Gravimetric assessment of postpartum blood loss: training and implementation in a low resource setting

What is already known about the topic? * The gravimetric method estimates the blood loss volume by weighing sanitary materials used during the labour process (i.e., gauze, sheets, swabs, pads, etc.) before and after being contaminated by the blood. * In clinical practice, the weight difference (in grams) is considered as 'blood loss volume' for ease of measurement and reported in millilitres without any formal conversion of units of weight to volume. * The benefits of the gravimetric method have been reported previously. What this paper adds * An online training programme is effective in increasing midwives' knowledge and awareness of the gravimetric method for postpartum blood loss assessment. * The midwives found the gravimetric method simple to adopt in clinical practice, which increased their confidence in detecting postpartum haemorrhage. * The midwives encountered some barriers while implementing the gravimetric method and provided strategies to mitigate the issues raised. BACKGROUND Postpartum haemorrhage (PPH) is defined as "a blood loss of 500 ml or more within 24 hours after birth1'?-3'" while severe PPH is "blood loss greater than or equal to 1000 ml within 24 hours.2'?-1'" Severe PPH is associated with one or more of the following conditions: blood transfusion, transcatheter arterial embolisation, arterial ligation, uterine surgery, hysterectomy, long-term psychological impact, or even maternal death.3"5 As a life-threatening condition,4 postpartum haemorrhage is estimated to account for 27% of maternal deaths worldwide6 and 30% of maternal deaths in Indonesia.7 In Indonesia, this percentage has remained stable from 2012 to 20ig.7,8 Postpartum haemorrhage diagnosis relies in part on the accuracy of blood loss assessment.9,10 A delay in PPH management may lead to poor outcomes which is often caused by a delayed diagnosis of PPH.11 Rosmaria et al. found that 94% of Indonesian midwives involved in that study did not routinely assess blood loss volume.10 Moreover, there is currently no recommended gold standard for assessing blood loss to help PPH diagnosis.1213 Blood loss can be measured using a number of methods, including colourimetric,14 photometric,15 semi-automatic,16,17 mathematical formulas,18 computer-based mathematical modelling,19 and radioisotope dilution methods.20 Nevertheless, most of them are complicated and impractical to apply in a real-life midwifery practice.18 The most common method used to estimate blood loss by health professionals worldwide is a visual method due to its ease of use, and can be easily and quickly done at various levels of health facilities.9,18,21 Despite the benefits of this method, it has been found to be inaccurate, in particular when there are higher levels of blood loss.10-15,18,22 Therefore, Bose et al. (2006) and Schorn (2010) suggested replacing visual checks with a more accurate measure for assessing blood loss volume.15,22 The gravimetric method (GM) has been recommended due to its accuracy and relative simplicity of use.23,24 This method is an assessment carried out by weighing all maternity pads before and after being exposed to blood, followed by calculating the weight difference.9,25,26 It is an evidence-based method of blood loss assessment, and evidence suggests that it may help in the diagnosis and management of PPH by providing a more accurate assessment of blood loss, therefore improving patient safety27 However, this method is not routinely used by Indonesian midwives.10 No previous research was identified that explored the evaluation of training midwives in the GM and exploring barriers and facilitators to the implementation in practice.

"We Should Be Working Together, and It Felt like They Disrupted That": Pregnant Women and Partners' Experiences of Maternity Care in the First UK COVID-19 Pandemic Lockdown.

Pregnant women were identified as being at elevated risk from COVID-19 early in the pandemic. Certain restrictions were placed upon birth partners accompanying their pregnant partner to in-person maternity consultations and for in-patient maternity care. In the absence of a central directive in England, the nature of restrictions varied across maternity services. Eleven participants (seven pregnant women and four partners), who were expectant parents during the first UK COVID-19 pandemic lockdown, took part in serial interviews in pregnancy and the postnatal period. Data were subject to a reflexive thematic analysis. Four main themes were identified, with sub-themes: uncertainty and anxiety (uncertainty and anxiety about COVID-19, uncertainty and anxiety about maternity services); disruption of partnering and parenting role; complexity around entering hospital spaces (hospitals offering protection while posing threat, individual health professionals in inflexible systems); and attempting to feel in control. Separating couples may result in disruption to their anticipated roles and significant distress to both partners, with potential impacts for mental health and future family relationships. Trauma-informed perspectives are relevant for understanding parents' experiences of maternity care in the pandemic and identifying ways to improve care to promote and protect the mental health of all parents.

Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector.

Background: Perinatal mental health (PMH) difficulties affect approximately one in five birthing women. If not identified and managed appropriately, these PMH difficulties can carry impacts across generations, affecting mental health and relationship outcomes. There are known inequalities in identification and management across the healthcare pathway. Whilst barriers and facilitators have been identified there is a lack of clarity about how these relate to the avoidable and unfair inequalities experienced by various groups of women. Further research is required to understand how to address inequalities in PMH. Aim: To understand the key factors that enable and hinder access to PMH care for women from minoritised groups across the PMH care pathway, and how these have been affected by the COVID-19 pandemic. Methods: A sequential mixed-methods approach gathered views and experiences from stakeholders in one region in northern England. This included an online survey with 145 NHS healthcare practitioners and semi-structured interviews with 19 women from ethnic minority and/or socio-economically deprived backgrounds who had experienced PMH difficulties, and 12 key informants from the voluntary and community sector workforce. Quantitative data were analysed using descriptive statistics and framework analysis was applied to qualitative data. Findings: Barriers and facilitators were mapped using a socio-technical framework to understand the role of (i) processes, (ii) people (organised as women, practitioners and others), (iii) technology, and (iv) the system as a whole in deepening or alleviating inequalities. Influences that were identified as pertinent to inequalities in identification and management included provision of interpreters, digital exclusion, stigma, disempowerment, distrust of services, practitioner attitudes, data capture, representation in the workforce, narrow rules of engagement and partnership working. Stakeholder groups expressed that several barriers were further compounded by the COVID-19 pandemic. Discussion: The findings highlight the need for change at the system level to tackle inequalities across the PMH care pathway. Four inter-connected recommendations were developed to enable this systems change: building emotional safety between professionals and women; making PMH a part of core healthcare business; increasing cultural competency specific to PMH; and enhanced partnership working.

Experiences of maternity care during the COVID-19 pandemic in the North of England

Background: During 2020, UK maternity services made changes to service delivery in response to the COVID-19 pandemic. Aims: To explore service users' and their partners' experiences of maternity services in the North of England during the COVID-19 pandemic. Methods: Respondents (n=606) completed a co-produced survey during August 2020. Data were analysed using descriptive statistics and content analysis. Findings: Five major categories were identified: valuing support from health professionals, feeling lost in and let down by the system, the impact of restrictions to partners and others, virtual contact is not the same as in-person contact, and the need for emotional and psychological wellbeing support. Conclusion: The changes implemented may have compromised mental health and wellbeing in a critical period of vulnerability. Bringing stakeholders together can maximise learning from the emergency measures, to better inform future service provision. Work is needed to better hear from minoritised groups and ensure they are not further marginalised by changes. [ABSTRACT FROM AUTHOR] Copyright of British Journal of Midwifery is the property of Mark Allen Holdings Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)