WHO recommendation on the use of uterine packing for the treatment of postpartum haemorrhage

WHO recommendation on the use of uterine packing for the treatment of postpartum haemorrhage

 

Recommendation

The use of uterine packing is not recommended for the treatment of postpartum haemorrhage due to uterine atony after vaginal birth.

(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 GDG noted that there was no evidence of benefit of uterine packing and placed a high value on concerns regarding its potential harm.

 

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.

 

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 RCTs were identified which reported on the use of uterine packing for the treatment of PPH. Evidence from case series and case report 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 uterine packing (I) compared to no treatment (C) improve outcomes (O)?

 

Evidence summary

No RCTs were identified which reported on the use of uterine packing for the treatment of PPH. Ten case series and one case report (with a combined total of 208 women) were found, and the largest of these had a sample size of 83 women. One study evaluated patients after caesarean sections undertaken due to placenta previa/accreta. Success rates (indicating that there was no use of hysterectomy or other invasive procedures) in the identified studies ranged from 75% 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

  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
  4. Nwagha UI, Okaro JM, Nwagha TU. Intraoperative uterine packing with mops: an effective, but under utilized method of controlling post partum haemorrhage experience from South Eastern Nigeria. Niger J Med. 2005 Jul-Sep;14(3):279-82.
  5. Haq G, Tayyab S. Control of postpartum and post abortal haemorrhage with uterine packing. J Pak Med Assoc. 2005 Sep;55(9):369-71.
  6. Naqvi S, Makhdoom T. Conservative management of primary postpartum haemorrhage. J Coll Physicians Surg Pak. 2004 May;14(5):296-7.
  7. Varatharajan L, Chandraharan E, Sutton J, Lowe V, Arulkumaran S. Outcome of the management of massive postpartum hemorrhage using the algorithm "HEMOSTASIS". Int J Gynaecol Obstet. May;113(2):152-4.
  8. Thapa K, Malla B, Pandey S, Amatya S. Intrauterine condom tamponade in management of post partum haemorrhage. J Nepal Health Res Counc. Apr;8(1):19-22.
  9. Hackethal A, Tcharchian G, Ionesi-Pasacica J, Muenstedt K, Tinneberg HR, Oehmke F. Uterine surgery in postpartum hemorrhage. Minerva Ginecol. 2009 Jun;61(3):201-13.
  10. Breathnach F, Geary M. Uterine atony: definition, prevention, nonsurgical management, and uterine tamponade. Semin Perinatol. 2009 Apr;33(2):82-7.
  11. Lombaard H, Pattinson RC. Common errors and remedies in managing postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol. 2009 Jun;23(3):317-26.
  12. Al-Harbi NA, Al-Abra ES, Alabbad NS. Utero-vaginal packing. Seven years review in the management of post partum hemorrhage due to placenta previa/accrete at a maternity hospital in Central Saudi Arabia. Saudi Med J. 2009 Feb;30(2):243-6.
  13. Mousa HA, Cording V, Alfirevic Z. Risk factors and interventions associated with major primary postpartum hemorrhage unresponsive to first-line conventional therapy. Acta Obstet Gynecol Scand. 2008;87(6):652-61.
  14. Bagga R, Jain V, Kalra J, Chopra S, Gopalan S. Uterovaginal packing with rolled gauze in postpartum hemorrhage. MedGenMed. 2004;6(1):50.
  15. Hsu S, Rodgers B, Lele A, Yeh J. Use of packing in obstetric hemorrhage of uterine origin. J Reprod Med. 2003 Feb;48(2):69-71.
  16. Wittich AC, Salminen ER, Hardin EL, Desantis RA. Uterine packing in the combined management of obstetrical hemorrhage. Mil Med. 1996 Mar;161(3):180-2. Hester JD. Postpartum hemorrhage and reevaluation of uterine packing. Obstet Gynecol. 1975 May;45(5):501-4.
  17. Wax JR, Channell JC, Vandersloot JA. Packing of the lower uterine segment--new approach to an old technique. Int J Gynaecol Obstet. 1993 Nov;43(2):197-8.
  18. Condous GS, Arulkumaran S. Medical and conservative surgical management of postpartum hemorrhage. J Obstet Gynaecol Can. 2003 Nov;25(11):931-6.
  19. Maier RC. Control of postpartum hemorrhage with uterine packing. Am J Obstet Gynecol. 1993 Aug;169(2 Pt 1):317-21; discussion 321-3.
  20. Kohoutek M. Significance of uterine tamponade in contemporary obstetrics (author's transl). Cesk Gynekol. 1976 Apr;41(2):88-9.
  21. Ushakova GA. Use of metrohemostat combined with tight tamponade of the vaginal fornices in the prevention and treatment of hypotonic hemorrhages in the early postnatal period. Akush Ginekol (Mosk). 1974 Nov(11):26-9.
  22. Avramov A, Todorov T. Utero-vaginal tamponade as a preventive measure in hypotonic uterine hemorrhage. Akush Ginekol (Sofiia). 1965;4(2):145-6.
  23. Pardini I. The uselessness of utero-vaginal tamponade in postpartum metrorrhagia. Riv Ostet Ginecol. 1962 Jul;17:465-76.
  24. Kozbagarov AA. Uterine tamponade in atonic hemorrhage. Akush Ginekol (Mosk). 1961 Jul-Aug;37:57-9.
  25. Sakulina AN. Control of atonic postpartum hemorrhage by an ether tamponade in the vagina according to P.A. Guzikov's method. Akush Ginekol (Mosk). 1957 Mar-Apr;33(2):86-8.

 

Citation: 

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