WHO guidelines for the management of postpartum haemorrhage ...

WHO guidelines for the management of postpartum haemorrhage and retained placenta
Initial rubbing of the uterus and expression of blood clots is not regarded as
therapeutic uterine massage.
Summary of evidence
There have been no RCTs on the use of uterine massage in the treatment of PPH. A
case report series (45) and indirect evidence from one systematic review (46) on the
use of uterine massage in PPH prevention were found.
In one RCT of the prophylactic use of uterine massage involving 200 women,
massage was associated with a nonsignificant decrease in incidence of blood loss
>500 ml (RR 0.52, 95%CI 0.16–1.67) and a significant reduction in the use of additional
uterotonics (RR 0.20, 95%CI 0.08–0.50) (page 31, GRADE Table B4).
Recommendation
Uterine massage should be started once PPH has been diagnosed. (Quality of
evidence: very low. Strength of recommendation: strong.)
Remarks
▪ Uterine massage to ensure the uterus is contracted and there is no bleeding is a
component of active management of the third stage of labour for the prevention
of PPH.
▪ The low cost and safety of uterine massage were taken into account in making this
recommendation strong.
(b) Should bimanual uterine compression be offered in the treatment
of PPH?
Summary of evidence
No RCTs on the use of bimanual uterine compression in the treatment of PPH were
identified. One case report (47) was found.
Recommendation
Bimanual uterine compression may be offered as a temporizing measure in the
treatment of PPH due to uterine atony after vaginal delivery. (Quality of evidence:
very low. Strength of recommendation: weak.)
Remark
The Consultation noted that health care workers would need to be appropriately
trained in the application of bimanual uterine compression and that the procedure
may be painful.
(c) Should uterine packing be offered in the treatment of PPH?
Summary of evidence
No RCTs on the use of uterine packing in the treatment of PPH were found. Seven
case series and one case report (48–55), with a total of 89 women (the largest
involved 33 women), and four overviews were identified. Success rates (i.e. no need
for hysterectomy or other invasive procedure) ranging from 75% to 100% are reported
in these studies.
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