Benefits, harms, and costs
- 1.An individualized risk assessment for postpartum hemorrhage should be documented in a checklist upon arrival to a labour unit and updated throughout labour and delivery (strong, high). The risk assessment should include a calculation of the maximum allowable blood loss (good practice point).
- 2.Both antenatal and postnatal anemia should be identified and treated aggressively (strong, high).
- 3.Quantitative blood loss measurement should replace estimated blood loss in all patients whenever possible (strong, moderate).
- 4.Staging and management of postpartum hemorrhage should be based on quantitative blood loss (strong, high).
- 5.Active management of the third stage of labour should be offered to all women (strong, high).
- 6.Prophylactic intramuscular oxytocin can be used for patients at low risk for postpartum hemorrhage (strong, high).
- 7.For patients at high risk of postpartum hemorrhage, prophylactic intravenous oxytocin should be used (conditional, moderate).
- 8.When given intravenously, oxytocin can be given either as a rapid infusion (max rate 1 IU/min) for 4 minutes, followed by 7.5–15 IU/h or as a 3 IU intravenous rapid injection (strong, moderate)
- 9.If there is inadequate response to oxytocin within 4 minutes, a second-line uterotonic should be administered (strong, high).
- 10.Carbetocin can be considered as a first-line agent for postpartum hemorrhage prophylaxis at cesarean delivery (strong, moderate).
- 11.Bimanual uterine compression and bladder emptying should be performed as first-line measures while waiting for pharmacologic agents to take effect (good practice point).
- 12.Misoprostol (sublingual/oral) is an effective adjunct to prophylactic or therapeutic oxytocin in high-risk individuals (strong, high)
- 13.Intramuscular ergotamine and intramuscular or intramyometrial carboprost, can both be used to treat active postpartum hemorrhage (strong, high).
- 14.Rectal misoprostol is inferior to other routes (both in onset and in bioavailability) and should not be used (strong, moderate).
- 15.Tranexamic acid can be used in all patients as an adjunct to uterotonics in the setting of postpartum hemorrhage, and can be used as a prophylactic agent in patients at high risk for postpartum hemorrhage (strong, high).
- 16.Uterine tamponade is an effective tool and should be considered for ongoing mild to moderate bleeding (conditional, moderate).
- 17.If the placenta has not been expelled spontaneously in the 30 minutes following delivery, measures should be taken to expedite delivery of the placenta (strong, high).
- 18.When there is ongoing bleeding, examine the patient for the presence of clots, retained placental tissue, or genital tract lacerations (good practice point).
- 19.In the case of uterine inversion, if immediate reversion is not possible, transfer the patient to an operating room for uterine relaxation and patient stabilization, as required (good practice point)
- 20.If pharmacologic interventions have not controlled bleeding, surgical intervention should be undertaken promptly (strong, high)
- 21.Compression sutures, ligation of uterine or internal iliac arteries, and uterine artery embolization are all effective interventions that can be considered; however, hysterectomy should not be delayed in an unstable patient (strong, high).
- 22.Severe obstetrical hemorrhage should be managed by a multidisciplinary team consisting of obstetrics, anaesthesia, nursing, and transfusion medicine (strong, high).
- 23.An obstetrical massive hemorrhage protocol, including defined roles and responsibilities of each team member, should be used (strong, moderate).
- 24.Initial resuscitative and monitoring measures should include intravenous access × 2, electrocardiography, oxygen saturation, blood pressure, placement of an indwelling urethral catheter, euthermia, and volume replacement with balanced crystalloid (good practice point).
- 25.Four units red blood cells should be given prior to other blood products in an actively bleeding patient who is approaching the maximum allowable blood loss, unless the patient has a coagulation defect (strong, moderate)
- 26.Fibrinogen levels should be measured in every moderate to severe case of postpartum hemorrhage, and if <2 g/L, should be replaced accordingly (strong, high).
- 27.A massive hemorrhage protocol with ratios of red blood cells to fresh frozen plasma to platelets of 1:1:1: or 2:1:1 can be used in the absence of timely lab results (strong, moderate).
- 28.Simulation training with all members of the multidisciplinary team should occur on a regular basis, ideally by a trained facilitator (strong, high).
Abbreviations:CD (cesarean delivery), MABL (maximum allowable blood loss), MHP (massive hemorrhage protocol), PPH (postpartum hemorrhage), TXA (tranexamic acid)
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- Frequency of and factors associated with severe maternal morbidity.Obstet Gynecol. 2014; 123: 804-810
- Épidémiologie de l'hémorragie du post-partum [Epidemiology of post-partum haemorrhage].J Gynecol Obstet Biol Reprod (Paris). 2014; 43: 936-950
- Temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada from 2003 to 2010.J Obstet Gynaecol Can. 2014; 36: 21-33
- Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group.BMC Pregnancy Childbirth. 2009; 9: 55
- Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study.Arch Gynecol Obstet. 2011; 283: 1207-1213
- Drape estimation vs. visual assessment for estimating postpartum hemorrhage [published erratum appears in Int J Gynaecol Obstet 2006;95:312].Int J Gynaecol Obstet. 2006; 93: 220-224
- Assessing preventability for obstetric hemorrhage.Am J Perinatol. 2011; 28: 753-760
- Quality improvement opportunities identified through case review of pregnancy-related deaths from obstetric hemorrhage.J Obstet Gynecol Neonatal Nurs. 2019; 48: 288-299
- Clinical experience with the implementation of accurate measurement of blood loss during cesarean delivery: influences on hemorrhage recognition and allogeneic transfusion.Am J Perinatol. 2018; 35: 655-659
- Incidence, risk factors and temporal trends in severe postpartum hemorrhage.Am J Obstet Gynecol. 2013; 209: 449.e1-449.e7
- California Maternal Quality Care Collaborative. Obstetric hemorrhage.(Available at:)https://www.cmqcc.org/content/obstetric-hemorrhage-0Date accessed: June 1, 2021
- Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania.J Health Popul Nutr. 2008; 26: 232-240
- Iron deficiency as energetic insult to skeletal muscle in chronic diseases.J Cachexia Sarcopenia Muscle. 2018; 9: 802-815
- Iron deficiency anemia among women of reproductive age, an important public health problem: situation analysis.Reprod Syst Sex Disord. 2016; 5: 187
- Prevalence of iron deficiency and iron deficiency anemia during pregnancy: a single centre Canadian study.Blood. 2019; 134: 3389
- Patient blood management in obstetrics: management of anaemia and hematinic deficiencies in pregnancy and in the post-partum period: NATA consensus statement.Transfus Med. 2018; 28: 22-39
- The efficacy and safety of vitamin c for iron supplementation in adult patients with iron deficiency anemia: a randomized clinical trial.JAMA Netw Open. 2020; 3e2023644
- UK guidelines on the management of iron deficiency in pregnancy.Br J Haematol. 2020; 188: 819-830
- Patient blood management in obstetrics: prevention and treatment of postpartum haemorrhage. A NATA consensus statement.Blood Transfus. 2019; 17: 112-136
- Three-year follow-up of a randomised clinical trial of intravenous versus oral iron for anaemia in pregnancy.BMJ Open. 2012; 2e000998
- Alberta Health Services. PPH staging and management guidelines.(Available at:)https://extranet.ahsnet.ca/teams/policydocuments/1/klink/et-klink-ckv-post-partum-hemorrhage-adult-inpatient.pdfDate: 2020Date accessed: June 1, 2021
- Active management of the third stage of labour: prevention and treatment of post partum hemorrhage.J Obstet Gynaecol Can. 2018; 40: e841-e855
- Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion, Number 814.Obstet Gynecol. 2020; 136: e100-e106
- Impact of controlled cord traction in the management of the third stage of labor on postpartum hemorrhage: a randomized controlled trial.EBWHJ. 2014; 4: 78-81
- Controlled cord traction for the third stage of labour.Cochrane Database Syst Rev. 2015; 1: CD008020
- Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial.Lancet. 2012; 379: 1721-1727
- Facility-based active management of the third stage of labour: assessment of quality in six countries in sub-Saharan Africa.Bull World Health Organ. 2015; 93: 759-767
- A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood loss.Int J Gynaecol Obstet. 2009; 107: 4-7
- Active versus expectant management for women in the third stage of labour.Cochrane Database Syst Rev. 2019; : CD007412
- The effect of mother-infant skin to skin contact after birth on third stage of labor: a systematic review and meta-analysis.Iran J Public Health. 2019; 48: 612-620
- The association between the time from oxytocin cessation during labour to Cesarean delivery and postpartum blood loss: a retrospective cohort study.Can J Anesth. 2017; 64: 820-827
- Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage.Cochrane Database Syst Rev. 2013; 10: CD001808
- Comparison of the effects and side effects of misoprostol and oxytocin in the postpartum period: a systematic review.Taiwan J Obstet Gynecol. 2019; 58: 748-756
- Carboprost versus oxytocin for active management of third stage of labor: a prospective randomized control study.J Obstet Gynaecol India. 2016; 66: 229-234
- Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour.Cochrane Database Syst Rev. 2004; 1: CD000201
- DrugBank Online. Oxytocin pharmacokinetics.(Available at:)https://go.drugbank.com/drugs/DB00107Date accessed: June 1, 2021
- Prophylactic intramyometrial oxytocin before placenta delivery during cesarean section prevents postpartum hemorrhage: a prospective randomized study of 150 women.J South Asian Feder Obst Gynae. 2012; 4: 93-96
- Safety, tolerability and pharmacokinetics of single doses of oxytocin administered via an inhaled route in healthy females: randomized, single blind, phase 1 study.Lancet. 2017; 22: 249-255
- Intravenous versus intramuscular prophylactic oxytocin for the third stage of labour.Cochrane Database Syst Rev. 2020; : CD009332
- International consensus statement on the use of uterotonic agents during caesarean section.Anaesthesia. 2019; 74: 1305-1319
- Up-down determination of the ED(90) of oxytocin infusions for the prevention of postpartum uterine atony in parturients undergoing Cesarean delivery.Can J Anesth. 2010; 57: 578-582
- The ED90 of prophylactic oxytocin infusion after delivery of the placenta during Cesarean delivery in laboring compared with nonlaboring women: an up-down sequential allocation dose-response study.Anesth Analg. 2015; 121: 159-164
- Lewis G. Why mothers die 1997–99. The confidential enquiry into maternal deaths in the United Kingdom. RCOG Press, London (UK)2001
- Oxytocin–ensuring appropriate use and balancing efficacy with safety.S Afr Med J. 2015; 105: 271-274
- Signs of myocardial ischaemia after injection of oxytocin: a randomized double-blind comparison of oxytocin and methylergometrine during Caesarean section.Br J Anaesth. 2008; 100: 683-689
- Haemodynamic effects of carbetocin and oxytocin given as intravenous bolus on women undergoing caesarean delivery: a randomised trial.Int J Obstet Gynaecol. 2011; 118: 1349-1356
- Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis.Cochrane Database Syst Rev. 2018; 12: CD011689
- Carbetocin at elective Cesarean delivery: a sequential allocation trial to determine the minimum effective dose.Can J Anaesth. 2014; 61: 242-248
- Carbetocin for prevention of postcesarean hemorrhage in women with severe preeclampsia: a before-after cohort comparison with oxytocin.J Clin Anesth. 2016; 35: 321-325
- Carbetocin versus oxytocin for prevention of postpartum hemorrhage in patients with severe preeclampsia: a double-blind randomized controlled trial.J Obstet Gynaecol Can. 2011; 33: 1099-1104
- Carbetocin for the prevention of post-partum hemorrhage: a review of clinical effectiveness, cost-effectiveness, and guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health.(Available at:)https://www.ncbi.nlm.nih.gov/books/NBK546425/Date accessed: July 29, 2019
- Misoprostol: pharmacokinetic profiles, effects on the uterus and side effects.Int J Gynecol Obstet. 2007; : S160-S167
- Sublingual misoprostol as an adjunct to oxytocin during cesarean delivery in women at risk of postpartum hemorrhage.Int J Gynaecol Obstet. 2015; 128: 48-52
- Randomized controlled trial comparing 200μg and 400μg sublingual misoprostol for prevention of primary postpartum hemorrhage.Int J Gynaecol Obstet. 2016; 133: 173-177
- Stop using rectal misoprostol for the treatment of postpartum hemorrhage caused by uterine atony.OBG Manag. 2016; 28 (8-10,12)
- Pharmacokinetics of tranexamic acid.(Available at:)https://go.drugbank.com/drugs/DB00302Date accessed: June 1, 2021
- Tranexamic acid - Stat Pearls.(Available at:)https://www.ncbi.nlm.nih.gov/books/NBK532909/Date accessed: June 1, 2021
- Tranexamic acid for treatment of primary postpartum hemorrhage after vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.J Matern Fetal Neonatal Med. 2020; 33: 869-874
- Role of intravenous tranexamic acid on cesarean section blood loss: a prospective randomized study.J Obstet Gynaecol India. 2016; 66: 347-352
- Tranexamic acid for postpartum hemorrhage prevention in vaginal delivery: a meta-analysis.Medicine (Baltimore). 2020; 99e18792
- Tranexamic acid for the prevention of blood loss after cesarean delivery.N Engl J Med. 2021; 384: 1623-1634
- The impact of early outcome events on the effect of tranexamic acid in post-partum haemorrhage: an exploratory subgroup analysis of the WOMAN trial.BMC Pregnancy Childbirth. 2018; 18: 215
- Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients.Lancet. 2018; 391: 125-132
- Pharmacokinetics of ergotamine.(Available at:)https://go.drugbank.com/drugs/DB01253Date accessed: June 1, 2021
- Ergometrine for postpartum hemorrhage and associated myocardial ischemia: two case reports and a review of the literature.Clin Case Rep. 2019; 7: 2433-2442
- Prophylactic use of ergot alkaloids in the third stage of labour.Cochrane Database Syst Rev. 2018; 6: CD005456
- Recommendations for the use of antiretroviral drugs during pregnancy and interventions to reduce perinatal HIV transmission in the United States.(Available at:)https://clinicalinfo.hiv.gov/en/guidelines/perinatal/intrapartum-antiretroviral-therapyprophylaxisDate accessed: June 1, 2021
- Postpartum haemorrhage: prevention.BMJ Clin Evid. 2008; 2008: 1410
- Pharmacokinetics of prostaglandins.Best Pract Res Clin Obstet Gynaecol. 2003; 17: 707-716
- A comparison of oxytocin and carboprost tromethamine in the prevention of postpartum hemorrhage in high-risk patients undergoing cesarean delivery.Exp Ther Med. 2014; 7: 46-50
- Carboprost - an overview. The Comprehensive Pharmacology Reference; Science Direct Topics.(Available at:)https://www.sciencedirect.com/topics/nursing-and-health-professions/carboprostDate accessed: June 1, 2022
- Management of postpartum hemorrhage. Comparative effectiveness review no. 151. AHRQ publication no. 15-EHC013-EF.Agency for Healthcare Research and Quality, Rockville (MD)2015
- The Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage.Int J Gynaecol Obstet. 2016; 135: 276-280
- Retained placenta after vaginal delivery: risk factors and management.Int J Womens Health. 2019; 11: 527-534
- Reducing hemodynamic compromise with placental removal at 10 versus 15 mins: a randomized clinical trial.Am J Perinatol. 2012; 29: 609-614
- How long is safe? Setting the cutoff for uncomplicated third stage length: a retrospective case-control study.Birth. 2016; 43: 36-41
- Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial.J Matern Fetal Neonatal Med. 2017; 30: 2179-2184
- Intraumbilical injection of three different uterotonics in the management of retained placenta.J Obstet Gynaecol Res. 2011; 37: 1203-1207
- Uterine inversion. Treasure Island (FL): StatPearls Publishing.(Available at:)https://www.ncbi.nlm.nih.gov/books/NBK525971/Date accessed: June 1, 2022
- B-Lynch uterine compression sutures in the conservative surgical management of uterine atony.Arch Gynecol Obstet. 2015; 291: 1005-1014
- The effectiveness of the double B-lynch suture as a modification in the treatment of intractable postpartum haemorrhage.J Obstet Gynaecol. 2018; 38: 796-799
- Uterine compression sutures with additional hemostatic procedures for the management of postpartum hemorrhage.J Obstet Gynaecol Res. 2020; 46: 2332-2339
- Internal iliac artery ligation for arresting postpartum haemorrhage.BJOG. 2007; 114: 356-361
- Outcomes of hypogastric artery ligation and transcatheter uterine artery embolization in women with postpartum hemorrhage.Taiwan J Obstet Gynecol. 2019; 58: 72-76
- Internal iliac artery ligation for severe postpartum hemorrhage and severe hemorrhage after postpartum hysterectomy.J Obstet Gynaecol Res. 2010; 36: 538-543
- Ligating internal iliac artery: success beyond hesitation.J Obstet Gynaecol India. 2016; 66: 235-241
- Uterine artery embolization versus hysterectomy in the treatment of refractory postpartum hemorrhage: a systematic review and meta-analysis.J Matern Fetal Neonatal Med. 2020; 33: 693-705
- Uterine artery embolization for primary postpartum hemorrhage.Iran J Reprod Med. 2013; 11: 511-518
- Emergency obstetric hysterectomy for life-threatening postpartum hemorrhage: a 12-year review.Medicine (Baltimore). 2017; 96e8443
- Hypovolemic shock.in: Phelan J.P. Critical care obstetrics. 6th ed. John Wiley & Sons Ltd, Oxford (UK)2019: 535-545
- Estimating allowable blood loss: corrected for dilution.Anesthesiology. 1983; 58: 277-280
- Blood, still saving lives but…there are risks (video).(Available at:)https://www.blood.gov.au/health-professionalsDate accessed: June 1, 2021
- Obstetric hemorrhage and hypothermia: chilling facts.Open J Obstet Gynecol. 2018; 8: 2160-2270
- Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: a nationwide cohort study.Eur J Obstetr Gynecol Reprod Biol. 2019; 235: 49-56
- Blood transfusion. Treasure Island (FL): StatPearls Publishing.(Available at:)https://www.ncbi.nlm.nih.gov/books/NBK499824/Date accessed: June 1, 2021
- Transfusion policy after severe postpartum haemorrhage: a randomised non-inferiority trial.BJOG. 2014; 121: 1005-1014
- Managing major obstetric haemorrhage: pharmacotherapy and transfusion.Best Pract Res Clin Anaesthesiol. 2017; 31: 107-124
- Intravenous iron vs blood for acute post-partum anaemia (IIBAPPA): a prospective randomised trial.BMC Pregnancy Childbirth. 2017; 17: 424
- Single-dose intravenous iron infusion versus red blood cell transfusion for the treatment of severe postpartum anaemia: a randomized controlled pilot study.Vox Sang. 2017; 112: 122-131
- Platelet count and transfusion requirements during moderate or severe postpartum haemorrhage.Anaesthesia. 2016; 71: 648-656
- Bloody easy 4: blood transfusions, alternatives and transfusion reactions. A guide to transfusion medicine. 4th ed. ORBCON.(Available at:)file:///C:/Users/cgreen/Downloads/EN_BE4-JULY11_FINAL.pdfDate: 2016Date accessed: June 1, 2021
- Coagulation management in obstetric anesthesia.Curr Anesthesiol Rep. 2022; 12: 266-276
- Early and systematic administration of fibrinogen concentrate in postpartum haemorrhage following vaginal delivery: the FIDEL randomised controlled trial.BJOG. 2021; 128: 1814-1823
- Treatment of obstetric hemorrhage with fibrinogen concentrate.Med Sci Monit. 2019; 25: 1814-1821
- Transfusion management of obstetric hemorrhage.Transfus Med Rev. 2018; 32: 249-255
- The incidence, aetiology, and coagulation management of massive postpartum haemorrhage: a two-year national prospective cohort study.Int J Obstet Anesth. 2021; 47102983
- Clinical value of early viscoelastometric point-of-care testing during postpartum hemorrhage for the prediction of severity of bleeding: a multicenter prospective cohort study in the Netherlands.Acta Obstet Gynecol Scand. 2021; 100: 1656-1664
- Four years' experience of a ROTEM -guided algorithm for treatment of coagulopathy in obstetric haemorrhage.Anaesthesia. 2019; 74: 984-991
- A regional MHP developed through a modified Delphi technique.CMAJ Open. 2019; 7: E546-E561
- Association between ionized calcium and severity of postpartum hemorrhage: a retrospective cohort study.Brit J Anaesth. 2021; 126: 1022-1028
- Role of effective teamwork and communication in delivering safe, high-quality care.Mt Sinai J Med. 2011; 78: 820-826
- A conceptual framework for the development of debriefing skills: a journey of discovery, growth and maturity.Simul Healthc. 2020; 15: 55-60
- More than one way to debrief: a critical review of healthcare simulation debriefing methods.Simul Healthc. 2016; 11: 209-217
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests, however, that they adequately document any such amendments.
Informed consent: Patients have the right and responsibility to make informed decisions about their care in partnership with their health care provider. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and personalized. The values, beliefs and individual needs of each patient in the context of their personal circumstances should be considered and the final decision about care and treatment options chosen by the patient should be respected.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral language will be used. In other circumstances, we continue to use gendered language because of our mission to advance women’s health. The SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person’s needs.