How much is too much? Exploring clinical recognition of excessive maternal blood loss during childbirth.

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Abstract

The University of Manchester Name: Angela Hancock Award: Doctor of Philosophy Research Title: How much is too much? Exploring clinical recognition of excessive maternal blood loss following childbirth. Submission Date: July 2017 ABSTRACT Background: Postpartum haemorrhage (PPH) is the leading cause of maternal death worldwide. For every woman that dies, 20 or 30 more will experience morbidity. Severe PPH is increasing and is the leading cause of severe maternal morbidity in the UK. Rapid recognition of PPH is essential, but concealed bleeding, underestimation of blood loss and a failure to appreciate the physiological effects of blood loss, lead to delays in recognition and treatment. Experts believe that most deaths from PPH could be avoided by earlier diagnosis, but there is a lack of evidence on how to achieve this. Aims: To explore the experiences of those involved in evaluating blood loss during childbirth; and to develop and test a theory of blood loss evaluation and PPH recognition, as a prerequisite to developing strategies to support earlier diagnosis. Study Design: A sequential, exploratory mixed methods design was used. Methods: Qualitative methods included 8 focus groups and 19 one-to-one semi-structured interviews, conducted with 50 participants. These included: women and their birth partners (recruited from Liverpool Women’s Hospital); and health professionals (midwives and obstetricians recruited from Saint Mary’s Hospital, Manchester). A purposive sampling strategy was used to recruit women, who had experienced vaginal birth with or without PPH, and health professionals, with varying levels of experience in blood loss evaluation and PPH management. A snowball sampling strategy was used to recruit the birth partners of women participants. Phase one was completed from June to September 2014. All discussions were audio-recorded and transcribed verbatim. Data were managed using NVivo 10 qualitative data analysis software, which also supported the Framework approach to analysis and interpretation. Quantitative methods were used in phase two and involved 10 midwives and 11 obstetricians, recruited from Liverpool Women’s Hospital, during February and March 2015. Two scenarios, one of fast and one of slow blood loss, were presented to the sample using clinical simulation with the NOELLE® childbirth simulator, in a pilot, randomised, cross-over study. Participants also completed three questions about the use of the NOELLE® mannequin for these types of scenarios. IBM SPSS Statistics version 23 software was used for quantitative data management and to estimate descriptive statistics. Numerical crossover data were copied into StatsDirect software, to perform the crossover analyses. Results: Women and birth partners were very perceptive to blood loss but felt ill-prepared for the reality of bleeding, with many experiencing negative emotional responses to both PPH and the lochia. Non-verbal communication from staff was used by women and their birth partners to interpret the seriousness of their blood loss. Health professionals: Recognition of PPH mainly occurs as an automatic response to the speed of blood flow. Volume of blood loss is often ascertained and used retrospectively after a PPH diagnosis, to validate the intuitive response and to guide and justify on-going decisions. This was confirmed by the simulation studies, where treatment was initiated at 100ml or less in all blood loss scenarios. Fast blood loss was more likely than slow blood loss to elicit a PPH response, despite volumes in the two groups being similar. Formal quantification of blood loss is not used routinely in practice. When it is used, values are often unofficially normalised to reflect health professionals’ perceptions of the woman’s clinical condition. Tools introduced to aid diagnosis, such as blood collection bags, routine weighing and the use of early warning scores, are not routinely used in the immediate post-birth period, especially if the woman and her blood loss are perceived to be normal. The tools are again used to validate intuitive feelings about blood loss and maternal condition. When they are used, the values are often modified if they contradict professional judgement. Conclusions: Women and birth partners want more information, open communication, and on-going support, to minimise the emotional impact of blood loss. For health professionals, the speed of blood loss is the crucial factor in PPH recognition rather than an accurate assessment of the volume of blood loss. The amount of visible blood is generally not initially interpreted as a volume, but is used to compare current blood losses to those previously witnessed. Experience therefore plays a crucial role in the decisions of whether blood loss is considered normal or excessive. Formal quantification of blood loss and regular recording of physiological observations do not occur routinely in the immediate post-birth period. Therefore, women with insidious blood loss can have delayed PPH diagnosis because they have a normal blood flow and exhibit minimal physiological changes, due to the compensatory mechanisms of shock. Often such women need to exhibit outward signs of physiological compromise, such as fainting or feeling unwell, before their physiological observations and blood loss are formally re-evaluated. Education of health professionals should highlight the common errors of judgement made during blood loss evaluation and provide feedback on cases of delayed recognition. Future research should examine normal postnatal bleeding in the hours following birth, and create visual aids for women to self-diagnose insidious blood loss. Training should focus on the skills of PPH recognition, particularly those with insidious blood loss and postnatal physiological assessments. Novel tools such as the shock index should be considered and evaluated as tools of assessment.

Keyword(s)

Clinical decision-making; Excessive blood loss; Postpartum haemorrhage; Recognition

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