4 T's of Postpartum Hemorrhage

[Dr. Christopher Beck]
Can we talk about what is postpartum hemorrhage? Roxane, why don't we start with you? Then I'll let you guys kind of guide the conversation after we get some floor information established.

[Dr. Roxane Rampersad]
Recently, ACOG has changed that definition to include blood loss greater than 1,000 ccs. I think that's the number that we're paying attention to. For vaginal delivery though, even though greater than 500 may not change your hemodynamic state, it's still an important number to look at for vaginal delivery. Greater than 500 and less than 1,000 is still an important number to pay attention to if someone has reached that state of blood loss after vaginal delivery.

[Dr. Anthony Shanks]
One thing I want to point out for people that are listening that don't know, ACOG is the American College of Obstetricians and Gynecologists and they set our ground rules for what we do in practice. I feel like many of us get a chance to serve on those committees to interpret the evidence and make these protocols, but we really take them as guidance on what we do. When we trained like when we talk about blood loss, if you remember--

[Dr. Christopher Beck]
When did you guys train? How far back are we talking?

[Dr. Roxane Rampersad]
Oh, Tony. Do you have to keep bringing that up?

[Dr. Roxane Rampersad]
We are not dinosaurs.

[Dr. Anthony Shanks]
We are not dinosaurs. That is true. Why I bring it up is, if you remember an interventional radiologist back when you were doing your clerkships through labor and delivery, the nature of deliveries, there is going to be blood loss at that time. When we do them, we used to qualitatively measure blood. I actually googled these pictures because I remember looking at a lap sponge and then having to make a guess on how much blood there is. Now, there's been this movement where we have to do quantitative blood loss. Dr. Rampersad, you want to tell us what quantitative blood loss is?

[Dr. Roxane Rampersad]
Gosh, quantitative blood loss, I think, is the bane of our practice at our university. You're right.

[Dr. Anthony Shanks]
Why is that?

[Dr. Roxane Rampersad]
Because it was really easy to estimate blood loss. I think we looked at the bag, we looked at the laps, and we looked at the blood all around, and we're like, "You know what? That's 500 ccs. We all learned what our 500 and what our 400 look like. Quantitative blood loss is a little bit more labor-intensive. Our nurses now have to gather everything that has blood on it and they have to weigh it.

They have to know what it weighs prior to the delivery and what it weighs with blood. We also have to take into account amniotic fluid, which is also lost at the time of delivery. It's not an easy thing to do, but it's something that we've switched over because qualitative blood loss is probably not as accurate as quantitative blood loss. I know that's controversial too.

There's a lot of people that battle that back and forth. I think even ACOG has changed a little bit on that where I don't think they're pushing, I think, quantitative blood loss. I think a lot of other societies and a lot of what are called perinatal quality collaboratives in each state that follow maternal mortality and follow metrics like these quality improvement metrics still use and are still pushing quantitative blood loss.

[Dr. Anthony Shanks]
It's like 1 gram is equivalent to 1 milliliter. With the new definitions of it being like 1,000 milliliters, whether it's a vaginal delivery or C-section. Now, it's really up to the nurses to help us out. Because when you're in a C-section, certainly, you're focused on the field and you're going to rely on your nurses to measure that. What Roxane was mentioning I find interesting is that there are so many things that we do where we're trying to be objective.

I do think going forward, I definitely feel like even though it's uncomfortable learning this new thing, I feel like it makes sense. We'll get better at measuring things and I think that we'll be able to respond to changes better. You're going to hear us use the term "protocol" a lot. I've shared this analogy with Roxane in the past, but I feel like labor and delivery, sometimes it's a lot like baseball. It's a sporting metaphor here is that there's a lot of times when you're just going to be sitting around.

You'll be waiting for the ball to be hit to you. When you have in your head like if you're in center field and you know if that ball is hit to you, what base you're going to throw to, same with protocols. I know exactly where I'm going to go with what's next. You have to think about that each time because even though we have some predictors that we'll get into, when it happens, you have to be ready in that moment and know where you're throwing.

[Dr. Christopher Beck]
All right, excellent. All right, so we know some quantitative numbers for postpartum hemorrhage. Do you guys make any distinction between early-late postpartum hemorrhage? Can you talk about maybe some of the timing issues regarding hemorrhage? Of course, you're counting laps and you're trying to have an idea of how much blood loss, but then there's also the clinical picture of what's the patient doing on the table or on the field.

[Dr. Roxane Rampersad]
Sure, so acute and late are how we differentiate the blood loss. Acute is within that first 24 hours and late is beyond that 24 hours and really up to 12 weeks is how we differentiate blood loss.

[Dr. Anthony Shanks]
All right, so let's think future state. We've covered, Roxane, what things are like now. What are we working on with Jada and everything? We have the protocols. Specifically, with postpartum hemorrhage, what do you think we need to be cognizant of? Where do you think things are going? What do you think we could potentially do to offset this in the future?

[Dr. Roxane Rampersad]
Gosh, Tony, that's a really good question and blew my mind here. I don't know besides [chuckles] tamponade and what else we can do. You know what? Actually, let me take that back. I think one of the things that's really exciting that potentially could help us are these devices that engineers are looking at that are wearable, that potentially could let us know about the hemodynamic state before we're behind the eight ball because that's the issue, right, is that oftentimes when we recognize it, that patient could be already behind the eight ball and we're trying to catch up.

I think that would be an amazing thing. Patients would come in. They would be laboring or they could be in the operating room. They would wear some sort of optical device that's looking at that volume and hemodynamic states. That could clue us in, "Hey, your patient is going to be in trouble." Start doing these things potentially. Maybe you need to start thinking about transfusion ahead of time, or maybe you need to start thinking about ligating vessels or being more expedient with your surgery. That, I think, could be something in the future that could really help us.

[Dr. Anthony Shanks]
Yes, I love to think about these moonshots. I think that's how you get these big developments, not just in medicine but in anything. It's usually something that's a little bit outside of the box. I love the idea of personalized medicine. That's just one aspect of it. Certainly, in the most acute of settings that you can keep track of that person's vital signs before they get too sick.

I think in terms of the etiology for these postpartum hemorrhages, we've had such a focus on creating a diagnosis and preparation. Boy, I wish there was a way to prevent it. If there was some way, maybe after a delivery that you could apply something on the inside of a non-pregnant uterus that can reestablish a stable wall internally. Again, pie in the sky. That may be something 50 years down the road. Somebody will be able to figure out, but I think that would be cool.