WHO recommendation on monitoring the use of uterotonics after birth for the prevention of PPH

WHO recommendation on monitoring the use of uterotonics after birth for the prevention of PPH


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)​


Publication history

First published: September 2012

Updated: No update planned

Assessed as up-to-date: September 2012



The GDG acknowledged that the implementation of formal protocols is a complex process which will require the local adaptation of general guidelines.

The GDG placed a high value on the costs of simulation programmes and acknowledged that there are different types of simulation programmes. Some programmes are hi-tech, computerized and costly while others are less expensive and more likely to be affordable in low- and middle-income countries. The GDG identified improvement in communication between health care providers and patients and their family members as an important priority in the training of health care providers in PPH management.

The GDG recommended monitoring the use of prophylactic uterotonics. This recommendation is based on experience from other areas of health care, particularly child health, where content-based health indicators are common and regarded as useful for programmatic purposes. The suggested indicator is calculated as the number of women receiving prophylactic uterotonic drugs after birth divided by all women giving birth.



Postpartum haemorrhage (PPH) is defined as blood loss of 500ml or more within 24 hours after birth. PPH is the primary cause of nearly one-fifth of all maternal deaths globally. Most of these deaths occur during the first 24 hours after birth. The majority could be prevented through the use of prophylactic uterotonics during the third stage of labour, and by timely and appropriate management. The primary goal of these recommendations is to provide a foundation for the implementation of strategic policy and programme developments for interventions shown to have been effective in reducing the burden of PPH. Health professionals responsible for developing national and local protocols and health policies constitute the main target audience of this document. Obstetricians, midwives, general medical practitioners, health care managers and public health policy-makers, particularly in under-re-sourced settings are also targeted. The guidance provided is evidence-informed and covers topics related to the management of PPH that were selected and prioritized by an international, multidisciplinary group of health care workers, consumers and other stakeholders. This document establishes general principles of PPH care and it is intended to inform the development of protocols and health policies related to PPH.



The recommendation was developed using standardized operating procedures in accordance with the process described in the “WHO handbook for guideline development”, based on the GRADE approach (1, 2) Outcomes used for this recommendation were the prioritized outcomes from the WHO recommendations on prevention and treatment of postpartum haemorrhage (2012).(3)

Trials relevant to the key question were screened by review authors, and data on relevant outcomes and comparisons were extracted. (4,5) Evidence profiles (in the form of GRADE tables) were prepared for comparisons of interest.

WHO convened a Guideline Development Group (GDG) meeting in March 2012. This group of independent experts used the evidence profiles to assess evidence on effects on the pre-specified outcomes.

GDG members discussed the balance between desirable and undesirable effects, overall quality of supporting evidence, values and preferences, magnitude of effect, balance of benefits versus disadvantages, resource usage, and feasibility, to formulate the recommendation. Remarks were added to clarify the recommendation, and aid implementation.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

  • For all women giving birth (P), does monitoring of the use of uterotonics after birth for the prevention of PPH (I) compared to standard care (C) improve maternal outcomes (O)?


Evidence summary

The GDG agreed by consensus during the technical consultation to include this recommendation for programmatic monitoring and evaluation based on the experience of other health areas (e.g. child health) that have content-oriented indicators for monitoring.


Further information on evidence supporting this recommendation are available here.


Implementation considerations


  • The successful introduction of evidence-based policies related to the prevention and management of PPH into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.


Related links

WHO recommendations on prevention and treatment of postpartum haemorrhage (2012) - full documentand evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice


Related resources

VIDEO: Active management of third stage of labour

Education material for teachers of midwifery. Managing postpartum haemorrhage.


Other WHO content related to these recommendations

Education material for teachers of midwifery



Research implications

The GDG did not identify any research priorities related to this recommendation.



  1. WHO Handbook for Guideline Development (second edition). Geneva: World Health Organization; 2014.
  2. Balshem H, Helfand M, Schünemann HJ, Oxman AD, Kunz R, Brozek J, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011;64(4):401-6. Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.07.015. PubMed PMID: 21208779.
  3. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: World Health Organization, 2012.



WHO Reproductive Health Library. WHO recommendation on monitoring the use of uterotonics after birth for the prevention of PPH (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.