KARTIKAWATI5, LESTARI P. ASTUTI6, ANIAH RITHA7 1 Poltekkes Jambi Jurusan Kebidanan, Jambi, Indonesia Akademi Kebidanan Bina Husada, Tangerang, Indonesia 3 Poltekkes Tanjungkarang Jurusan Kebidanan, Lampung, Indonesia 4 Balai Pelatihan Kesehatan, West Nusa Tenggara, Indonesia 5 Sekolah Tinggi Ilmu Kesehatan Bakti Kencana, West Jawa, Indonesia 6 Sekolah Tinggi Ilmu Kesehatan Karya Husada Semarang, Indonesia 7 Sekolah Tinggi Ilmu Kesehatan Wiyata Husada Samarinda, East Kalimantan, Indonesia Correspondence to Indrayani, Akademi Kebidanan Bina Husada, Tangerang. Kutai Raya No.1, Bencongan Kelapa Dua, Tangerang, Banten, Indonesia. Zip Code 15811 Ph. +62-21-55655372 Fax. +62-21-55655372. Email: indrayani_akbid@yahoo.co.id 2 ABSTRACT Background: Postpartum hemorrhage (PPH) remains the primary cause of maternal mortality in developing countries, and blood loss assessment (BLA) is a crucial factor in PPH management. Aim: To describe how midwives undergo BLA during labor. Methods: A sequential exploratory mixed-method study was used to answer the research question.Twenty-three midwives were involved with in-depth interviews, and 167 maternity rooms were observed. Results: There were four methods of BLA theoretically known to midwives, but there was only one applicable method. The majority of midwives used delivery bed type A and an underpad as a delivery pad, but they did not know the brand of the underpads used. Also, the majority of them did not apply BLA during labor. Conclusion: The BLA was not undertaken in most labors. Physiological parameters were the most applicable method for the Indonesian midwives. Keywords: postpartum hemorrhage, blood loss assessment, visual method, gravimetric method, physiological parameters INTRODUCTION Maternal mortality remains the primary issue in developing countries where postpartum hemorrhage (PPH) has been reported as its leading cause1-3.PPH is defined as a blood loss of or over 500 ml4-6. Its percentage is higher in developing countries (over 30%) compared to developed countries (13%)2, 7. In Indonesia, it caused 30.1% of maternal deaths8.Most cases of PPH occur within two hours after the birth of the placenta, so a rapid and accurate blood loss assessment (BLA) is a crucial factor for PPH management9. A delay in diagnosing PPH will cause further delay in handling PPH, which can then lead to an increased risk of adverse outcomes 10, such as hypovolemic shock and death6, 11. The existence of a standard operating procedure (SOP) for assessing blood loss at the fourth stage of labor, as part of the normal labor and delivery care protocol, will help midwives to diagnose PPH quickly and accurately. The Indonesian government determined the mandatory protocol and training of intrapartum care for midwives. Since 1998, the protocol has been revised five times, however, there were no substantial changes or clear descriptions about the standard procedures for BLA12-14. Overall, the goal of this study was to determine how midwives conduct BLAs during labor. METHODS This study used a sequential exploratory mixed-method strategy. It was started by a qualitative study followed by a quantitative one. Research subjects were midwife practitioners who actively assist maternity women and experienced in handling PPH. Data was collected after 1124 P J M H S Vol. 13, NO. 4, OCT – DEC 2019 approval from the participant based on the Helsinki declaration from March to August 2018. In the qualitative study, samples were chosen by a purposive technique. Data was collected through in-depth interviews that lasted for 40-60 minutes. The focus of this study was to explore how midwives diagnose and handle PPH. Twenty-three midwives were involved in these interviews. They were 10 midwives who work at hospitals, eight midwives from public health centers (PHCs), a village midwife, and four others were independent midwifery practices (IMPs). The data were analyzed via thematic analysis. The qualitative result analysis was then confirmed by a quantitative study with an observational study. The objects observed were BLA conducted by midwives, delivery bed types in maternity rooms, and delivery pads used by midwives during labor. The observation results were described with a frequency distribution table. RESULTS Qualitative data analysis Diagnosis of PPH: All participants stated that there is no explicit protocol regarding BLA procedures. However, there were four methods of BLA theoretically known by participants, include assessing blood loss using physiological parameters, a visual method with an underpad, a kidney dish to collect blood, and underpad weighing (gravimetric). The participants did not implement the theories, as complication arose when applying those methods during labor. Some participants, who had applied the visual method, stated that this method was easy to work on, but it was challenging to interpret, inaccurate, and caused a debate between midwives. An underpad measuring 60 x 90 cm full of blood was assumed to vary by Rosmaria, Indrayani, Yetty Anggraini et al participants ranging from 200 mL-1000 mL. Other participants, who had experience in collecting blood directly to the kidney dish, expressed that it was tough to do given its smaller size. A medium kidney dish filled with blood was also estimated differently by participants in the range of 100-500 mL. While only a few participants knew about the gravimetric method, but they had no experience with this method. “The visual method was easy to do, but it was difficult to be interpreted. We often argued when determining blood loss with the underpad, so it is no longer carried out. Meanwhile, collecting blood into a kidney dish was not an easy task since not all blood can be accommodated to the kidney dish.” (Midwife of PHC) The possible method to be applied according to the participants was a physiological parameter assessment, such as blood pressure (BP) and pulse. The participants stated that the assessment was only carried out when the patient’s condition showed emergency signs. Moreover, they did not know the level of BP and pulse when classifying a hemorrhage. They only knew that if the patient’s condition showed a decrease in BP and an increase in pulse from the initial levels, it meant that PPH is occurring. “We only assess blood loss through the BP and pulse when the patient’s condition revealed emergency signs. We do not have great knowledge about the hemorrhage degree based on the level of BP and pulse. We work under doctors’ supervision. If there were a decrease in BP and an increase in pulse from the initial rate, the doctors asked us to treat it as PPH.” (Hospital midwife) PPH management: All hemorrhage patients were given oxytocin as uterotonic drugs and intravenous liquid. The most frequent liquid used by health providers was RingerLactate (RL) solution. Determining the amount of fluid was based on the patient’s condition (such as general condition, BP, pulse, and hemoglobin level) and not based on the amount of blood loss. Table 2: Hemorrhage classes Signs monitored oninitial presentation* Blood loss (mL) Blood loss (% blood volume) Pulse rate Blood pressure Pulse pressure (mm Hg) Respiratory rate Urine output (mL/hr) CNS/mental status Fluid replacement (3:1 rule) Source: Cocchi et al.16 Class 1 Up to 750 Up to 15% <100 Normal Normal or increased 14-20 >30 Slightlyanxious Crystalloid “During my work here, I handled five cases of PPH. We work under doctors’ supervision. Determination of fluid and blood transfusion needs were usually based on the BP, pulse, and hemoglobin levels.” (Hospital midwife) Quantitative data analysis: A total of 167 maternity rooms were observed in 10 provinces in Indonesia include Jambi, South Sumatra, Lampung, West Java, Central Java, Yogyakarta, West Nusa Tenggara, West Kalimantan, East Kalimantan, and Southeast Sulawesi. They were 16 hospitals, eight midwifery clinics, 30 PHCs, an auxiliary health center, two village maternity posts, and 110 IMPs. The observation results can be seen in both Figure 1 and Table 1. Table 1: Observation results (N=167) Aspects BLA during labor Physiological parameters Visual method used underpad Collecting blood into a kidney dish Gravimetric method None Type of delivery bed* Type A Type B Type C Delivery pad* Patient’s fabric Underpad 60 cm x 90 cm** **)Brand of underpad used in labor (N=158) Do not know Non-branded underpad Sensipad Top underpads Oto underpads Diapro underpads ProCare underpads Note: *) Some health facilities have more than a type Class 2 750-1500 15%-30% >100 Normal Decreased 20-30 20-30 Mildly anxious Crystalloid Class 3 1500-2000 30%-40% >120 Decreased Decreased 30-40 5-15 Anxious, confused Crystalloid and blood f (%) 7 (4.2) 3 (1.8) 0 (0.0) 0 (0.0) 157 (94.0) 96 (53.6) 51 (28.5) 32 (17.9) 13 (7.6) 158 (92.4) 68 (43.0) 12 (7.6) 42 (26.6) 11 (6.9) 9 (5.7) 2 (1.3) 14 (8.9) Class 4 >2000 >40% >140 Decreased Decreased >35 Negligible Confused, lethargic Crystalloid and blood Fig. 1: Three types of delivery beds used by Indonesian midwives P J M H S Vol. 13, NO. 4, OCT – DEC 2019 1125 How Indonesian Midwives assess blood loss during labor DISCUSSION The velocity and accuracy of BLA does not only play in the success of PPH management9 but also for the earlier detection of a clotting disorder15. Unfortunately, this study found that 94% of participants did not undertake BLA during labor. While a few other participants, who estimated blood loss visually or assessed BP and pulse, did not know how to interpret the results. BP and pulse are indicators suggested by the Advanced Trauma Life Support (ATLS) to classify the degree of hemorrhage, as illustrated in Table 216. However, Mutschler et al.17 and Guly et al.18 questioned the validity of this classification. Although a decrease in BP and an increase in pulse were associated with increased blood loss, it was not at the level suggested by the ATSL shock classification19. This finding is strengthened by the Brasel et al.study20stating that tachycardia, which is pulse over 100 beats per minute, was not typically present after excess blood loss. Guly et al.19also reported that the changes in respiratory frequency were not associated with increased blood loss. BLA is not only needed to diagnose PPH but to also determine the amount of fluid given to the patient. The fluid restoration is required to replace the intravascular fluid loss and to recharge the interstitial fluid deficits 21. Fluid overload may cause pulmonary edema and cardiac failure 22. The ATLS suggested the administration of Crystalloid fluid in order to restore the bleeding with a ratio of 3:1 16. However, Cervera and Moss stated that the stability and normovolemia in arterial hemorrhage cases could only be recovered after fluid restoration with a ratio of 8:1 23. On the other hand, participants expressed that visual BLA using underpads was easy to be implemented, but it was difficult to be interpreted, not accurate, and frequently led to a debate between midwives. The inaccuracy of visual BLA was also reported by some previous studies 6, 2427.Nevertheless, this method is still the most frequently used by health practitioners worldwide 9, 28.Maintaining this action is futile24, 29 since the accuracy of BLA is a critical factor to the success of PPH management9. Buckland and Homer reported that the use of a kidney dish in assessing blood loss was more accurate than the visual method30.A kidney dish filled with blood equals to 500 mL15.However, this study found that collecting blood with it was complicated due to its small size. Toledo et al.10 recommendeda calibrated drape to collect blood during labor. The previous studies proved the accuracy of delivery drape in assessing blood loss compared to the visual method28, 30, 31 while Lilley et al. stated that the gravimetric method was more accurate than the visual method. BLA using gravimetric correlated with a decrease in hemoglobin in PPH over 1500 mL9.The formula for calculating blood loss volume using the gravimetric method is the volume deviation between the underpads’weight (both dry and contaminated with blood)9, 32divided by blood density (ρ)33. CONCLUSION The BLA was not undertaken in most of the labors. Physiological parameters were the most applicable method for the Indonesian midwives. The findings of this study 1126 P J M H S Vol. 13, NO. 4, OCT – DEC 2019 provide support for further research on the gravimetric methods and delivery drapes to assess blood loss during labor and encourage the government to improve BLA protocols as a part of the intrapartum care protocol. Acknowledgments: We thank Mrs. Utari Wijayanti, Mrs. Dewi Anggraini, and Mr. Hadi, who have provided suggestions related to this study. We would also like to thank the observer team, who has assisted researchers in collecting data. Competition Interests: All authors declare that they have no competing interests within this study. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. El-Refaey H, Rodeck C. Post-partum haemorrhage: definitions, medical and surgical management. A time for change. Br Med Bull. 2003;67(1):205–17. [DOI: https://doi.org/10.1093/bmb/ldg016]. Retrieved from https://academic.oup.com/bmb/articlepdf/67/1/205/25152035/ldg016.pdf. Haeri S, Dildy GA. Maternal mortality from hemorrhage. Semin Perinatol. 2012;36(1):48-55. [DOI: https://doi.org/10.1053/j.semperi.2011.09.010]. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Look PFAV. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-74. [DOI: https://doi.org/10.16/S0140-6736(06)68397-9]. Retrieved from http://www.hpc4.go.th/director/data/region/WHO_MMR.pdf. WHO. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva, Switzerland: World Health Organization; 2012. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/75411/978924 1?sequence=1. Dildy GA. Postpartum hemorrhage: New management options. Clin Obstet Gynecol. 2002;45(2):330–44. [DOI: 10.1097/00003081-200206000-00005]. Dildy GA, Paine AR, George NC, Velasco C. Estimating blood loss: Can teaching significantly improve visual estimation? Obstet Gynecol. 2004;104(3):601-6. [DOI: 10.1097/01.AOG.0000137873.07820.34]. Mousa HA, Walkinshaw S. Major postpartum haemorrhage. Curr Opin Obstet Gynecol. 2001;13(6):595–603. [DOI: 10.1097/00001703-200112000-00008]. Indonesian_Health_Ministry. Pusat data dan informasi Kementerian Kesehatan Republik Indonesia. In: Health, editor. Jakarta: Health Ministry of the Republic of Indonesia; 2014. p. Retrieved from www.depkes.go.id/resources/download/pusdatin/infodatin/info datin-ibu.pdf. Lilley G, Burkett-st-Laurent D, Precious E, Bruynseels D, Kaye A, Sanders J, et al. Measurement of blood loss during postpartum haemorrhage. Int J Obstet Anesth. 2015;24(1):814 [DOI: http://dx.doi.org/0.1016/j.ijoa.2014.07.009]. Toledo P, McCarthy RJ, Hewlett BJ, Fitzgerald PC, Wong CA. The accuracy of blood loss estimation after simulated vaginal delivery. Anesth Analg. 2007;105(6):1736-40. [DOI: 10.213/01.ane.0000286233.48111.d8]. ACOG. Postpartum hemorrhage. Int J Gynecol Obstet. 1998;61(1):79–86. [DOI: 10.1016/s0020-7292(98)90114-x]. JNPK-KR, JHPIEGO, Indonesian_Health_Ministry. [The reference book of normal intranatal care]. Jakarta: Jaringan Nasional Pelatihan Klinik-Kesehatan Reproduksi (JNPK-KR), JHPIEGO, MNH, Indonesian Health Ministry; 2002. JNPK-KR, POGI. [The reference book and guidelines of normal intranatal care and early breastfeeding initiation]. Jakarta: Jaringan Nasional Pelatihan Klinik Kesehatan Rosmaria, Indrayani, Yetty Anggraini et al 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Reproduksi (JNPK-KR), Perkumpulan Obstetri dan Ginekologi Indonesia (POGI); 2008. JNPK-KR, AUPKOP. [The reference book of normal intranatal care; Essential care for maternity and newborns and management of immediate after childbirth and postpartum]. Jakarta: Jaringan Nasional Pelatihan Klinik-Kesehatan Reproduksi (JNPK-KR), Asosiasi Unit Pelatihan Klinik Organisasi Profesi (AUPKOP); 2012. Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006;113(8):919–24. [DOI: 10.1111/j.471-0528.2006.01018.x]. Cocchi MN, Kimlin E, Walsh M, Donnino MW. Identification and resuscitation of the trauma patient in shock. Emerg Med Clin N Am. 2007;25(3):623-42. [DOI: https://doi.org/10.1016/j.emc.2007.06.001]. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.688 .9838&rep=rep1&type=pdf. Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, et al. A critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical reality? Resuscitation. 2013;84(3):309-13. [DOI: https://doi.org/10.1016/j.resuscitation.2012.07.012]. Guly HR, Bouamra O, Little R, Dark P, Coats T, Driscoll P, et al. Testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation. 2010;81(9):1142-7. [DOI: https://doi.org/10.016/j.resuscitation.2010.04.007]. Guly HR, Bouamra O, Spiers M, Dark P, Coats T, Lecky FE. Vital signs and estimated blood loss in patients with major trauma: Testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation. 2011;82(5):556-9. [DOI: https://doi.org/10.1016/j.resuscitation.2011.01.013]. Brasel KJ, Guse C, Gentilello LM, Nirula R. Heart rate: is it truly a vital sign? J Trauma: Injury, Infection, Critical Care. 2007;62(4):812-7. [DOI: 10.1097/TA.0b013e31803245a1]. Alam HB, Rhee P. New developments in fluid resuscitation Surg Clin N Am. 2007;87(1):55-72. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.570 .2334&rep=rep1&type=pdf. Mukherjee S, Arulkumaran S. Post-partum haemorrhage. Obstet Gynaecol Reprod Med. 2009;19(5):121-6. [DOI: https://doi.org/10.1016/j.ogrm.2009.01.005]. Cervera AL, Moss G. Progressive hypovolemia leading to shock after continuous hemorrhage and 3:1 crystalloid replacement. Am J Surg. 1975;129(6):670-4. [DOI: https://doi.org/10.1016/0002-9610(75)90343-8]. 24. Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Women's Health. 2010;55(1):20–7. [DOI: https://doi.org/10.1016/j.jmwh.2009.02.014]. 25. Tall G, Wise D, Grove P, Wilkinson C. The accuracy of external blood loss estimation by ambulance and hospital personnel. Emerg Med. 2003;15(4):318–21. [DOI: https://doi.org/10.1046/j.442-2026.03.00469.x]. 26. Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and laboratory determination of blood loss during the third stage of labour. Aust N Z J Obstet Gynaecol. 1996;36(2):152-4. [PMID: 8798302]. 27. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstetricia et Gynecologica Scandinavica. 2006;85(12):144852. [DOI: 10.080/00016340600985032]. Retrieved from http://www.academia.edu/download/43811082/Estimation_of_ blood_loss_after_cs20160317-9005-tgmv76.pdf. 28. 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 Obstet Gynecol. 2006;93(3):220-4. [DOI: 10.1016/j.ijgo.2006.02.014]. 29. Lertbunnaphong T, Lapthanapat N, Leetheeragul J, Hakularb P, Ownon A. Postpartum blood loss: visual estimation versus objective quantification with a novel birthing drape. Singapore Med J. 2016;57(6):325–8. [DOI: 10.11622/smedj.2016107]. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971452/pdf/S MJ-57-325.pdf. 30. Buckland SS, Homer CSE. Estimating blood loss after birth: Using simulated clinical examples. Women and Birth. 2007;20(2):85-8. [DOI: https://doi.org/10.1016/j.wombi.2007.01.001]. Retrieved from https://opus.lib.uts.edu.au/bitstream/10453/5571/3/20060146 32.pdf. 31. Tourné G, Collet F, Lasnier P, Seffert P. [Usefulness of a collecting bag for the diagnosis of post-partum hemorrhage]. J Gynecol Obst Bio R. 2004;33(3):229-34. [DOI: https://doi.org/10.1016/S0368-2315(04)96443-5]. 32. 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(6):1207–13. [DOI: 10.007/s00404-010-1522-1]. 33. Vitello DJ, Ripper RM, Fettiplace MR, Weinberg GL, Vitello JM. Blood density is nearly equal to water density: A validation study of the gravimetric method of measuring intraoperative blood loss. J Vet Med. 2015;2015(Article ID 152730):1-4. 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