New Study: Powering Stage-Based Hemorrhage Protocols in Obstetrics


By Griffeth Tully, M.D., Chief Medical Officer, Gauss Surgical

Between 1993 to 2014, severe maternal morbidity increased by almost 200 percent in the United States.1 The rise in severe maternal morbidity is attributed mainly to an increase in red cell and component transfusion given in response to postpartum hemorrhage. Tragically, these medical incidents are frequently preventable.

Image courtesy US Centers for Disease Control and Prevention

Image courtesy US Centers for Disease Control and Prevention

Leading obstetrics organizations, such as ACOG, CMQCC, and SMFM, unilaterally recommend protocols that link hemorrhage management with cumulative blood loss measurement during vaginal or cesarean delivery. 2 3 To follow these stage-based protocols, however, providers must access cumulative blood loss information in real time. This is a formidable challenge as most hospitals still either rely upon visual estimation of blood loss, which is notoriously inaccurate4, or use manual approaches to the quantification of blood loss (QBL). For example, a recent publication from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) reported that gravimetric QBL compliance within two hours of delivery in New Jersey and Georgia is below 12%, due to several factors, including the associated workflow burden. 5 QBL effectiveness is further complicated in the operating room due to the presence of non-sanguineous fluids. 6 As argued in a recent AWHONN “Quantification of Blood Loss” Practice Brief, the lack of effective blood loss monitoring workflows is contributing to a national maternal health crisis. 7

This month, the International Journal of Obstetric Anesthesia published a groundbreaking study of a system-wide attempt to modernize blood loss monitoring workflows and assess the clinical and financial impact of improved stage-based hemorrhage protocol compliance. 8

Katz D, et al. researchers used Gauss Surgical’s Triton system to monitor blood loss in over 3800 vaginal and cesarean deliveries at Mount Sinai Hospital. Researchers compared these to a similar number of deliveries the prior year in which blood loss was assessed using visual estimation. Katz D, et al. subsequently determined that this comprehensive effort to monitor blood loss, supported by the Triton system as enabling technology, drove stage-based hemorrhage management compliance and produced earlier hemorrhage identification and intervention.

Key findings from the study are summarized here:


Wider distribution of blood loss

In both vaginal and cesarean delivery intervention (i.e., Triton) groups, study authors observed a lower mean blood loss and a wider distribution of blood loss.

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Increased hemorrhage recognition

Study authors also reported an increase in the incidence of hemorrhage (blood loss > 1 L) recognized in the intervention group for both vaginal and cesarean deliveries. Researchers detected postpartum hemorrhage in 2.2% of vaginal deliveries vs. in 0.5% of the control group (P<0.001). In the Triton group, the authors also found postpartum hemorrhage in 12.6% of cesarean deliveries, vs. in 6.4% of the control group (P<0.001).

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Earlier transfusions (vaginal deliveries)

In the Triton group, earlier recognition of hemorrhage led to earlier management. With Triton, when a transfusion occurred in a vaginal delivery, it was much less likely to have been given outside of the labor floor (71% of control group transfusions in vaginal deliveries occurred in the postpartum ward vs. 47% in the Triton group; P=0.046).

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Increased secondary uterotonic usage (vaginal deliveries)

There was also a significant increase in the use of secondary uterotonics in vaginal deliveries in the intervention group, indicating more timely intervention for bleeding.

Katz, D. Increased Use of Secondary Uterotonics.JPG

Reduced transfusion dose (C-sections)

For transfused c-section patients, there was a statistically significant decrease in transfusion dose in the intervention group, indicating a more targeted and efficient use of blood product.

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Decreased lab costs

The study found that more accurate blood loss information also led the clinical team to change their protocol for ordering lab tests.

In the intervention group, the information provided by the Triton system enabled clinicians to order CBCs more selectively rather than on every patient as a surrogate for hemorrhage recognition. This led to a significant reduction in direct lab costs per patient, which drove over $200,000 in annualized cost savings in the intervention group, providing an estimated 152% return on investment vs. the acquisition cost of the Triton system.

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Growing Evidence for Patient Care Impact 

To date, there have been fifteen published peer-reviewed articles investigating Triton. This body of research, including the new study from Katz D, et al., asserts that accurate, real-time blood loss monitoring, powered by Triton, positively impacts patient care and outcomes.

The medical community has the tools to support widespread implementation of stage-based hemorrhage protocols. Now is the time. 


Watch Dr. Katz present the results of his study and share clinical experiences with use of Triton at Mount Sinai Hospital in this recorded webinar, hosted by Gauss.



1 Severe Maternal Morbidity in the United States | Pregnancy | Reproductive Health |CDC. (n.d.). Retrieved June 17, 2019, from Page last reviewed and updated: May 22, 2017

2 Shields LE, et al. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol 2015; March: 272-280

3 Main, et al. National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol 2015;126:155–62

4 Patel et al., 2006Patel, A., Goudar, S.S., Geller, S.E., Kodkany, B.S., Edlavitch, S.A., Wagh, K., and Derman, R.J. Drape estimation vs. visual assessment for estimating postpartum hemorrhage. International Journal of Gynaecology & Obstetrics. 2006; 93: 220–224

5 Bingham D, Scheich B, Byfield R, Wilson B, Bateman BT Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. J Obstet Gynecol Neonatal Nurs. 2016 Mar-Apr;45(2):227-38. doi: 10.1016/j.jogn.2015.12.003.

6 Bingham, D., Scheich, B., Byfield, R., Wilson, B., & Bateman, B. T. (2016). Postpartum Hemorrhage Preparedness Elements Vary Among Hospitals in New Jersey and Georgia. Retrieved from

7 Quantification of Blood Loss: AWHONN Practice Brief Number 1 (Vol. JOGNN, 00, 1–3; 2014., Issue brief). (n.d.). Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses. Doi: 10.1111/1552-6909.12519

8 Katz, D., Wang, R., O'Neil, L., Gerber, C., Lankford, A., Rogers, T., Gal, J., Sandler, R., Beilin, Y., The association between the introduction of quantitative assessment of postpartum blood loss and institutional changes in clinical practice: an observational study, International Journal of Obstetric Anesthesia (2019), doi:

James Smith