WHO recommendation on the use of intrauterine balloon tamponade for the treatment of postpartum haemorrhage

WHO recommendation on the use of intrauterine balloon tamponade for the treatment of postpartum haemorrhage

Recommendation

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)

 

Publication history

First published: September 2012

Updated: No update planned

Assessed as up-to-date: September 2012

 

Remarks

  • The GDG noted that the use of manoeuvres and other procedures requires training and that maternal discomfort and complications associated with these procedures have been reported.
  • The use of balloon tamponade was considered by the GDG to be a measure that can potentially avoid surgery or as a temporizing measure while awaiting transfer to a higher level facility. The GDG acknowledges that balloon tamponade can be obtained with specific devices as well as with lower cost adaptations, including those based on the use of condoms and surgical gloves.

 

Background

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 use of intrauterine balloon tamponade can potentially avoid surgery or could be used as a temporizing measure while awaiting transfer to a higher level facility.   

 

Methods

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)

No randomized controlled trials have examined the use of uterine tamponade for the treatment of PPH. Evidence from case series and case reports was evaluated. Data on relevant outcomes and comparisons were extracted.

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 women with postpartum haemorrhage (P), does intrauterine balloon tamponade (I) compared to placebo or no treatment (C) improve outcomes (O)?

 

Evidence summary

No RCTs were identified on the use of uterine tamponade for the treatment of PPH. Twenty-two case series and 18 case reports were identified (278 women), as well as two reviews. The instruments used included Sengstaken-Blakemore and Foley catheters, Bakri and Rusch balloons, and condoms. Case series have reported success rates (indicating that there was no use of hysterectomy or other invasive procedures) that ranged from 60 % to 100 %.

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.

 

Research implications

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

 

References

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Citation: WHO Reproductive Health Library. WHO recommendation on the use of uterine tamponade for the treatment of postpartum haemorrhage (September 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.