WHO recommendations on the use of manoeuvers and other procedures for the treatment of postpartum haemorrhage (PPH)

WHO recommendations on the use of manoeuvers and other procedures for the treatment of postpartum haemorrhage (PPH)

Recommendations

 

  • Uterine massage is recommended for the treatment of PPH.  (Strong recommendation, very-low-quality evidence)
  • 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)
  • 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)
  • 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)
  • 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)
  • 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)
  • The use of non-pneumatic anti-shock garments is recommended as a temporizing measure until appropriate care is available. (Weak recommendation, low-quality evidence)
  • 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)

 

Date these recommendations were published: September 2012

 

Remarks

The GDG noted that the application of these interventions requires training and that maternal discomfort and complications associated with these procedures have been reported.

Uterine massage as a therapeutic measure is defined as the rubbing of the uterus achieved through the manual massaging of the abdomen. This is typically sustained until the bleeding stops or the uterus contracts. The GDP considered that uterine massage should be started once PPH has been diagnosed.

The initial rubbing of the uterus and expression of blood clots are not regarded as therapeutic uterine massage.

When rating the recommendation of uterine massage as ‘strong’, the low cost and safety of uterine massage were taken into account.

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. The GDG noted that uterine artery embolization requires significant resources, in terms of the cost of the treatment, the facilities, and the training of health care workers.

The GDG noted that conservative surgical approaches should be tried first. If these do not work, they should be followed by more invasive procedures. Compression sutures, for example, may be attempted as a first intervention, and if these fail, then uterine, utero-ovarian and hypogastric vessel ligation may be tried. If life-threatening bleeding continues even after ligation, then a subtotal (otherwise known as supracervical) or total hysterectomy should be performed.

The GDG acknowledged that the level of health care provider skills will play a role in the selection and sequence of the surgical interventions.

External aortic compression has long been recommended as a potential life-saving technique, and mechanical compression of the aorta, if successful, slows blood loss. The GDG placed a high value on this procedure as a temporizing measure in the treatment of PPH.

The GDG noted that research evaluating the potential benefits and harms of non-pneumatic anti-shock garments is ongoing. Based on the evidence available, the GDG regarded non-pneumatic anti-shock garments as a temporizing measure while transfer is awaited.

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

 

 

Related links

WHO recommendations for the prevention and treatment of postpartum haemorrhage

Evidence Base and GRADE tables for these recommendations

 

Resources

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

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

 

These recommendations should be cited as: WHO Reproductive Health Library. WHO recommendations on the use of manoeuvres and other procedures for the treatment of postpartum haemorrhage (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.