- 1Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women (I-A).
- 2Oxytocin (10 IU), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder (I-A).
- 3Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL (I-B).
- 4An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section (II-B).
- 5Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin owing to the greater risk of maternal adverse effects and of the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension (I-A).
- 6Carbetocin, 100 µg given as an IV bolus over 1 minute, should be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics. (I-B)
- 7For women delivering vaginally with 1 risk factor for PPH, carbetocin 100 µg IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin (I-B).
- 8Ergonovine, 0.2 mg IM, and misoprostol, 600 to 800 µg given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available (II-1B).
- 9Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping (I-A).
- 10For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping (I-C).
- 11There is no evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH (II-2C).
- 12Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH (II-1C).
- 13Intraumbilical cord injection of misoprostol (800 µg) or oxytocin (10 to 30 IU) can be considered as an alternative intervention before manual removal of the placenta (II-2C).
- 14For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation (III-B).
- 15Management of ongoing PPH requires a multidisciplinary approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss (III-C).
- 16All obstetric units should have a regularly checked PPH emergency equipment tray containing appropriate equipment (II-2B).
- 17Evidence for the benefit of recombinant activated factor VII has been gathered from very few cases of massive PPH. Therefore this agent cannot be recommended as part of routine practice (II-3L).
- 18Uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy (III-L).
- 19Surgical techniques such as ligation of the internal iliac artery, compression sutures, and hysterectomy should be used for the management of intractable PPH unresponsive to medical therapy (III-B).
|Quality of Evidence Assessment
|Classification of Recommendations
|I: Evidence obtained from at least one properly randomized controlled trial||A. There is good evidence to recommend the clinical preventive action|
|II-1: Evidence from well-designed controlled trials without randomization||B. There is fair evidence to recommend the clinical preventive action|
|II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group||C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making|
|II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category||D. There is fair evidence to recommend against the clinical preventive action|
|III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees||E. There is good evidence to recommend against the clinical preventive action|
|L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making|
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- Global burden of maternal death and disability.Br Med Bull. 2003; 67: 1-11
- Postpartum hemorrhage: practical approach to a life-threatening complication.Clin Exp Obstet Gynecol. 2006; 33: 81-84
- Postpartum hemorrhage: frequency, consequences in terms of health status, and risk factors before delivery].J Gynecol Obstet Biol Reprod (Paris). 2004; 33 (4S9–4S16)
- Postpartum haemorrhage.Curr Obstet Gynaecol. 2006; 16: 6-13
- Maternal mortality in Giza, Egypt: magnitude, causes, and prevention.Stud Fam Plann. 1992; 23: 45-57
- Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions.BJOG. 2006; 113: 919-924
- Approach to the patient with shock.(editors)in: Kasper DL Braunwald E Fauci AS Hauser SL Longo DL Jameson JL Harrison's principles of internal medicine. 16th ed. McGraw-Hill, New York2004 (1600–6)
- Active versus expectant management in the third stage of labour.Cochrane Database Syst Rev. 2000; (CD000007)
- Joint statement: management of the third stage of labour to prevent post-partum haemorrhage.J Midwifery Womens Health. 2004; 49: 76-77
- Recommendations for the Prevention of Postpartum Haemorrhage.WHO, Geneva2007
- Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial.Am J Obstet Gynecol. 1997; 177: 770-774
- Prophylactic ergometrine–oxytocin versus oxytocin for the third stage of labour.Cochrane Database Syst Rev. 2004; (CD000201)
- Prophylactic oxytocin for the third stage of labour.Cochrane Database Syst Rev. 2001; (CD001808)
- Routine oxytocin in the third stage of labour: a placebo controlled randomised trial.Br J Obstet Gynaecol. 1997; 104: 781-786
- A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage.Am J Obstet Gynecol. 2001 Oct; 185: 873-877
- A comparison of ‘active’ and ‘physiological’ management of the third stage of labour.Midwifery. 1990; 6: 3-17
- Maternal hemodynamics after oxytocin bolus compared with infusion in the third stage of labor: a randomized controlled trial.Obstet Gynecol. 2005; 105: 294-299
- Hemodynamic effects of oxytocin given as IV bolus or infusion on women undergoing caesarean section.Br J Anaesth. 2007; 98: 116-119
- Signs of myocardial ischemia after injection of oxytocin: a randomized double-blind comparison of oxytocin and methylergometrine during caesarean section.Br J Anaesth. 2008; 100: 683-689
- Double-blind comparison of carbetocin versus oxytocin in prevention of uterine atony after cesarean section.Am J Obstet Gynecol. 1999; 180: 670-676
- Pharmacokinetics of a long-acting oxytocin analogue, in non-pregnant women.Curr Ther Res. 1990; 47: 528-540
- Comparison of carbetocin and oxytocin for the prevention of postpartum hemorrhage following vaginal delivery: a double-blind randomized trial.J Obstet Gynaecol Can. 2004; 26: 481-488
- Oxytocin agonists for preventing postpartum hemorrhage.Cochrane Database Syst Rev. 2007; (CD005457)
- A randomized trial of carbetocin versus Syntometrine in the management of the third stage of labour.BJOG. 2006; 113: 1459-1464
- Misoprostol for third stage of labour [letter].Lancet. 1996; 347: 1257
- Misoprostol to treat postpartum haemorrhage: a systematic review.BJOG. 2005; 112: 547-553
- Prostaglandins for prevention of postpartum haemorrhage.Cochrane Database Syst Rev. 2004; (CD000494)
- Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage.Obstet Gynecol. 2002; 100: 1301-1312
- Misoprostol use during the third stage of labor.Int J Gynaecol Obstet. 2003; 82: 143-152
- WHO multicentre randomised trial of misoprostol in the management of the third stage of labour.Lancet. 2001; 358: 689-695
- Rectal misoprostol versus oxytocin in the management of the third stage of labour.J Obstet Gynaecol Can. 2007; 29: 711-718
- Cord closure: Can hasty clamping injure the newborn?.OBG Manage. 1998; (July): 29-36
- The complete blood count: physiologic basis and clinical usage.J Perinat Neonatal Nurs. 1997; 11: 1-18
- Distribution of blood between infant and placenta after birth.Lancet. 1969; 2: 871-873
- Early versus delayed umbilical cord clamping in preterm infants.Cochrane Database Syst Rev. 2004; (CD003248)
- Placental transfusion: umbilical cord clamping and preterm infants.J Perinatol. 2000; 20: 351-354
- Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.JAMA. 2007; 297: 1241-1252
- Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.Cochrane Database Syst Rev. 2008; (CD004074)
- Third stage of labor: analysis of duration and clinical practice.Am J Obstet Gynecol. 1995; 172: 1279-1284
- Prolonged third stage of labor; morbidity and risk factors.Obstet Gynecol. 1991; 77: 863-867
- Timing of placental delivery to prevent post-partum haemorrhage: lessons learned from an abandoned randomised clinical trial.AustNZJ Obstet Gynaecol. 2006; 46: 549-551
- Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour.Cochrane Database Syst Rev. 2005; (CD004665)
- Evaluation of placental drainage as a method of placental delivery in vaginal deliveries.Arch Gynecol Obstet. 2005; 271: 343-345
- Umbilical vein injection for management of retained placenta.Cochrane Database Syst Rev. 2001; (CD001337)
- Umbilical vein injection for the routine management of third stage of labour [Protocol].Cochrane Database Syst Rev. 2006; (CD006176.)
- Avoiding manual removal of placenta: evaluation of intra-umbilical injection of uterotonics using the Pipingas technique for management of adherent placenta.Acta Obstet Gynecol. 2007; 86: 48-54
- Surgical management of severe obstetrical hemorrhage: experience with an obstetrical hemorrhage equipment tray.J Obstet Gynaecol Can. 2004; 26: 805-808
- The use of recombinant activated factor VII in obstetric and gynaecological haemorrhage.BJOG. 2007; 114: 8-15
- Uterine artery embolization: an underused method of controlling pelvic hemorrhage.Am J Obstet Gynecol. 1997; 176 (938–48)
- Ligation of both internal iliac arteries for hemorrhage in hysterectomy for carcinoma uteri.Bull Johns Hopkins Hosp. 1984; 5: 53
- Internal iliac artery ligation for arresting postpartum haemorrhage.BJOG. 2007; 114: 356-361
- The B-Lynch surgical technique for the control of massive postpartum haemorrhage: An alternative to hysterectomy? Five cases reported.Br J Obstet Gynaecol. 1997; 104: 372-375
- Hemostatic suturing technique for uterine bleeding during cesarean delivery.Obstet Gynecol. 2000; 96: 129-131
This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate and tailored to their needs.
This guideline was written using language that places women at the centre of care. That said, the SOGC is committed to respecting the rights of all people – including transgender, gender non-binary, and intersex people – for whom the guideline may apply. We encourage healthcare providers to engage in respectful conversation with patients regarding their gender identity as a critical part of providing safe and appropriate care. The values, beliefs and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.