Arch Gynecol Obstet (2011) 283:1207–1213
DOI 10.1007/s00404-010-1522-1
M A T ER N O - F E T A L M E D I C I N E
Visual estimation versus gravimetric measurement of postpartum
blood loss: a prospective cohort study
Hanan M. F. Al Kadri · Bedayah K. Al Anazi ·
Hani M. Tamim
Received: 26 March 2010 / Accepted: 10 May 2010 / Published online: 28 May 2010
© Springer-Verlag 2010
Abstract
Purpose One of the major problems in international liter-
ature is how to measure postpartum blood loss with accu-
racy. We aimed in this research to assess the accuracy of
visual estimation of postpartum blood loss (by each of two
main health-care providers) compared with the gravimetric
calculation method.
Methods We carried out a prospective cohort study at
King Abdulaziz Medical City, Riyadh, Saudi Arabia
between 1 November 2009 and 31 December 2009. All
women who were admitted to labor and delivery suite and
delivered vaginally were included in the study. Postpartum
blood loss was visually estimated by the attending physi-
cian and obstetrics nurse and then objectively calculated by
a gravimetric machine. Comparison between the three
methods of blood loss calculation was carried out.
Results A total of 150 patients were included in this
study. There was a signiWcant diVerence between the gravi-
metric calculated blood loss and both health-care providers’
estimation with a tendency to underestimate the loss by
about 30%. The background and seniority of the assessing
health-care provider did not aVect the accuracy of the esti-
mation. The corrected incidence of postpartum hemorrhage
in Saudi Arabia was found to be 1.47%.
H. M. F. Al Kadri (&) · B. K. Al Anazi
Department of Obstetrics and Gynecology,
King Abdulaziz Medical City,
King Saud Bin Abdulaziz University for Health Sciences,
College of Medicine, Riyadh, Saudi Arabia
e-mail: halkadri@gmail.com
H. M. Tamim
Department of Medical Education, College of Medicine,
King Saud Bin Abdulaziz University for Health Sciences,
Riyadh, Saudi Arabia
Conclusion Health-care providers tend to underestimate
the volume of postpartum blood loss by about 30%. Train-
ing and continuous auditing of the diagnosis of postpartum
hemorrhage is needed to avoid missing cases and thus pre-
venting associated morbidity and mortality.
Keywords Postpartum hemorrhage · Postpartum blood
loss · Maternal mortality · Maternal morbidity · Blood loss
estimation
Introduction
Postpartum hemorrhage (PPH) accounts for the majority of
obstetric hemorrhage cases internationally [1]. It is consid-
ered to be the world’s leading cause of maternal mortality.
PPH was found to be responsible for 24% of the annual
maternal deaths [1]. Overall, maternal morbidity and mor-
tality resulting from PPH depend mainly on the accurate
estimation and management of postpartum blood loss.
However, measurement of postpartum blood loss with
accuracy remains a major problem in international litera-
ture. Published data on the adequate and accurate gold-stan-
dard measurement method are lacking [2–4].
Over the years, diVerent methods have been used for the
estimation of postpartum blood loss. While visual estima-
tion of postpartum blood loss remains the most commonly
used method [2], clinical estimation remains the primary
means to diagnose the extent of obstetric bleeding. The
diagnosis of PPH can be based on a graded physiological
response to the loss of circulating blood volume [5], which
will help in directing the interventional therapy of obstetric
hemorrhage accurately.
SigniWcant diVerences between visual estimates and
actual measurements have been consistently demonstrated
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1208
in several studies [5–7]. The most common error is under-
estimation of blood loss, with an average error of 46%.
Large losses were mostly underestimated, while less than
average losses tend to be overestimated [8]. The accuracy
of estimated blood loss was not found to be dependent on
age or clinical experience of the provider [7, 9, 10]. Fur-
thermore, teaching and standardization of visual estimation
was found to signiWcantly reduce the error in visual estima-
tion performed by both experienced and inexperienced cli-
nicians [7, 9, 10].
The gravimetric method is one of the objective methods
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 sub-
tracting the known dry weights of these materials to deter-
mine the actual blood loss [11]. This method, despite its
objectivity, is time consuming and is diYcult to implement
in a busy clinical setup.
The inaccuracy in the postpartum blood loss estimation
aVects the precision of the data set collected for population-
based research. This inaccuracy may aVect the precision of
the decisions resulting from it. To achieve more reliable
data sets, continuous auditing and accurate and complete
documentation of estimated blood loss in medical records
are required [12]. Therefore, a reliable method of estima-
tion is needed.
The incidence of PPH in a tertiary care center in Riyadh,
Saudi Aarabia, based on visual estimation of postpartum
blood loss, was reported to be 1.1% [13]. If this result reX-
ects the true incidence of PPH in Saudi Arabia, it may be
considered one of the lowest PPH incidences worldwide.
The primary objective of this study was to assess the
accuracy of visually estimated postpartum blood loss com-
pared with the gravimetric calculation method in a tertiary
care center where health care is supervised and provided by
experienced obstetricians and nurses. We also assessed the
level of agreement for the visually estimated postpartum
blood loss between the two main health-care providers
(obstetrics nurse and attending physician). Furthermore, the
incidence of PPH in the same center in Saudi Arabia was
re-calculated based on the study results.
Methods
We carried out a prospective cohort study between 1
November 2009 and 31 December 2009 at the Department
of Obstetrics and Gynecology, King Abdulaziz Medical
City (KAMC), Riyadh, Saudi Arabia. KAMC is a tertiary
care referral center with more than 900 beds. Over 8,500
patients are admitted and delivered yearly, with a cesarean
section rate of about 20% and primary PPH rate of about
1.1% [13].
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Arch Gynecol Obstet (2011) 283:1207–1213
All women who were admitted to the labor and delivery
suite at KAMC and delivered vaginally were eligible to be
included in the study. Patients who received blood transfu-
sion within 24 h from their delivery or those who had ante-
partum hemorrhage within 24 h of their delivery were
excluded from the study. Included in the study were
patients who were at ¸20 weeks of gestation and did not
meet any of the exclusion criteria. Five senior residents
were trained on the use of the gravimetric machine prior to
the initiation of data collection. The training ensured that
their methods and skills in using the machine were accurate
and consistent. The obstetrics nurses and senior residents
who contributed in this research did not receive any train-
ing on postpartum blood visual estimation by the research
team.
Once the patient was included in the study and reached
the second stage of labor, she was placed in a lithiotomy
position and a special plastic bag with a pocket was placed
under her buttocks. Care was taken to prevent the contami-
nation of the collected blood with the Xuid. An assisting
physician was assigned to place an absorbable sheet under
the patients’ buttocks on top of the collecting plastic bag.
Once the baby is delivered and the Wrst gush of Xuid, urine
and feces passes, he/she will immediately remove this sheet
and open the plastic bag to allow the collection of blood.
This removed absorbable sheet was not included in the
weighted sheets and pads. All the Wve senior residents who
were involved in this study were trained to carry out this
process to guarantee timed and accurate action.
All the gauze, sheets and pads used during patients’
delivery process, suturing and fourth stage of labor were
collected. The absorbable materials placed under the
patients after delivery and those used to cover the patients
were collected when contaminated with blood. Sanitary
pads utilized during the initial patients’ observation imme-
diately after delivery were also collected. The same assist-
ing physician who helped to avoid contamination with
amniotic Xuid was responsible to keep track of any used
gauze, pads, etc., which were contaminated with blood.
These were spread on a speciWc plastic sheet to facilitate
appropriate observation. Once the patient was ready to be
transferred from labor and delivery room (usually within
1 h after delivery), the attending physician independently
estimated postpartum blood loss by visual means. Similar
estimation was done independently by the attending obstet-
rics nurse. Both the attending physician and attending nurse
did not know about each other’s estimation. After that, the
weight of all the collected gauzes, pads and absorbable
material was found using a sensitive weighing gravimetric
tool. The weight of the blood collected in the plastic bag
was also found using the same weighing machine. The pro-
cess of weighing for each patient’s actual blood loss was
performed independently by one of the research teams,
Arch Gynecol Obstet (2011) 283:1207–1213
other than the one who did the visual estimation of blood
loss for the same patient. He/she was blinded to the visual
estimation of patients’ blood loss.
Out of the total weight obtained, the dry weight of the
gauze, pads, absorbable materials, plastic sheet and the
plastic bag was subtracted. Finally, the achieved weight
represented the actual blood loss obtained through using the
gravimetric machine.
Information collected included patients’ age, parity,
labor and delivery characteristics. Moreover, information
pertaining to the investigators was collected and included
the level of experience and position. The three estimations
of blood loss, by the attending physician, attending obstet-
rics nurse and the objective gravimetric method, were docu-
mented.
Attending physicians are deWned as any senior resident
with a minimum of 3 years of experience in the obstetrics
and gynecology specialty. The physician conducted the
patients’ delivery and implemented the study methodology
as per the study protocol. Attending obstetrics nurse is one
with a minimum of 3 years of experience in labor and
delivery patients’ management.
The gravimetric estimation of blood loss is an objective
method that includes sensitive weighing of the lost blood
collected as well as materials such as soaked pads, gauze
and others. Visual estimation of blood loss is the physician/
obstetrics nurse estimation of blood loss in milliliters (ml)
based on their impression utilizing their previous experi-
ence.
Serum antenatal hemoglobin concentration is deWned as
the level of hemoglobin in gram/deciliter (g/dl) estimated at
or within 1 week prior to the onset of labor. Postpartum
hemoglobin is deWned as serum hemoglobin in g/dl esti-
mated 6–72 h after delivery. Active management of third
stage of labor is practiced by giving the patients 10 units of
oxytocin intramuscularly with the crowning of the head and
delivering the placenta by controlled cord traction.
Data management and analysis
Collected data were entered into SPSS program (version
15). Continuous variables were categorized according to
clinically relevant cutoV points. Descriptive analyses were
carried out by calculating the number and percentage for
the categorical variables, and mean and standard deviation
(SD) for continuous variables. The signiWcance of the
diVerence between the three methods of blood loss calcula-
tion was found and correlation between the three methods
carried out. A p value of ·0.05 was considered to be statis-
tically signiWcant. The correlation between the diVerent
methods of blood loss estimation and maximum hemoglo-
bin drop after delivery was also calculated. Moreover, we
calculated the diVerence between the calculated blood loss
1209
and the estimations done by each of the nurse and the doc-
tor, and the mean and 95% conWdence interval were calcu-
lated.
To detect a diVerence of 60 ml between the diVerent
methods used to calculate postpartum blood loss (estima-
tion of blood loss by attending physician, attending obstet-
rics nurse and gravimetric method) with the power of 80%,
a minimum sample size of 139 patients was decided to be
included.
King Abdullah International Medical Research Centre
approval was obtained prior to the conduction of the study.
As the study did not interfere with patients’ management,
no consent was obtained from the involved patients.
Results
A total of 150 patients were included in this study and met
the inclusion and exclusion criteria. The attending physi-
cians who calculated the patients’ postpartum blood loss
included Wve senior residents. Their average number of
years of experience was 3.8 (SD 0.8) years. The attending
nurses included 23 obstetrics nurses. Their average number
of years of experience was 6.6 (SD 3.2) years.
The characteristics of the patients included in the study
are presented in Table 1. The patients’ age was ranging
between 16 and 44 years old, mean age and standard devia-
tion were 27.8 § 5.9. The majority of patients, 138 (92%),
were free from any medical disorder. Previous CS delivery
was found in 12 patients (8%). It was found that 125 (83%)
started their labor spontaneously, while the rest required
induction of labor either by oxytocin or prostaglandins E2.
Moreover, 137 (91.3%) patients had spontaneous vaginal
delivery (SVD), while 7 (4.7%) had ventouse delivery and
4 (2.7%) were delivered by forceps.
Table 2 summarizes the estimation of postpartum blood
loss by the attending physicians and obstetrics nurses, and
the gravimetric calculation of blood loss. There were no
signiWcant diVerences between the estimation done by the
obstetrics nurse 213.0 (SD 86.2) ml ranging between 100
and 900 ml, and the attending physicians 214.3 (SD 88.1)
ml ranging between 100 and 950 ml. On the other hand, the
diVerence was clear between their visual estimation assess-
ment and the gravimetric calculation of postpartum blood
loss 304.9 (SD 114.9) ml ranging between 75 and 1,430 ml.
There were signiWcant diVerences between the gravimetric
calculation and estimation of blood loss by both nurses and
physicians.
The error in PPH estimation between the gravimetric
calculation and obstetrics nurse estimation was approxi-
mately 30%. An error of 29.5% was found between the
postpartum blood loss estimated by the attending physi-
cians and the gravimetric calculation of blood loss. The
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1210 Arch Gynecol Obstet (2011) 283:1207–1213

Table 1 Characteristics of the patients included in the study obtained in the correlation between the estimation of blood
Patients characteristics N (%)
loss done visually by the attending obstetrics nurse and the
gravimetric calculation of blood loss, p < 0.0001. Serum
Yes No hemoglobin of 147 patients was estimated within the Wrst
Booking status 111 (74.0) 39 (26.0) 12 h after delivery and in only 3 patients 12 h after deliv-
Medical history
ery. There was no linear correlation or signiWcant correla-
No medical problem 138 (92.0) 12 (8.0)
tion between all the three methods of postpartum blood loss
and the drop of patients’ hemoglobin (before and after
Type II diabetes 1 (0.7) 149 (99.3)
delivery). This lack of linear correlation persisted even after
GDM 11 (7.3) 139 (92.7)
excluding the three cases who had their postpartum hemo-
PET 2 (1.3) 148 (98.7)
globin estimated later than 12 h after delivery.
Essential hypertension 1 (0.7) 149 (99.3)
The level of inaccuracy of the estimated postpartum
Hemoglobinopathies 1 (0.7) 149 (99.3)
blood loss was assessed to be about 30% in this study.
Others 6 (4.0) 144 (96.0)
Obstetrics history
Previous CS 12 (8.0) 138 (92.0)
Discussion
Previous PPH 3 (2.0) 147 (98.0)
Multiple pregnancies 2 (1.3) 148 (98.7)
PPH is one of the main reasons behind maternal death
Labor characteristics worldwide, and it remains a signiWcant source of maternal
Spontaneous labor 125 (83.3) 25 (16.7) morbidity [2]. The results of this study showed signiWcant
Induction by PGE2 13 (8.7) 137 (91.3) diVerences between the estimation (underestimation) of
Induction by other methods 12 (8) 138 (92) postpartum blood loss by the attending physicians and its
CTG abnormalities 5 (3.3) 145 (76.7) calculation utilizing a sensitive gravimetric machine. The
Delivery characteristics study also showed signiWcant diVerences between the esti-
Spontaneous vaginal delivery 137 (91.3) 13 (8.7) mation of postpartum blood loss by the obstetrics nurses
Ventouse delivery 7 (4.7) 143 (95.3) attending patients’ delivery and the calculated blood loss
Forceps delivery 4 (2.7 146 (97.3) using a gravimetric machine. However, these diVerences
Active management of third stage 142 (94.7) 8 (5.3) were not observed on comparing the visual estimation per-
Delivery complications formed by the two health-care providers involved in this
Vaginal/cervical tears 1 (0.7) 149 (99.3) research. The two groups of health-care providers wrongly
Uterine atony 3 (2.0) 147 (98.0) estimated postpartum blood loss. This indicates a similar
RPOC/retained placenta 0 (0.0) 150 (100.0) level of error despite the diVerent backgrounds and experi-
GDM gestational diabetes, PET preeclampsia, CS cesarean section,
ences. It may reXect also a similar inherited wrong strategy
PPH postpartum hemorrhage, CTG cardiotocography, RPOC retained in their visual estimation of blood loss. The visual estima-
products of conception tion of postpartum blood loss as a standard procedure of
estimation of obstetric bleeding was found to be an unreli-
able method in agreement with other research [14]. The lit-
mean of hemoglobin drop (pre-delivery minus post-deliv- erature indicates that the seniority of the health-care
ery hemoglobin) was ¡0.89 (SD 0.41) (Table 2). provider assessing postpartum blood loss does not aVect the
In Table 3, we calculated the correlation between the accuracy of this estimation [15]. Moreover, visual estima-
three main methods used for the estimation of postpartum tion of blood loss by health-care professionals compared to
blood loss. We found a linear correlation and signiWcant laypersons was found to be highly inaccurate [16].
diVerence between the estimation of blood loss done visu- As a result of inaccurate visual estimation of postpartum
ally by the attending physician and the gravimetric calcula- blood loss (30% in this study), primary PPH at KAMC,
tion of blood loss, p < 0.0001. A similar Wnding was Riyadh is estimated to be higher than 1.1% that reported
Table 2 The diVerence between diVerent blood estimation methods and the decrease in hemoglobin of the studied population
Type of estimation N Mean (ml) SD p value (95% CI)

Gravimetric calculated blood loss 150 304.1 114.9 Reference

Estimated blood loss by obstetrics nurse 150 213.0 86.2 <0.0001 (80.1–102.1)
Estimated blood loss by attending physicians 150 214.3 88.1 <0.0001 (79.1–100.6)
Decrease in hemoglobin level (pre–post delivery) 150 ¡0.9 0.4 Not applicable

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Arch Gynecol Obstet (2011) 283:1207–1213 1211

Table 3 SigniWcance of the correlation between the diVerent postpartum blood loss assessment methods used for the study population and level
of hemoglobin drop
Type of estimation Type of estimation Correlation p value

Gravimetric calculated blood loss Estimated blood loss by obstetrics nurse 0.95 <0.0001
Estimated blood loss by attending physicians 0.95 <0.0001
Decrease in hemoglobin level (pre–post delivery) ¡0.11 0.19
Estimated blood loss by obstetrics nurse Gravimetric calculated blood loss 0.95 <0.0001
Estimated blood loss by attending physicians 0.99 <0.0001
Decrease in hemoglobin level (pre–post delivery) ¡0.80 0.33
Estimated blood loss by attending physicians Gravimetric calculated blood loss 0.95 <0.0001
Estimated blood loss by obstetrics nurse 0.99 <0.0001
Drop of hemoglobin level (pre–post delivery) ¡0.82 0.32
Drop of hemoglobin level (pre–post delivery) Gravimetric calculated blood loss ¡0.11 0.19
Estimated blood loss by obstetrics nurse ¡0.80 0.33
Estimated blood loss by attending physicians ¡0.82 0.32

previously [13]. On re-calculation, PPH has been found to
aVect approximately 1.43% of the delivering patients in a
tertiary care center in Saudi Arabia. Being the only inci-
dence reported on primary PPH in Saudi Arabia, it can be
taken as a benchmark for further multicenter studies on the
incidence of primary PPH that represents the whole Saudi
population.
Inaccurate diagnosis of this serious delivery complica-
tion (PPH) in 30–46% [8] of the patients expose them to
preventable morbidity and mortality [17]. Therefore, eVort
should be taken to prevent or at least detect and manage
PPH early [18]. However, primary PPH incidence of 1.43 is
considered low compared to other countries of the world.
Wide variation in PPH incidence has been reported in liter-
ature, ranging from as low as 0.55% of deliveries in Qatar
to as high as 17.5% in Honduras [19]. We expect that the
level of blood loss estimation inaccuracy and possible
missed PPH cases are much higher in less advanced setups
even within Saudi Arabia. A population-based research to
determine the true incidence of postpartum hemorrhage is
recommended.
Universally, guidelines on the management of PPH have
stressed the importance of accurate estimation of blood loss
and the clinical condition of the hemorrhaging patient [5].
The utilized method of blood loss assessment should be
accurate, practical, consistent and able to be communicated
and incorporated into labor ward protocols. Moreover, it
should be easily measurable and reproducible. The major
advantages favoring visual estimation of blood loss are its
simplicity and real-time assessment where the birth atten-
dants can correlate their Wndings on an individualized basis.
This should be correlated with patients’ clinical condition
that reXects the seriousness of the loss. This act is important
even when the estimated loss does not indicate the presence
of PPH. For example, patients who start their labor while
anemic are at higher risk that should be considered seri-
ously in deciding their management [5]. A classiWcation
was proposed by Benedetti et al. [20] where volume loss is
assessed in conjunction with clinical signs and symptoms.
This classiWcation was proposed as being mainly useful in
fully equipped hospitals and obstetric units [20]. The pro-
posed classiWcation adopts a practical clinical approach.
However, to our knowledge no research has assessed the
eVect of these factors combined (education and clinical
assessment) on the accuracy of visual estimation of post-
partum blood loss: a topic for future research. Meanwhile,
management of PPH patients, as discussed before, should
be planned and decided based primarily on clinical Wndings
rather than solely on the visual estimation of blood loss.
Research has conWrmed the role of education and simu-
lation utilization [21], including clinical assessment of
bleeding patients, in the accuracy of postpartum blood loss
estimation. Therefore, based on this research and other pub-
lished [5, 22–24], we recommend the implementation of an
education program to accurately estimate postpartum blood
loss and utilize patients’ clinical scenarios in this estima-
tion. We expect such a program to reduce the error in post-
partum blood loss estimation from 30% based on this
research to 46% [8].
The utilization of a collection pelvis bag has proved to
be a rapid and more precise procedure to diagnose PPH in
the delivery suite. It enables a quantitative non subjective
rather than visual subjective estimation of blood loss.
Because of its simplicity and very low cost, the collecting
pelvis bag has been advised for use widely as a routine pre-
ventive measure [2]. In this research, the bag was utilized
subjectively for the visual estimation of blood loss and,
therefore, it did not lead to error reduction.
Lack of signiWcant correlation between the decrease in
patients’ hemoglobin pre- and post-delivery and their

123
1212
gravimetric calculated blood loss could be a result of our
exclusion criteria. All patients who bled within 24 h before
delivery and those who had blood transfusion within 24 h
after delivery were excluded from the study. As a result,
patients who had a signiWcant decrease in their hemoglobin
were not included in the research. On the other hand, this
prevented the inclusion of patients who had decreased
hemoglobin before delivery and those who had their hemo-
globin concentration elevated due to blood transfusion and
therefore their levels were unreliable in reXecting their
postpartum blood loss. We should not neglect the possible
eVect of physiological changes occurring postpartum on the
blood circulation [25] and the accuracy of early postpartum
hemoglobin concentration. Another factor to be considered
is the role of intravenous hydration received by the patients
during labor on the accuracy of their postpartum hemoglo-
bin concentration [26]. Another limitation in this research
is the possibility of contamination of the collected blood
with other Xuids. Although eVorts were taken to avoid this
contamination, we cannot rule out such an eVect. But, we
believe that it will not aVect the Wnal conclusion of the
study.
Conclusion
An average error of postpartum blood loss estimation up to
30% was detected when visual estimates at the time of
delivery were compared with more precise measurements.
There was a level of agreement between the diVerent care
providers in the estimation of blood loss. The background
and seniority of the assessing health-care providers did not
aVect the accuracy of the estimation. Based on the achieved
30% error in the assessment of blood loss, the corrected
incidence of primary PPH in Saudi Arabia was recalculated
as 1.47%. This remains as one of the lowest reported inci-
dences in the world. Finally, eVorts should be made to unify
the assessment and management of PPH patients through
education and standardization.
ConXict of interest statement The authors declare no conXict of
interest.
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