How is postpartum hemorrhage prevented?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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High-quality evidence suggests that active management of the third stage of labor reduces the incidence and severity of PPH. [9] Active management is the combination of (1) uterotonic administration (preferably oxytocin) immediately upon delivery of the baby, (2) early cord clamping and cutting, and (3) gentle cord traction with uterine countertraction when the uterus is well contracted (ie, Brandt-Andrews maneuver).

The value of active management in the prevention of PPH cannot be overstated (see Management of the Third Stage of Labor). The use of active versus expectant management in the third stage was the subject of 5 randomized controlled trials (RCTs) and a Cochrane meta-analysis. [19, 8, 9] These trials included more than 6000 women, and the findings are summarized in Table 1.

Table 1. Benefits of Active Management Versus Expectant Management (Open Table in a new window)


Control Rate, %

Relative Risk

95% CI*


95% CI

PPH of 500 mL






PPH of 1000 mL






Hemoglobin < 9 g/dL






Blood transfusion






Therapeutic uterotonics






*CI: Confidence interval

† NNT: Number needed to treat


The findings show a conclusive benefit for active management, with an approximate 60% reduction in the occurrence of PPH greater than or equal to 500 mL and 1000 mL, hemoglobin concentration of less than 9 g/dL at 24-48 hours after delivery, and the need for blood transfusion. An 80% reduction in the need for therapeutic uterotonic agents was noted. These results were all highly significant as indicated by the 95% confidence interval figures. The results indicate that for every 12 patients receiving active rather than physiological management, one PPH would be prevented. For every 67 patients so treated, one patient would avoid transfusion with blood products.

One concern regarding active management is that retained placenta may occur more frequently. This concern is not supported by the trials. This is especially true if oxytocin is used as the uterotonic. [20, 21] The US RCTs mentioned above compared the use of active management protocols in which the oxytocin was administered either immediately after delivery of the baby or immediately after delivery of the placenta. The authors stated that no statistically significant difference was noted in the PPH rate and that delaying administration until after placental delivery was justified.

Noteworthy is the finding that early administration of oxytocin (before placental delivery) did not increase the rate of retained placenta. Additionally, the trial showed trends toward a benefit for early administration of oxytocin, including a 25% reduction in PPH and a 50% reduction in the need for transfusion. [10] These findings are clearly consistent with the previous RCTs and the early administration of oxytocin with delivery of the baby is strongly recommended.

They also stated that administration with delivery of the baby did not increase the rate of retained placenta, but they did not point out that this finding clearly supports early administration. Additionally, the trial showed trends toward a benefit for early administration of oxytocin, including a 25% reduction in PPH and a 50% reduction in the need for transfusion. [10] These differences may be due to chance, but, given the results of the previous RCTs, the administration of oxytocin with delivery of the baby would seem to be warranted.

Following delivery, administering a uterotonic drug that lasts at least 2-3 hours is reasonable. [3] This could be 10 U of oxytocin in 500 mL of intravenous fluid by continuous drip, 200-250 mcg of ergonovine intramuscularly, or 250 mcg of 15-methyl prostaglandin F2-alpha (carboprost [Hemabate]) intramuscularly. The use of misoprostol and a long-acting oxytocin analogue (carbetocin) is being studied for this use. [22] It has been suggested that distribution of misoprostol ahead of childbirth in communities where home birth is unavoidable can be an effective approach. However, there is insufficient evidence to support this and there are concerns that the drug might be used for starting labor or terminating pregnancy. [23]

The presence of significant antepartum or intrapartum risk factors warrants delivery in maternity units that have readily available resources to deal with massive obstetric hemorrhage. All medical facilities should have protocols for dealing with PPH and obstetric hemorrhage.

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