• P Bose, F Regan, and S Paterson-Brown.
• Department of Obstetrics and Gynaecology, Queen Charlotte's Hospital, London, UK. Email p.bose@imperial.ac.uk
• BJOG. 2006 Aug 1;113(8):919-24.

ObjectivesFollowing the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of 'visual estimation of blood loss' and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage.DesignObservational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL).SettingTeaching hospital.PopulationHundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants.MethodsClinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial 'algorithm' suitable for use as a teaching tool in labour ward.Main Outcome MeasuresAreas of greatest discrepancy between EBL and ABL.ResultsSignificant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500-ml (50-cm diameter) floor spill, 1000-ml (75-cm diameter) floor spill, 1500-ml (100-cm diameter) floor spill, 350-ml capacity of soaked 45- x 45-cm large swab and the 2-l vaginal postpartum haemorrhage on bed/floor.ConclusionsAccurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.

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