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Latest report: prevention and treatment of postpartum haemorrhage” by WHO 2012

Latest publication on “WHO recommendations for the prevention and treatment of postpartum haemorrhage” by WHO, 2012.

Every minute around the world 380 women become pregnant,

190 women face unplanned or unwanted pregnancies,

110 women experience pregnancy related complications,

40 women have unsafe abortions,

1 woman dies.”

The World Health Organization states that every minute, at least one woman dies from complications related to pregnancy or – that means 529 000 women a year. Unavailable, inaccessible, unaffordable, or poor quality care is fundamentally responsible.

Find the latest recommendations below.
The report in its guideline development method, section of the report reads out as follows: “The scientific evidence for the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. For each of the previous WHO recommendations on (2007 and 2009) and for all the newly-added questions, evidence profiles were prepared based on 22 up-to-date systematic reviews. The revised and new recommendations were developed and adopted by an international group of experts who participated in the WHO Technical Consultation on the Prevention and Treatment of PPH, held in Montreux, Switzerland, 6–8 March 2012. The WHO Technical Consultation adopted 32 recommendations and these are shown in Boxes A, B and C. For each recommendation, the quality of the supporting evidence is graded as ‘very low’, ‘low’, ‘moderate’ or ‘high’………………”
Box A: Recommendations for the prevention of PPH
1. The use of uterotonics for the prevention of PPH during the third stage of labour is recommended for all births. (Strong recommendation, moderate-quality evidence)
2. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. (Strong recommendation, moderate-quality evidence)
3. In settings where 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. (Strong recommendation, moderate quality evidence)
4. In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 μg PO) by community care workers and lay  workers is recommended for the prevention of PPH. (Strong recommendation, moderate quality evidence)
5. In settings where skilled birth attendants are available, CCT 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 (Weak recommendation, 
6. In settings where skilled birth attendants are unavailable, CCT is not recommended. (Strong recommendation, moderate-quality evidence)
7. Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births while initiating simultaneous essential newborn care. (Strong recommendation, moderatequality evidence)
8. Early cord clamping (<1 minute after birth) is not recommended unless the neonate is asphyxiated and needs to be moved immediately for resuscitation. (Strong recommendation, moderate-quality evidence)
9. Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have received prophylactic oxytocin. (Weak recommendation, low-quality evidence)
10. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is recommended for all women. (Strong recommendation, very-low-quality evidence)
11. Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in caesarean section. (Strong recommendation, moderate-quality evidence)
12. Controlled cord traction is the recommended method for removal of the placenta in caesarean section. (Strong recommendation, moderate-quality evidence)
Box B: Recommendations for the treatment of PPH
13. Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of PPH. (Strong recommendation, moderate-quality evidence)
14. If intravenous oxytocin is unavailable, or if the 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. (Strong recommendation, low-quality evidence)
15. The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous fluid resuscitation of women with PPH. (Strong recommendation, low-quality evidence)
16. The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly due to trauma. (Weak recommendation, moderate-quality evidence)
17. Uterine massage is recommended for the treatment of PPH. (Strong recommendation, verylow- quality evidence)
18. 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 PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
19. If other measures have failed and if the necessary resources are available, the use of uterine artery embolization is recommended as a treatment for PPH due to uterine atony. (Weak recommendation, very-low-quality evidence)
20. 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. (Strong recommendation, very-low-quality evidence)
21. The use of bimanual uterine compression is recommended as a temporizing measure until appropriate care is available for the treatment of PPH due to uterine atony after vaginal delivery. (Weak recommendation, very-low-quality evidence)
22. The use of external aortic compression for the treatment of PPH due to uterine atony after vaginal birth is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, very-low-quality evidence)
23. The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, low-quality evidence)
24. The use of uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal birth. (Weak recommendation, very-low-quality evidence)
25. If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in combination with controlled cord traction is recommended. (Weak recommendation, very-low-quality evidence)
26. 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. (Weak recommendation, very-low-quality evidence)
27. The use of prostaglandin E2 alpha (dinoprostone or sulprostone) for the management of retained placenta is not recommended. (Weak recommendation, very-low-quality evidence)
28. A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised. (Weak recommendation, very-low-quality evidence)
Box – C: Organisation of Care
29. The use of formal protocols by health facilities for the prevention and treatment of PPH is recommended. (Weak recommendation, moderate-quality evidence)
30. The use of formal protocols for referral of women to a higher level of care is recommended for health facilities. (Weak recommendation, very-low-quality evidence)
31. The use of simulations of PPH treatment is recommended for pre-service and in-service training programmes. (Weak recommendation, very-low-quality evidence)
32. Monitoring the use of uterotonics after birth for the prevention of PPH is recommended as a process indicator for programmatic evaluation. (Weak recommendation, very-low-quality evidence)

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