Advances in the Treatment of Postpartum Hemorrhage

Alison M El Ayadi; Nuriya Robinson; Stacie Geller; Suellen Miller


Expert Rev of Obstet Gynecol. 2013;8(6):525-537. 

In This Article

Prevention of Atonic PPH

As uterine atony is the leading cause of PPH, agents that improve uterine tone and increase uterine smooth muscle contractility are most beneficial for overall prevention and treatment of PPH. The WHO recommends prophylactic uterotonic administration during the third stage of labor, with oxytocin (IM/IV, 10 IU) the preferred drug.[6] Where oxytocin is unavailable, WHO recommends the use of other injectable uterotonics (e.g., ergometrine/methlergometrine or oxytocin/ergometrine) or oral misoprostol (600 μg).[6] Updated evidence regarding other common components of active AMTSL prompted the WHO to change recommendations around controlled cord traction (CCT). It is considered optional in the presence of skilled birth attendants, but not recommended in the absence of a skilled provider. NICE and International Federation of Gynecology and Obstetrics (FIGO) also support AMTSL, though the individual components vary by recommending body.[26,27] Early cord clamping and cutting was favored by NICE while fundal massage following placental delivery was recommended by FIGO.[26,27] Recent WHO recommendations suggest performing delayed cord clamping (1–3 min after birth) and intermittent uterine tone assessment.[6] AMTSL requires a trained healthcare provider for implementation; the risks of AMTSL performed by unskilled birth attendants, particularly CCT, are not well studied.[6]

A number of other pharmacologic agents have been evaluated for PPH prophylaxis. Recent literature suggests carbetocin may soon play a greater role in PPH prevention given demonstrated equal efficacy as oxytocin and decreased need for subsequent uterotonic administration at cesarean section, less blood loss and fewer adverse effects than Syntometrine for vaginal deliveries and greater cost–effectiveness over oxytocin among cesarean deliveries.[28,29]