estimating blood loss in a birthing pool: development and … · of pph •showed that the tool...
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Estimating blood loss in a
birthing pool: development and evaluation
of an eLearning tool
Dr Ethel Burns, Oxford Brookes University @Ethel_Burns_07
Professor Lesley Smith, University of Hull @OxBUMP
Background
• PPH global prevalence of about 6% (range
5% - 15%)
• Responsible for around 25% of maternal
deaths globally LMIC
• Incidence of PPH is increasing in the UK
• 0.88% per 100,000 maternities 2013-2015
(MBRRACE-UK 2017)
Quick recognition relies primarily on
accurate estimation of blood loss
22 (0.88%: 95% CI; 0.55-1.33)
maternal deaths from
haemorrhage - care could have
been improved by better clinical
recognition
9 atonic uterus (5 CS)
1 genital tract trauma
9 placenta accreta
3 placental abruption
https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202017%20-
%20Web.pdf
Common methods for estimation of
clinical blood loss
Method Process Strengths &
limitations
Mechanical methods Calibrated drapes or
canisters
Objective
No transferability
Gravimetric methods Weighing of blood soaked
materials
Objective
No transferability
Laboratory methods Haematocrit/haemoglobin
levels
Objective
No transferability
Visual estimation of
blood loss (VEBL)
Estimation based on what
is seen
Subjective
Training improves accuracy of
visual estimations
Simulations and tools to
aid decisions
Gaps – no evaluations of
visual estimation in
waterbirth
No evidence that the
learning was retained
Aims and objectives
Develop a tool to improve midwives skills regarding
accuracy of visual estimations of blood loss, during water
birth
•To estimate the effects of an eLearning tool on
midwives’ ability to accurately estimate blood loss
during waterbirth
•To estimate midwives level of confidence in visual
estimation of blood loss
•To evaluate the acceptability of the e-learning tool
Methods – develop simulated
clinical scenarios
Video recordings in
real time
Different volumes of
blood loss from
200ml up to 1200 mls
Tool development
•Videos used with an educational session on recognition
of PPH
•Showed that the tool improved accuracy of student
midwives estimates
•Improved confidence - was acceptable
•To a certain degree was retained
•Tool refined based on these findings
•eLearning tool developed to be tested in midwives
Education Component
Evaluation of the tool
Recruitment
All qualified midwives (n=384) employed by
Oxford University Hospitals NHS Foundation
Trust (OUHT) were invited via email to participate
in this study.
Waterbirth as primary or secondary midwife
Desired sample size n=30
eLearning tool evaluation
Baseline
A self-assessment of competence questionnaire.
Six pre-recorded videos of blood loss as it occurs in a standard size
birthing pool.
Three test questions about the blood loss in each video.
Follow-up (1)
*Education Component*
A self-assessment of competence questionnaire.
Six pre-recorded videos of blood loss as it occurs in a standard size
birthing pool.
Three test questions about the blood loss in each video.
Follow-up (2)
Competence, accuracy and acceptability
Accuracy of estimates at baseline
and follow-up
0%
5%
10%
15%
20%
25%
30%
35%
40%
400mls 500mls 700mls 800mls 1000mls 1100mls
Pro
po
rtio
n o
f P
arti
cip
ants
' (%
)
Volume of actual blood loss (mls)
Pre Test
Post Test
Recognition of PPH
Midwives became better at recognising a
PPH for volumes 500-1100mls
Accuracy at follow-up
Accuracy improved
after eLearning
across all volumes
Improvement was
sustained at 6 weeks
follow-up
700 and 800 mls
were trickier
Acceptability at follow up
‘Easy to access and do in own time.’
‘The visual aid of the blood moving in the water –
much better than just pictures.’
‘The suggested ways in which to assess blood loss.’
‘Audio explanation with plan of care for each volume.’
‘Shorter videos.’
‘Be able to go back and forth between videos, to
compare then before giving answers.’
Conclusion
• The findings suggest an eLearning tool improved
visual estimation of simulated blood loss during water
birth
• Sustained at 6 weeks follow up
• Improved midwives confidence
• Was acceptable
Next steps
• Refine the tool
• Evaluate on a larger, more representative
sample
• Final adjustments and make available as a
CPD resource
Acknowledgements
Dr Ethel Burns
Megan Beckhurst
Zoe Rodd
Dr Louise Hunter
Irmgard Hupp
Anousha Goodwin
Midwives who participated
Oxford Medical Illustration
Santander student bursary
