Guideline

WHO recommendations for the prevention and treatment of postpartum haemorrhage

Year of Publication

2012

Issuing Institution

World Health Organization

Links

WHO IRIS

Recommendations

32 included recommendations

The use of uterotonics for the prevention of postpartum haemorrhage during the third stage of labour is recommended for all births

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of postpartum haemorrhage

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

In settings where oxytocin is unavailable, the use of other injectable uterotonics (if appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine) or oral misoprostol (600 µg) is recommended (for the prevention of postpartum haemorrhage)

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 µg PO) by community health care workers and lay health workers is recommended for the prevention of postpartum haemorrhage

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

In settings where skilled birth attendants are available, controlled cord traction is recommended for vaginal births if the care provider and the parturient woman regard a small reduction in blood loss and a small reduction in the duration of the third stage of labour as important

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

High

In settings where skilled birth attendants are unavailable, controlled cord traction is not recommended.

Status

Maintained

Recommended against

Strong

Certainty of evidence

Moderate

Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation

Status

Retired

Recommended against

Strong

Certainty of evidence

Moderate

Sustained uterine massage is not recommended as an intervention to prevent postpartum haemorrhage in women who have received prophylactic oxytocin

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Low

Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of postpartum haemorrhage in caesarean section

Status

Retired

Recommended in favor

Strong

Certainty of evidence

Moderate

Controlled cord traction is the recommended method for removal of the placenta in caesarean section

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of postpartum haemorrhage

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Moderate

If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin, the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 µg) is recommended (for the treatment of postpartum haemorrhage)

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous fluid resuscitation of women with postpartum haemorrhage

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Low

The use of tranexamic acid is recommended for the treatment of postpartum haemorrhage if oxytocin and other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly due to trauma

Status

Retired

Recommended in favor

Conditional

Certainty of evidence

Moderate

Uterine massage is recommended for the treatment of postpartum haemorrhage

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

If women do not respond to treatment using uterotonics, or if uterotonics are unavailable, the use of intrauterine balloon tamponade is recommended for the treatment of postpartum haemorrhage due to uterine atony

Status

Retired

Recommended in favor

Conditional

Certainty of evidence

Very low

If other measures have failed and if the necessary resources are available, the use of uterine artery embolization is recommended as a treatment for postpartum haemorrhage due to uterine atony

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage). If bleeding does not stop in spite of treatment using uterotonics and other available conservative interventions (e.g. uterine massage, balloon tamponade), the use of surgical interventions is recommended.

Status

Maintained

Recommended in favor

Strong

Certainty of evidence

Very low

The use of bimanual uterine compression is recommended as a temporizing measure until appropriate care is available for the treatment of postpartum haemorrhage due to uterine atony after vaginal delivery.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The use of external aortic compression for the treatment of Postpartum haemorrhage due to uterine atony after vaginal birth is recommended as a temporizing measure until appropriate care is available

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage). The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Low

The use of uterine packing is not recommended for the treatment of postpartum haemorrhage due to uterine atony after vaginal birth

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage). If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in combination with controlled cord traction is recommended

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage). The use of ergometrine for the management of retained placenta is not recommended as this may cause tetanic uterine contractions which may delay the expulsion of the placenta

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage).The use of prostaglandin E2 alpha (dinoprostone or sulprostone) for the management of retained placenta is not recommended

Status

Maintained

Recommended against

Conditional

Certainty of evidence

Very low

(Postpartum haemorrhage). A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised.

Status

Maintained

Recommended in favor

Conditional

Certainty of evidence

Very low

The use of formal protocols by health facilities for the prevention and treatment of postpartum haemorrhage is recommended

Status

New

Recommended in favor

Conditional

Certainty of evidence

Moderate

(Prevention and treatment of postpartum haemorrhage).The use of formal protocols for referral of women to a higher level of care is recommended for health facilities

Status

New

Recommended in favor

Conditional

Certainty of evidence

Very low

The use of simulations of postpartum haemorrhage treatment is recommended for pre-service and in-service training programmes

Status

New

Recommended in favor

Conditional

Certainty of evidence

Very low

Monitoring the use of uterotonics after birth for the prevention of postpartum haemorrhage is recommended as a process indicator for programmatic evaluation

Status

New

Recommended in favor

Conditional

Certainty of evidence

Very low