WHO recommendations on the use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour

WHO recommendations on the use of uterotonics for the prevention of postpartum haemorrhage (PPH) during the third stage of labour

Recommendations

 

  • 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)
  • Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH. (Strong recommendation, moderate-quality evidence)
  • In settings where oxytocin 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)
  • In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 µg PO) by community health care workers and lay health workers is recommended for the prevention of PPH. (Strong recommendation, moderate-quality evidence)

 

Date these recommendations were published: September 2012

 

Remarks

Available comparisons are limited, but a significant difference between the benefits of oxytocin and ergometrine is unlikely. These recommendations place a high value on avoiding the adverse effects of ergometrine and assume a similar benefit from using oxytocin and ergometrine for the prevention of PPH.

Caution should be exercised when opting for ergot derivatives for the prevention of PPH as these drugs have clear contraindications in women with hypertensive disorders. Thus, it is probably safer to avoid the use of ergot derivatives in unscreened populations.

Misoprostol (600 µg PO) was regarded by the GDG as an effective drug for the prevention of PPH. However, the GDG considered the relative benefits of oxytocin compared to misoprostol in preventing blood loss, as well as the increased adverse effects of misoprostol compared to oxytocin. The GDG acknowledged that there is no evidence to show that a 600 µg dose of misoprostol provides greater efficacy over a 400µg dose. Lower doses have a lower side-effect profile but the efficacy of lower doses of misoprostol has not been evaluated sufficiently.

The recommendations concerning alternative uterotonics should not detract from the objective of making oxytocin as widely accessible as possible.

In view of past concerns regarding the community-level distribution of misoprostol and the potential for serious consequences of administration before birth, the GDG places emphasis on training persons administering misoprostol and monitoring community distribution interventions with scientifically sound methods and appropriate indicators.

 

Related links

WHO recommendations for the prevention and treatment of postpartum haemorrhage

Evidence Base and GRADE tables for these recommendations

 

Links to the supporting systematic reviews

Begley CM, Gyte GM, Murphy DJ, Devane D, McDonald SJ, McGuire W. Active versus expectant management for women in the third stage of labour.

Brass E, Cotter AM, Ness A, Tolosa JE, Westhoff G. Prophylactic oxytocin for the third stage of labour.

Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage.

 

Resources

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

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

 

Other WHO content related to these recommendations

Education material for teachers of midwifery

WHO RECOMMENDATIONS ON PREVENTION AND TREATMENT OF POSTPARTUM HAEMORRHAGE Highlights and Key Messages from New 2012 Global

 

These recommendations should be cited as: WHO Reproductive Health Library. WHO recommendations on the use of uterotonics for postpartum haemorrhage prevention in the third stage of labour (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.