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Guideline Summary
Guideline Title
Prevention and management of postpartum haemorrhage.
Bibliographic Source(s)
Royal College of Obstetricians and Gynaecologists (RCOG). Prevention and management of postpartum haemorrhage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2009 Nov. 24 p. (Green-top guideline; no. 52).  [110 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Postpartum hemorrhage (PPH)

Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Anesthesiology
Hematology
Obstetrics and Gynecology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide recommendations for the management of primary postpartum hemorrhage (PPH) of 500 ml or more
  • To provide recommendations for the management of major secondary PPH
Target Population
  • Women experiencing primary postpartum hemorrhage (PPH) of 500 ml or more
  • Women experiencing major secondary PPH

Note: This Green-top guideline is restricted in scope to the management of PPH. Nevertheless, antepartum haemorrhage is often associated with subsequent PPH and the content of this guideline will have relevance for the care of these women.

These guidelines are not intended for use in the following populations:

  • Women with pre-existing bleeding disorders such as hemophilia and women taking therapeutic anticoagulants
  • Women who refuse blood transfusion
Interventions and Practices Considered
  1. Prediction and prevention of postpartum hemorrhage (PPH)
    • Active management of the third stage of labor
    • Drugs for prophylaxis (oxytocin, Syntometrine, misoprostol)
    • Ultrasound determination of placental site in women who have had a previous caesarean section
    • Magnetic resonance imaging (MRI) to detect placenta accreta/percreta
    • Management of placenta accreta/percreta
  2. Management of PPH by simultaneous initiation and progression of:
    • Communication: basic measures for minor PPH and full protocol for major PPH
    • Resuscitation: basic measures for minor PPH and full protocol for major PPH according to clinical judgment
    • Monitoring and investigation: basic measures for minor PPH and full protocol for major PPH
    • Arresting the bleeding
      • Evaluation of cause
      • Mechanical and pharmacological measures
      • Surgical hemostasis
      • Hysterectomy
    • Treatment of secondary PPH by antibiotics (ampicillin, clindamycin, metronidazole, gentamicin)
Major Outcomes Considered
  • Maternal blood loss
  • Maternal mortality
  • Risk of postpartum hemorrhage (PPH)
  • Time spent in intensive care
  • Transfusion requirement
  • Need for hysterectomy
  • Adverse events associated with treatments

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

This Royal College of Obstetricians and Gynaecologists (RCOG) guideline is based on an earlier guideline on the management of postpartum haemorrhage developed in 1998, under the auspices of the Scottish Committee of the RCOG, and updated in 2002. This guideline was developed in accordance with standard methodology for producing RCOG Green-top Guidelines. The Cochrane Library (including the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews and Effects [DARE] and EMBASE), Turning Research into Practice (TRIP), Medline, and PubMed (electronic databases) were searched for relevant randomised controlled trials, systematic reviews, and meta-analyses. The search was restricted to articles published between 2002 and March 2007. The databases were searched using the relevant MeSH terms, including all subheadings, and this was combined with a keyword search. Search words included 'postpartum haemorrhage', 'factor VII', 'Syntocinon', 'carbetocin', 'carboprost', 'oxytocics', 'uterotonics', 'B-lynch suture', 'uterine artery embolism', 'bilateral ligation', 'balloon, Rusch, Sengstaken catheters' and the search limited to humans and English language. The National Library for Health and the National Guideline Clearinghouse were also searched for relevant guidelines and reviews. Guidelines and recommendations produced by organisations such as British Committee for Standards in Haematology Transfusion Taskforce and national bodies were considered.

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

Classification of Evidence Levels

1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias

1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal

3 Non-analytical studies; e.g., case reports, case series

4 Expert opinion

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

Reviewing and Grading of Evidence

Once the evidence has been collated for each clinical question it needs to be appraised and reviewed (refer to section 3 in "Development of RCOG Green-top guidelines: producing a clinical practice guideline" for information on the formulation of the clinical questions; see the "Availability of Companion Documents" field). For each question, the study type with least chance of bias should be used. If available, randomised controlled trials (RCTs) of suitable size and quality should be used in preference to observational data. This may vary depending on the outcome being examined.

The level of evidence and the grade of the recommendations used in this guideline originate from the guidance by the Scottish Intercollegiate Guidelines Network (SIGN) Grading Review Group, which incorporates formal assessment of the methodological quality, quantity, consistency, and applicability of the evidence base. The methods used to appraise individual study types are available from the SIGN Web site (www.sign.ac.uk/methodology/checklists.html External Web Site Policy). An objective appraisal of study quality is essential, but paired reviewing by guideline leads may be impractical because of resource constraints.

Once evidence has been collated and appraised, it can be graded. A judgement on the quality of the evidence will be necessary using the grading system (see the "Rating Scheme for the Strength of the Evidence" field). Where evidence is felt to warrant 'down-grading', for whatever reason, the rationale must be stated. Evidence judged to be of poor quality can be excluded. Any study with a high chance of bias (either 1– or 2) will be excluded from the guideline and recommendations will not be based on this evidence. This prevents recommendations being based on poor-quality RCTs when higher-quality observational evidence is available.

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

Guideline Development

The development of guidelines involves more than the collation and reviewing of evidence. Even with high-quality data from systematic reviews of randomised controlled trials, a value judgement is needed when comparing one therapy with another. This will therefore introduce the need for consensus.

Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guidelines are drafted by nominated developers, in contrast to other guideline groups such as the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), who use larger guideline development groups. Equally, in contrast to other guideline groups, the topics chosen for development as Green-top guidelines are concise enough to allow development by a smaller group of individuals.

In agreeing the precise wording of evidence-based guideline recommendations and in developing consensus-based 'good practice points', the Guidelines Committee (GC) will employ an informal consensus approach through group discussion. In line with current methodologies, the entire development process will follow strict guidance and be both transparent and robust. The RCOG acknowledges that formal consensus methods have been described, but these require further evaluation in the context of clinical guideline development. It is envisaged that this will not detract from the rigor of the process but prevent undue delays in development.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendations

A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or

A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results.

B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D - Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group

Cost Analysis

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

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

Following discussion in the Guidelines Committee (GC), each Green-top guideline is formally peer reviewed. At the same time, the draft guideline is published on the Royal College of Obstetricians and Gynaecologists (RCOG) Web site for further peer discussion before final publication.

All comments will be collated by the RCOG and tabulated for consideration by the guideline leads. Each comment will require discussion. Where comments are rejected then justification will need to be made. Following this review, the document will be updated and the GC will then review the revised draft and the table of comments.

Once the GC signs-off on the guideline, it is submitted to the Standards Board for approval before final publication.

Recommendations

Major Recommendations

In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.

Classification of evidence levels (1++ to 4) and grades of recommendations (A-D) are defined at the end of the "Major Recommendations" field.

Definition of Postpartum Haemorrhage

C - Primary post partum haemorrhage (PPH) involving an estimated blood loss of 500–1000 ml (and in the absence of clinical signs of shock) should prompt basic measures (close monitoring, intravenous access, full blood count, group and screen) to facilitate resuscitation should it become necessary.

C - If a woman with primary PPH is continuing to bleed after an estimated blood loss of 1000 ml (or has clinical signs of shock or tachycardia associated with a smaller estimated loss), this should prompt a full protocol of measures to achieve resuscitation and haemostasis.

Prediction and Prevention of Postpartum Haemorrhage

What Are the Risks of PPH and How Can They Be Minimised?

A - Active management of the third stage of labour lowers maternal blood loss and reduces the risk of PPH.

A - Prophylactic oxytocics should be offered routinely in the management of the third stage of labour in all women as they reduce the risk of PPH by about 60%.

A - For women without risk factors for PPH delivering vaginally, oxytocin (5 iu or 10 iu by intramuscular injection) is the agent of choice for prophylaxis in the third stage of labour.

C - For women delivering by caesarean section, oxytocin (5 iu by slow intravenous injection) should be used to encourage contraction of the uterus and to decrease blood loss.

A bolus dose of oxytocin may possibly be inappropriate in some women, such as those with major cardiovascular disorders, suggesting that a low-dose infusion might be a safer alternative.

C - Syntometrine (® Alliance) may be used in the absence of hypertension (for instance, antenatal low haemoglobin) as it reduces the risk of minor PPH (500-1000 ml) but increases vomiting.

A - Misoprostol is not as effective as oxytocin, but it may be used when the latter is not available, such as the home-birth setting.

C - All women who have had a previous caesarean section must have their placental site determined by ultrasound. Where facilities exist, magnetic resonance imaging (MRI) may be a useful tool and assist in determining whether the placenta is accreta or percreta.

C - Women with placenta accreta/percreta are at very high risk of major PPH. If placenta accreta or percreta is diagnosed antenatally, there should be consultant-led multidisciplinary planning for delivery. Consultant obstetric and anaesthetic staff should be present, prompt availability of blood, fresh frozen plasma and platelets be confirmed, and the timing and location for delivery chosen to facilitate consultant presence and access to intensive care.

B - Available evidence on prophylactic occlusion or embolisation of pelvic arteries in the management of women with placenta accreta is equivocal. The outcomes of prophylactic arterial occlusion require further evaluation.

How Should PPH Be Managed?

C - Once PPH has been identified, management involves four components, all of which must be undertaken SIMULTANEOUSLY: communication, resuscitation, monitoring and investigation, arresting the bleeding.

The pattern of management presented in this guideline is dependent on the woman being cared for in a consultant-led maternity unit with access to laboratory and blood bank facilities and with skilled obstetric and anaesthetic staff readily available. On occasions where primary PPH occurs in a woman delivering in a different setting (such as at home or in a midwife-led maternity unit), the role of the professionals on site is to institute 'first aid' measures while arranging transport to a consultant-led maternity unit by the most expeditious means.

Communication

Who Should Be Informed When the Woman Presents with Postpartum Haemorrhage?

C - Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock):

  • Alert the midwife-in-charge.
  • Alert first-line obstetric and anaesthetic staff trained in the management of PPH.

Full protocol for MAJOR PPH (blood loss more than 1000 ml and continuing to bleed OR clinical shock):

  • Call experienced midwife (in addition to midwife-in-charge).
  • Call obstetric middle grade and alert consultant.
  • Call anaesthetic middle grade and alert consultant.
  • Alert consultant clinical haematologist on call.
  • Alert blood transfusion laboratory.
  • Call porters for delivery of specimens/blood.
  • Alert one member of the team to record events, fluids, drugs, and vital signs.

Early involvement of appropriate senior staff (including anaesthesia team, laboratory specialists) is fundamental to the management of PPH. Clinicians and blood transfusion staff should liaise at a local level to agree:

  • A standard form of words (such as 'we need compatible blood now' or 'group-specific blood') to be used in cases of major obstetric haemorrhage.
  • A timescale in which to produce various products.

The use of the term 'controlled major obstetric haemorrhage' or 'ongoing major obstetric haemorrhage' may be used to define the urgency for the need of the team.

It is vital that junior obstetricians and anaesthetists do not perceive the calling of senior colleagues as involving 'loss of face'. Senior staff must be receptive to concerns expressed by juniors and by midwives. In contemporary UK maternity services, intrapartum care within consultant units should be consultant-based, rather than simply consultant-led. In the face of major PPH with continuing bleeding, a consultant obstetrician should be alerted and should normally attend to provide hands-on patient care. If a midwife perceives a need for a consultant obstetrician's presence, they should feel able to call a consultant colleague themselves if onsite obstetric junior staff appear reluctant to do so.

Communication with the patient and her birthing partner is important and clear information of what is happening should be given, as this is a very frightening event.

Resuscitation

A primary survey of a collapsed or severely bleeding woman should follow a structured approach of simple 'ABC', with resuscitation taking place as problems are identified; that is, a process of simultaneous evaluation and resuscitation. The urgency and measures undertaken to resuscitate and arrest haemorrhage need to be tailored to the degree of shock.

A and B – Assess Airway and Breathing

A high concentration of oxygen (10–15 litres/minute) via a facemask should be administered, regardless maternal oxygen concentration. If the airway is compromised owing to impaired conscious level, anaesthetic assistance should be sought urgently. Usually, level of consciousness and airway control improve rapidly once the circulating volume is restored.

C – Evaluate Circulation

Establish two 14-gauge intravenous lines; 20 ml blood sample should be taken and sent for diagnostic tests, including full blood count, coagulation screen, urea and electrolytes and cross match (4 units). The urgency and measure undertaken to resuscitate and arrest haemorrhage need to be tailored to the degree of shock.

C - Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock):

  • Intravenous access (14-gauge cannula x 1).
  • Commence crystalloid infusion.

Full protocol for MAJOR PPH (blood loss >1000 ml and continuing to bleed OR clinical shock):

  • Assess airway.
  • Assess breathing.
  • Evaluate circulation.
  • Oxygen by mask at 10–15 litres/minute.
  • Intravenous access (14-gauge cannula x 2, orange cannulae).
  • Position flat.
  • Keep the woman warm using appropriate available measures.
  • Transfuse blood as soon as possible.
  • Until blood is available, infuse up to 3.5 litres of warmed crystalloid Hartmann's solution (2 litres) and/or colloid (1–2 litres) as rapidly as required.
  • The best equipment available should be used to achieve RAPID WARMED infusion of fluids.
  • Special blood filters should NOT be used, as they slow infusions.
  • Recombinant factor VIIa therapy should be based on the results of coagulation.

Fluid therapy and blood product transfusion (please refer to sections 6.2.1 and 6.2.2 in the original guideline document):

Crystalloid Up to 2 litres Hartmann's solution
Colloid Up to 1–2 litres colloid until blood arrives
Blood Crossmatched. If crossmatched blood is still unavailable, give uncrossmatched group-specific blood OR give 'O RhD negative' blood
Fresh frozen plasma 4 units for every 6 units of red cells or prothrombin time/activated partial thromboplastin time >1.5 x normal (12–15 ml/kg or total 1 litre)
Platelets concentrates If platelet count <50 x 109
Cryoprecipitate If fibrinogen <1 g/l

C - Apply clinical judgement on each situation.

Monitoring and Investigation

What Investigations Should Be Performed and How Should the Woman Be Monitored?

C - Basic measures for MINOR PPH (blood loss 500–1000 ml, no clinical shock and bleeding ceasing):

  • Consider venepuncture (20 ml) for:
    • Group and screen
    • Full blood count
    • Coagulation screen including fibrinogen
    • Pulse and blood pressure recording every 15 minutes

Full Protocol for MAJOR PPH (blood loss greater than 1000 ml and continuing to bleed OR clinical shock):

  • Consider venepuncture (20 ml) for:
    • Crossmatch (4 units minimum)
    • Full blood count
    • Coagulation screen including fibrinogen
    • Renal and liver function for baseline
  • Monitor temperature every 15 minutes.
  • Continuous pulse, blood pressure recording, and respiratory rate (using oximeter, electrocardiogram, and automated blood pressure recording).
  • Foley catheter to monitor urine output.
  • Two peripheral cannulae, 14- or 16-gauge.
  • Consider arterial line monitoring (once appropriately experienced staff available for insertion).
  • Consider transfer to intensive therapy unit once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate.
  • Recording of parameters on a flow chart such as the modified obstetric early warning system charts.
  • Documentation of fluid balance, blood, blood products, and procedures.

Fluid replacement and the use of blood and blood products should be strictly monitored and the amount given should be dictated by the lead clinician (consultant anaesthetist or consultant obstetrician) aided by the results of full blood count and clotting screen under the guidance of a haematologist and/or consultant in transfusion medicine. The full blood count will include estimation of haematocrit and platelet count. The clotting screen should include prothrombin time, thrombin time, partial thromboplastin time and fibrinogen assay.

Anaesthetic Management

The anaesthetist needs to able to assess the woman quickly, to initiate or continue resuscitation to restore intravascular volume and provide adequate anaesthesia.

The presence of cardiovascular instability is a relative contraindication to regional anaesthesia. Blockage of the sympathetic system can potentially lead to worsening hypotension due to haemorrhage. If cardiovascular stability has been achieved and there is no evidence of coagulation failure, regional anaesthesia can be used. This may be particularly appropriate where a working epidural has been in place during labour. Continuous epidural block is preferred over spinal, as it allows better blood pressure control and for prolonged surgery.

When there is continuing bleeding and the cardiovascular stability is compromised, general anaesthesia is more appropriate. Rapid sequence induction is the gold standard to reduce the risk of aspiration. Cardiostable induction agents with minimal peripheral vasodilators should be considered and adrenaline and atropine being available during induction. Ventilation with high oxygen concentrations may be needed until the bleeding is under control.

Arresting the Bleeding

Causes for PPH may be considered to relate to one or more of 'the four Ts':

  • Tone (abnormalities of uterine contraction)
  • Tissue (retained products of conception)
  • Trauma (of the genital tract)
  • Thrombin (abnormalities of coagulation)

C - The most common cause of primary PPH is uterine atony. However, clinical examination must be undertaken to exclude other or additional causes:

  • Retained products (placenta, membranes, clots)
  • Vaginal/cervical lacerations or haematoma
  • Ruptured uterus
  • Broad ligament haematoma
  • Extragenital bleeding (for example, subcapsular liver rupture)
  • Uterine inversion

B - When uterine atony is perceived to be a cause of the bleeding, the following mechanical and pharmacological measures should be instituted, in turn, until the bleeding stops:

  • Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
  • Ensure bladder is empty (Foley catheter, leave in place).
  • Syntocinon 5 units by slow intravenous injection (may have repeat dose).
  • Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
  • Syntocinon infusion (40 units in 500 ml Hartmann's solution at 125 ml/hour) unless fluid restriction is necessary.
  • Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
  • Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
  • Misoprostol 1000 micrograms rectally.

C - If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. Intrauterine balloon tamponade is an appropriate firstline 'surgical' intervention for most women where uterine atony is the only or main cause of haemorrhage. If this fails to stop the bleeding, the following conservative surgical interventions may be attempted, depending on clinical circumstances and available expertise:

  • Balloon tamponade
  • Haemostatic brace suturing (such as using procedures described by B-Lynch or modified compression sutures)
  • Bilateral ligation of uterine arteries
  • Bilateral ligation of internal iliac (hypogastric) arteries
  • Selective arterial embolisation

C - Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture).

How Should Secondary PPH Be Treated?

C - Secondary PPH is often associated with endometritis. When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended.

Definitions:

Classification of Evidence Levels

1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias

1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal

3 Non-analytical studies; e.g., case reports, case series

4 Expert opinion

Grades of Recommendations

A - At least one meta-analysis, systematic review or randomised controlled trial rated as 1++, and directly applicable to the target population; or

A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results.

B - A body of evidence including studies rated as 2++ directly applicable to the target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C - A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D - Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Good Practice Point - Recommended best practice based on the clinical experience of the guideline development group

Clinical Algorithm(s)

The original guideline document contains a flow chart of the different steps for the management of major postpartum haemorrhage.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for most recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate prevention and management of postpartum haemorrhage, which may reduce maternal morbidity and mortality

Potential Harms
  • Four Cochrane reviews addressed prophylaxis in the third stage of labour for women delivering vaginally. The first (Active Versus Expectant Management in the Third Stage of Labour) included five trials and found that active management (which included the use of a uterotonic, early clamping of the umbilical cord and controlled traction for the delivery of the placenta) was associated with lower maternal blood loss and with reduced risks of postpartum haemorrhage and prolonged third stage. However, active management was also associated with an increased incidence of nausea, vomiting, and raised blood pressure.
  • A more recent Cochrane review addressed prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour; six trials were included. There were major differences between ergometrine-oxytocin and oxytocin alone in the unpleasant side effects of nausea, vomiting and elevation of blood pressure, with ergometrine–oxytocin carrying a five-fold increased risk (odds ratio 4.92, 95% confidence interval 4.03–6.00).
  • Misoprostol (600 micrograms orally) is not as effective when compared with oxytocin (10 iu intravenously) in preventing post-partum haemorrhage (PPH); it also carries increased adverse effects, which are dose related.
  • Central venous pressure monitoring requires early involvement of a senior skilled anaesthetist, who will usually take responsibility for this aspect of management. The use of ultrasound is more likely to make the procedure safer, as this procedure carries significant morbidity and mortality.

Contraindications

Contraindications
  • The presence of cardiovascular instability is a relative contraindication to regional anaesthesia.
  • Ergometrine is contraindicated in women with hypertension.
  • Carboprost (intramuscular or intramyometrial) is contraindicated in women with asthma.

Qualifying Statements

Qualifying Statements
  • These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
  • The Royal College of Obstetricians and Gynaecologists (RCOG) produces guidelines as an educational aid to good clinical practice. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor or other attendant in the light of clinical data presented by the patient and the diagnostic and treatment options available. This means that RCOG Guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of management. Departure from the local prescriptive protocols or guidelines should be fully documented in the patient's case notes at the time the relevant decision is taken.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Audit Criteria/Indicators
Chart Documentation/Checklists/Forms
Clinical Algorithm
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
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Royal College of Obstetricians and Gynaecologists (RCOG). Prevention and management of postpartum haemorrhage. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2009 Nov. 24 p. (Green-top guideline; no. 52).  [110 references]
Adaptation

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

Date Released
2009 Nov
Guideline Developer(s)
Royal College of Obstetricians and Gynaecologists - Medical Specialty Society
Source(s) of Funding

Royal College of Obstetricians and Gynaecologists

Guideline Committee

Guidelines Committee

Composition of Group That Authored the Guideline

Authors: Professor S Arulkumaran FRCOG, London; Dr E Mavrides MRCOG, London; Dr GC Penney FRCOG, Aberdeen

Peer Reviewers: Dr Shubha Allard MD FRCP FRCPath, Consultant Haematologist, Barts & the London NHS Trust and NHSBT; Dr G Attilakos MRCOG, Bristol; Dr WL Martin FRCOG, British Maternal and Fetal Medicine Society (BMFMS); DJ Bamber, SDU Director for Anaesthesia, Lead Consultant for Obstetric Anaesthesia, Addenbrooke's and Cambridge University Teaching Hospitals, Cambridge; Dr TP Baglin, Chair, British Committee for Standards in Haematology; Dr S Catling, Lead Obstetric Anaesthetist, Singleton Hospital, Department of Anaesthetics, Swansea; Dr C Connolly, Consultant Anaesthetist, Ninewells Hospital, Dundee; Dr A Copplestone, Consultant Haematologist, Derriford Hospital, Plymouth, Devon; Mr TJ Draycott MRCOG, Bristol; Dr PP Fogarty FRCOG, Belfast, Northern Ireland; Mr DI Fraser MRCOG, Norwich; Mr ARK Haloob FRCOG, Basildon; Drs W Harrop-Griffiths and V Bythell, Association of Anaesthetists of Great Britain and Ireland; Mr HKS Hinshaw FRCOG, Sunderland; Professor GJ Hofmeyr FRCOG, East London, South Africa; Jehovah's Witness Organisation; Dr T Kay MRCOG, Devon; Dr SM Kinsella, Obstetric Anaesthetists' Association; Dr AJJ Kirkpatrick MRCOG, RCOG Patient Information Sub-Group; Dr TA Mahmood FRCOG, Kircaldy, Scotland, Vice President Standards, RCOG; Professor E Massey, National Blood Service, Oxford; Dr KT Moriarty MRCOG, Daventry; Professor DJ Murphy MRCOG, Dublin, Republic of Ireland; Dr ME Quinn DRCOG, Belfast, Northern Ireland; RCOG Consumers' Forum; Dr FAM Regan, Consultant of Stem Cell and Immunotherapies, National Blood Service, London; Dr KP Rege, Peterborough District Hospital, Department of Haematology, Peterborough; Royal College of Midwives; Dr SS Sharma MRCOG, Cambridge; Dr T Sibanda MRCOG, Swansea, Wales; Dr M Scrutton Bristol Royal Infirmary Department of Anaesthesia, Bristol; Professor PJ Steer FRCOG, London; Miss SM Tuck FRCOG, London; Mr DJ Tuffnell FRCOG, Bradford; Dr M Vellayan MRCOG, Gloucestershire; Mr SHJ Zaidi FRCOG, East Sussex

Guidelines and Audit Committee Lead Peer Reviewer: Mrs C Overton FRCOG

Financial Disclosures/Conflicts of Interest

Guideline authors are required to complete a "declaration of interests" form.

Guideline Status

This is the current release of the guideline.

Guideline Availability
Availability of Companion Documents

The following are available:

  • Development of RCOG Green-top guidelines: policies and processes. Clinical Governance Advice No 1a. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2006 Nov. 6 p. Electronic copies: Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site External Web Site Policy.
  • Development of RCOG Green-top guidelines: producing a scope. Clinical Governance Advice No 1b. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2006 Nov. 4 p. Electronic copies: Available from the RCOG Web site External Web Site Policy.
  • Development of RCOG Green-top guidelines: producing a clinical practice guideline. Clinical Governance Advice No 1c. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2006 Nov. 13 p. Electronic copies: Available from the RCOG Web site External Web Site Policy.
  • Development of RCOG Green-top guidelines: consensus methods for adaptation of Green-top guidelines. Clinical Governance Advice No 1d. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2010 Feb. 9 p. Electronic copies: Available from the RCOG Web site External Web Site Policy.

Appendix 1 of the original guideline document External Web Site Policy contains an example of a postpartum haemorrhage chart, and Appendix 3 contains an obstetric early warning chart.

In addition, auditable standards can be found in section 10 of the original guideline document External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 13, 2011.

Copyright Statement

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

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