WHO guidelines for the management of postpartum haemorrhage ...

WHO guidelines for the management of postpartum haemorrhage and retained placenta
Recommendation
After childbirth, blood loss and other clinical parameters should be closely monitored.
At present, there is insufficient evidence to recommend quantification of blood loss
over clinical estimation. (Quality of evidence: low. Strength of recommendation:
strong)
Remarks
The participants identified several priority research topics related to the definition
and diagnosis of PPH.
▪ What quantity of blood loss should be the marker for diagnosis of PPH?
▪ Does the act of quantifying blood loss alter (or lead to improved) clinical outcomes
for the mother and her baby?
▪ Which clinical consequences of blood loss are of greatest value for the diagnosis
and treatment of PPH?
B. Management of atonic PPH
As a general preventive approach, the use of oxytocin for active management of the
third stage of labour is strongly recommended, because it reduces PPH by more than
60% (17).
1. Medical interventions for management of PPH
The Consultation was asked to assess the value of injectable uterotonics (oxytocin,
ergometrine, fixed dose combination of oxytocin and ergometrine, carbetocin and
injectable prostaglandin), misoprostol (tablet form used via oral, sublingual and
rectal routes), injectable tranexamic acid and injectable recombinant factor VIIa in
the management of PPH thought to be due to uterine atony.
For oxytocin, ergometrine and prostaglandin F2α, the Consultation agreed with the
doses recommended in the WHO guide, Managing complications in pregnancy and
childbirth (18), as given in Table 1 (overleaf).
The recommendations below may also be used in cases of PPH due to uterine
atony following caesarean section. The Consultation acknowledged that these
recommendations were based primarily on data following vaginal birth, and that
specific data on PPH due to uterine atony following caesarean section were scarce
and not evaluated separately from data on vaginal births.
(a) Which uterotonics should be offered in the management of PPH
due to uterine atony?
Summary of evidence
Except for the specific misoprostol trials evaluated in section (b), the evidence
has been extrapolated from research on prevention of PPH. Systematic reviews
comparing the effects of oxytocin with ergometrine (19), a fixed-dose combination
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