The Recognition of Excessive blood loss At ChildbirTh (REACT) Study: A two-phase exploratory, sequential mixed methods inquiry using focus groups, interviews, and a pilot, randomised crossover study
Division of Nursing, Midwifery & Social Work, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK. Sanyu Research Unit, Dept of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Crown St, Liverpool, L8 7SS, UK. Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
BJOG : an international journal of obstetrics and gynaecology. 2021
Women following vaginal birth, birth partners, midwives and obstetricians in two centres in the UK (n= 51).
Intervention
Simulation of ‘slow blood loss followed by fast blood loss’ (n= 10).
Comparison
Simulation of ‘fast blood loss followed by slow blood loss’ (n= 11).
Outcome
This mixed methods study had a qualitative phase involving focus groups and interviews, and a quantitative phase consisting in a randomised crossover study. Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a postpartum haemorrhage (PPH) diagnosis, to validate intuitive decisions and guide on-going management. During simulations, PPH treatment was initiated at volumes at or below 200ml (fast mean blood loss 79.6ml, SD 41.1; slow mean blood loss 62.6ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2ml).
Abstract
OBJECTIVES To explore how childbirth-related blood loss is evaluated and excessive bleeding recognised; and develop and test a theory of postpartum haemorrhage (PPH) diagnosis. DESIGN Two-phase, exploratory, sequential mixed methods design using focus groups, interviews and a pilot, randomised crossover study. SETTING Two hospitals in North West England. SAMPLE Women (following vaginal birth with and without PPH), birth partners, midwives
and obstetricians. METHODS Phase 1 (qualitative): 8 focus groups and 20 one-to-one, semi-structured interviews were conducted with 15 women, 5 birth partners, 11 obstetricians, 1 obstetric anaesthetist and 19 midwives (n=51). Phase 2 (quantitative): 11 obstetricians and 10 midwives (n=21) completed two simulations of fast and slow blood loss using a high-fidelity childbirth simulator. RESULTS Responses to blood loss were described as automatic, intuitive reactions to the speed, nature and visibility of blood flow. Health professionals reported that quantifying volume was most useful after a PPH diagnosis, to validate intuitive decisions and guide on-going management. During simulations, PPH treatment was initiated at volumes at or below 200ml (fast mean blood loss 79.6ml, SD 41.1; slow mean blood loss 62.6ml, SD 27.7). All participants treated fast, visible blood loss, but only half treated slow blood loss, despite there being no difference in volumes (difference 18.2ml, 95% CI -5.6 to 42.2ml, p=0.124). CONCLUSIONS Experience and intuition, rather than blood loss volume, inform recognition of excessive blood loss after birth. Women and birth partners want more information and open communication about blood loss. Further research exploring clinical decision-making and how to support it is required.
