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Guideline Summary
Guideline Title
Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage.
Bibliographic Source(s)
Leduc D, Senikas V, Lalonde AB, Ballerman C, Biringer A, Delaney M, Duperron L, Girard I, Jones D, Lee LS, Shepherd D, Wilson K. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can. 2009 Oct;31(10):980-93. [55 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Postpartum hemorrhage (PPH)

Guideline Category
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Critical Care
Hematology
Nursing
Obstetrics and Gynecology
Preventive Medicine
Surgery
Intended Users
Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To review the clinical aspects of postpartum hemorrhage (PPH) and provide guidelines to assist clinicians in the prevention and management of PPH

Target Population

All parturient women with or at risk for postpartum hemorrhage

Interventions and Practices Considered

Prevention

  1. Active management of the third stage of labour
  2. Use of uterotonics (oxytocin, carbetocin, ergonovine, misoprostol, and carboprost)
  3. Delaying of cord clamping
  4. Placental cord drainage (not recommended as a routine practice)

Treatment

  1. Estimation of blood loss using clinical markers
  2. Multidisciplinary management of ongoing postpartum hemorrhage
  3. Availability of postpartum hemorrhage emergency equipment tray in all obstetric units
  4. Use of recombinant activated factor VII (considered but insufficient evidence to recommend)
  5. Uterine tamponade
  6. Surgical techniques such as ligation, uterine compression sutures, and hysterectomy
Major Outcomes Considered

Maternal morbidity and mortality rates

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Medline, PubMed, the Cochrane Database of Systematic Reviews, American College of Physicians (ACP) Journal Club, and British Medical Journal (BMJ) Clinical Evidence were searched for relevant articles, with concentration on randomized controlled trials (RCTs), systematic reviews, and clinical practice guidelines published between 1995 and 2007. Each article was screened for relevance and the full text acquired if determined to be relevant.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Each full-text article was critically appraised with use of the Jadad Scale and the levels of evidence definitions of the Canadian Task Force on Preventive Health Care.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Classification of Recommendations

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

This Clinical Practice Guideline has been prepared by the Clinical Practice Obstetrics Committee and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Recommendations

Major Recommendations

The quality of evidence (I–III) and classification of recommendations (A–E, L) are defined at the end of the "Major Recommendations" field.

Prevention of Postpartum Hemorrhage (PPH)

  1. Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A)
  2. Oxytocin (10 international units [IU]), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder. (I-A)
  3. Intravenous (IV) infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL. (I-B)
  4. An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH prevention after vaginal birth but is not recommended at this time with elective Caesarean section. (II-B)
  5. Ergonovine can be used for prevention of PPH but may be considered second choice to oxytocin owing to the greater risk of maternal adverse effects and of the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension. (I-A)
  6. Carbetocin, 100 micrograms (µg) given as an IV bolus over 1 minute, should be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics. (I-B)
  7. For women delivering vaginally with 1 risk factor for PPH, carbetocin 100 µg intramuscularly (IM) decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin. (I-B)
  8. Ergonovine, 0.2 milligrams (mg) IM, and misoprostol, 600 to 800 µg given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available. (II-1B)
  9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (<37 weeks' gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A)
  10. For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping. (I-C)
  11. There is no evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH. (II-2C)
  12. Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH. (II-1C)
  13. Intraumbilical cord injection of misoprostol (800 µg) or oxytocin (10 to 30 IU) can be considered as an alternative intervention before manual removal of the placenta. (II-2C)

Treatment of PPH

  1. For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation. (III-B)
  2. Management of ongoing PPH requires a multidisciplinary approach that involves maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss. (III-C)
  3. All obstetric units should have a regularly checked PPH emergency equipment tray containing appropriate equipment. (II-2B)
  4. Evidence for the benefit of recombinant activated factor VII has been gathered from very few cases of massive PPH. Therefore this agent cannot be recommended as part of routine practice. (II-3L)
  5. Uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy. (III-L)
  6. Surgical techniques such as ligation of the internal iliac artery, compression sutures, and hysterectomy should be used for the management of intractable PPH unresponsive to medical therapy. (III-B)

Definitions:

Quality of Evidence Assessment*

I: Evidence obtained from at least one properly randomized controlled trial

II-1: Evidence from well-designed controlled trials without randomization

II-2: Evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from more than one centre or research group

II-3: Evidence obtained from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Classification of Recommendations

A. There is good evidence to recommend the clinical preventive action

B. There is fair evidence to recommend the clinical preventive action

C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making

D. There is fair evidence to recommend against the clinical preventive action

E. There is good evidence to recommend against the clinical preventive action

L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making

*Adapted from the Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care

†Adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is specifically stated for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention and treatment of postpartum hemorrhage in parturient women

Potential Harms

Maternal side effects associated with medication use and surgical interventions

Contraindications

Contraindications
  • Ergonovine is contraindicated in patients with hypertension and those taking certain drugs (e.g., proteases for human immunodeficiency virus [HIV] infection).
  • Asthma is a relative contraindication to the use of 15-methyl prostaglandin (carboprost tromethamine [Hemabate])

Qualifying Statements

Qualifying Statements

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Foreign Language Translations
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness

Identifying Information and Availability

Bibliographic Source(s)
Leduc D, Senikas V, Lalonde AB, Ballerman C, Biringer A, Delaney M, Duperron L, Girard I, Jones D, Lee LS, Shepherd D, Wilson K. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can. 2009 Oct;31(10):980-93. [55 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Oct
Guideline Developer(s)
Society of Obstetricians and Gynaecologists of Canada - Medical Specialty Society
Source(s) of Funding

Society of Obstetricians and Gynaecologists of Canada

Guideline Committee

Clinical Practice Obstetrics Committee

Composition of Group That Authored the Guideline

Primary Authors: Dean Leduc, MD, Ottawa ON; Vyla Senikas, MD, Ottawa ON; André B. Lalonde, MD, Ottawa ON

Clinical Practice Obstetrics Committee: Dean Leduc (Chair), MD, Ottawa ON; Charlotte Ballerman, MD, Edmonton AB; Anne Biringer, MD, Toronto ON; Martina Delaney, MD, St. John's NL; Louise Duperron, MD, Montreal QC; Isabelle Girard, MD, Montreal QC; Donna Jones, MD, Calgary AB; Lily Shek-Yun Lee, MD, Vancouver BC; Debra Shepherd, MD, Regina SK; Kathleen Wilson, RM, Ilderton ON

Financial Disclosures/Conflicts of Interest

Disclosure statements have been reviewed from all members of the committee.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Society of Obstetricians and Gynaecologists of Canada (SOGC) Web site External Web Site Policy. Also available in French from the SOGC Web site External Web Site Policy.

Print copies: Available from the Society of Obstetricians and Gynaecologists of Canada, La société des obstétriciens et gynécologues du Canada (SOGC) 780 promenade Echo Drive Ottawa, ON K1S 5R7 (Canada); Phone: 1-800-561-2416

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 1, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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