Microsoft word - no 9 - prevention and management of pph

This guideline has been reviewed and approved by the AOM Board of Directors on March 30, 2006. Principal Authors
AOM Clinical Practice Guideline Working Group
Lynne-Marie Culliton, R.M., Owen Sound, ON Kathelijne Keeren, R.M., Mississauga, ON
countries. The midwife plays a central role in prevention and treatment of postpartum hemorrhage. This This guideline is based on a review of the evidence on guideline provides midwives with an accessible review the prevention and management of postpartum of the current evidence on postpartum hemorrhage that hemorrhage. MEDLINE was used to identify relevant can be used to guide clinical practice and informed research from 1990 onwards. The Cochrane and choice discussions. The physiology of third stage of CINAHL databases were also accessed. Randomized labour is reviewed, and management of the third stage controlled studies and other relevant studies were and of established postpartum hemorrhage are outlined. obtained and a search for published obstetric and midwifery clinical practice guidelines was undertaken. PHYSIOLOGY OF THIRD STAGE
The level and quality of evidence following each recommendation is based on the grading system The third stage of labour consists of two phases: developed by the Canadian Task Force on the Periodic placental separation and placental expulsion. Separation Health Exam (Appendix 1).1 This guideline has been occurs as a result of the sudden decrease in the size of developed and reviewed by the Association of Ontario the uterine cavity after the birth. As the uterus contracts, Midwives (AOM), and approved by the AOM Board of the site of placental attachment decreases in size, while the size of the placenta remains unchanged. The stress thereby created causes the placenta to buckle and it is INTRODUCTION
sheared from the uterine wall.2,3 Separation most often begins in the central portion of the placenta, resulting in Postpartum hemorrhage is one of the top five causes of the formation of a haematoma between the placenta and maternal mortality in both developed and developing remaining decidua. The retroplacental clot is thought to facilitate the completion of separation, as the additional This guideline review reflects information consistent with the best practice as of the date issued and is subject to change. The information is not intended to dictate a
course of action. Local standards may cause additions to or modifications of this guideline. Such changes should be well documented by practice groups.

The Association of Ontario Midwives respectfully acknowledges the financial support of the Ministry of Health and Long-Term Care in the development of this guideline.
The views expressed in this guideline are strictly those of the Association of Ontario Midwives. No official endorsement by the Ministry of Health and Long-Term Care
is intended or should be inferred.
weight in the mid-point of the placenta helps to strip the Incidence
adherent lateral borders, and to peel the membranes from the uterine wall.
PPH occurs in five to fifteen percent of all deliveries and contributes to twenty-five to thirty percent of maternal Once it has separated, the placenta descends into the mortality worldwide.10 PPH with blood loss of >1000 ml lower uterine segment or into the upper vaginal vault. affects one to five percent of births in the developed This is evidenced by: a sudden trickle or small gush of blood, lengthening of the amount of umbilical cord visible at the introitus, change in the size of the uterus from discoid to globular, or change in the position of the  Uterine atony. The uterus fails to contract
effectively to control bleeding. Uterine atony accounts for 80-85% of all cases of primary PPH.13 The expulsion of the placenta from the uterus occurs by one of two mechanisms. The more common Schultz  Partial separation of the placenta. With the
mechanism results in the fetal side of the placenta placental in utero, the uterus is unable to contract presenting at the introitus, with the membranes effectively and there is copious blood loss from the inverted, trailing behind the placenta, and containing the retroplacental clot. The less common Duncan  Retained placental fragments. Placental fragments
mechanism causes the placenta to escape sideways, with the maternal side presenting first. The membranes in this presentation are not peeled off as effectively, and  Placental pathology. This includes variations of
may more often be delayed or retained.5 It is thought placenta previa, placenta accreta, percreta, increta or that the two mechanisms occur as a result of the original site of attachment in the uterus, with higher  Trauma. Trauma most commonly includes
implantations resulting in a Schultz presentation and episiotomy, perineal, vaginal or cervical tears placentas attached in the lower segment being expelled (particularly tears involving an artery). Trauma is often associated with operative delivery or caesarean section. Once expulsion of the placenta has occurred, bleeding from the placental site is controlled by the contraction of  Coagulation disorders. Such disorders are rarely
the “living ligature” of the oblique uterine muscle fibres seen. They may be inherited or acquired. in the upper uterine segment about the uterine blood The SOGC Alarm course suggests that one can easily vessels. As well, coagulation and fibrinolytic systems remember these causes when categorized as the “4 T’s”: are activated, securing hemostasis by the formation of a fibrin “mesh” over the placental site.4 Risk Factors
The likelihood that a woman will experience a postpartum hemorrhage is dependent upon a variety of Definition
factors. Table 1 outlines risk factors which may be The World Health Organization defines postpartum identified antenatally as well as those that may be hemorrhage (PPH) during vaginal delivery as blood loss identified during the intrapartum or postpartum of greater than 500 cc.7 Alternative definitions of PPH as periods. It is important to note that although blood loss greater than 600 cc or greater than 1000 ccs previously regarded as a risk factor, grand multiparity have also been suggested.6,8 For clinical purposes any has not been found to be associated with an increased blood loss that has the potential to produce hemo- dynamic compromise is considered a PPH. Estimating blood loss is fraught with inconsistencies – it has been Risk factor assessment is an ongoing process that begins suggested that clinicians’ subjective assessments may with initial history taking and continues throughout the underestimate blood loss by as much as 50%.4,9 course of care. Assessment of risk factors is not prescriptive and needs to encompass the entire clinical PPH can be divided into primary PPH, which occurs picture including planned place of birth. within 24 hours of birth, and secondary PPH, which occurs between 24 hours and 6 weeks postpartum.4 While risk factor identification is an ongoing aspect of management, two-thirds of PPHs occur without any 2 March 2006
predisposing factors.18 As many as twenty-eight percent as is sometimes assumed. Rather, it describes a regimen of women who require postpartum blood transfusion which includes no routine use of oxytocics, delaying the have no risk factors.19 Current evidence about risk clamping of the umbilical cord until pulsations cease, no factors is primarily based on practitioners’ clinical uterine manipulation or controlled cord traction, and experience and opinions. A higher quality of evidence delivery of the placenta by maternal effort within one would clarify the implications of risk factors on hour of birth. Full physiologic management, as defined management of third stage. In the meantime, risk here, is not commonly used by practitioners in North factors can be used to develop plans for care which America. However, care providers who do not routinely prevent or minimize the risks associated with PPH. administer oxytocin, but who do employ controlled cord traction (sometimes called the Brandt-Andrews manoeuvre), may consider their management style to be physiologic rather than active. According to the Antenatal Risk
Risk Factors
definitions used in relevant clinical trials, this approach falls into neither category. The same discrepancy occurs for active management where, in practice, the oxytocic drug of choice, the timing of drug administration and route of delivery, the timing of cord clamping and the use of controlled cord traction may all vary. Active Management
A systematic review comparing active versus expectant management of third stage21 identified five relevant randomized controlled trials,22,23,24,25,2 four of which the reviewers assessed to be of good quality. In these trials, active management was defined as administering a prophylactic uterotonic with the anterior shoulder or immediately after birth, early cord clamping and cutting, and controlled cord traction, while expectant management was defined as awaiting spontaneous delivery of the placenta with the aid of gravity or nipple stimulation. Active management resulted in statistically significant reductions in the risk of maternal blood loss (Source: ESW, Scottish Obstetric Guideline, Reyel, SOGC, Aikins) (weighted mean difference -79.33 ml, 95% CI -94.29 to -64.37), postpartum hemorrhage (relative risk 0.38, 95% Recommendation #1: Identification of risk factors for
CI 0.32-0.46), and prolonged third stage of labour PPH should occur in an ongoing manner throughout
(weighted mean difference -9.77minutes, 95% CI -10.00 the course of care. (III)
to -9.53). On the other hand, increases in the risk of maternal nausea (relative risk 1.83, 95% CI 1.51 to2.23), MANAGEMENT OF THIRD STAGE
vomiting and raised blood pressure were associated with active management. These adverse effects were Two common options for the management of third stage attributed primarily to the use of ergometrine. The are expectant (or physiological) management and active Cochrane reviewers advocate for active management of management. Expectant management can be defined as third stage as the routine management of choice for watchful waiting for signs of separation, and women planning a vaginal delivery in hospital, and spontaneous delivery of the placenta.20 Active suggest that additional research is needed to clarify the management involves prophylactic measures to facilitate implications in other settings, including homebirths.21 expulsion of the placenta, including administration of a prophylactic oxytocic, early clamping of the cord, and In 2003, the International Confederation of Midwives (ICM) and International Federation of Gynecologists and Obstetrics (FIGO) published a joint statement on the Comparison of these two approaches is confounded by prevention of PPH.27 In addition to recommending that variations in the clinical practice of these two techniques. birth attendants have the knowledge, skills and The term “physiologic management” in research trials judgment to carry out active management of the third does not refer just to avoiding the use of oxytocic drugs, stage of labour and access to needed supplies and 3 March 2006
equipment, the statement recommends that active Recommendation #2: Active management should be
management should be offered to all women in labour. offered to all pregnant women.(I-A)
The ICM/FIGO definition of active management includes delivery of oxytocin (10 IU IM) within one Recommendation #3: Active management is
minute of the birth of the baby, clamping of the cord strongly recommended for women with an identified
once it stops pulsing, controlled cord traction, and increased risk of postpartum hemorrhage.(I-A)
massage of the fundus until it is contracted. A) Delivery of Uterotonic
One debated aspect of active management is the ideal shoulder, delivery on infant, or delivery of the choice of prophylactic uterotonic. While some argue that currently there is little evidence that any route, dose Give oxytocin 10 IU IM – other routes of delivery include 5 IU IV push, or 20-50 IU in or timing of oxytocin administration is superior,14,32 there has, in fact, been a fair amount of research done Oxytocin should be stored between 15-30 C, which compares the effects of oxytocin, ergonovine or a combination of these drugs, administered intravenously Clamp the cord close to the perineum after A systematic review comparing ergometrine-oxytocin Keep tension on the uterus and wait for a (Syntometrine) versus oxytocin (Syntocinon) for third stage management,33 identified six relevant trials Encourage mother to push with contraction (involving 9332 women). The combination of ergonovine and oxytocin was associated with a small If the placenta does not descend during 30-40 sec of CCT do not continue with traction. reduction in the risk of blood loss >500ml compared to As placenta delivers hold the placenta in two oxytocin alone (odds ratio 0.82, 95% CI 0.71 to 0.95). There was no statistically significant difference between twisted. Slowly pull to complete delivery. groups for blood loss of >1000 ml. Ergometrine- oxytocin was associated with statistically significant Massage the fundus to ensure contraction. increases in the risks of nausea, vomiting and elevated Palpate uterus every 15 minutes in the first 2 Another systematic review examined the effects of There is a gap in current research regarding what impact prophylactic oxytocin in the third stage of labour on each of the individual components of active maternal and neonatal outcomes.34 A total of fourteen management has on preventing blood loss. It appears randomized or quasi-randomized trials were included. that the key element of active management is the Seven trials in which prophylactic oxytocin was administration of an oxytocic drug, but evaluation of the compared to no uterotonics demonstrated the following other components of active management is benefits to be associated with oxytocin: reduced blood incomplete.28,29 Subsequent sections of this guideline loss (RR for blood loss >500 ml 0.50; 95% CI 0.43 to 0.59) review the evidence regarding each of the components and reduced need for therapeutic oxytocics (RR 0.50, of active management. While future research may 95% CI 0.39 to 0.64). Six trials35,36,37,38,39,40 in which define the components of active management that are oxytocin was compared to ergot alkaloids demonstrated most effective in preventing PPH and which, if any, hold little difference in effect other than a lower risk of risk if used incorrectly or alone,30,31 current evidence manual removal of the placenta with oxytocin (RR 0.57, suggests that active management of the third stage is the 95% CI 0.41 to 0.79), and a non-significant trend most effective tool in preventing PPH and adverse suggesting less raised blood pressure with oxytocin (RR sequelae. Informed choice discussions with women 0.53, 95% CI 0.19 to 1.52). A comparison of ergometrine regarding active management of third stage must be alone to ergometrine with oxytocin was examined in five trials, which demonstrated little difference in effect. The reviewers note that while oxytocin appears to be beneficial for the prevention of postpartum hemorrhage, overall there is insufficient information about other outcomes and adverse effects.34 4 March 2006
The results of these reviews suggest that oxytocin use of oxytocics at the time of birth confers a decreased appears to be the agent of choice of third stage chance of hemorrhage when compared to giving management in low risk women.30 Prophylactic oxytocics after the placenta has been contradicted. A oxytocin may be given as 10 IU IM, 20-50 IU per litre IV recent RCT that compared giving oxytocin before versus drip run at 100-150 cc/hr or 5 IU IV push.10,14 Some after placental delivery found no difference in the authorities caution against the use of a bolus of incidence of PPH or the length of third stage.48 Given intravenous oxytocin, citing small studies which suggest the lack of clarity in the research and limited evidence that such practices could compromise women’s on which to base recommendations, prophylactic hemodynamic state3. However, a recent randomized oxytocin can be given after the birth of the anterior controlled trial41 has demonstrated no significant shoulder, or after the delivery of the baby up to and difference in hemodynamic status between women including within one minute of delivery of the baby.14,27 given prophylactic intravenous oxytocin by infusion or by bolus; this study does not address giving intravenous Recommendation #4: When active management is
boluses of oxytocin to women who are already employed, prophylactic oxytocin (given as 10 IU IM
hemodynamically unstable. When caring for women or 5 IU IV slow push) should be given after delivery
who give birth without pain medication, care providers of the anterior shoulder within up to one minute after
should remember that intramuscular oxytocin is birth of the infant. (I-B)
experienced by most women as being relatively painful. B) Clamping of the Cord
Recent research focussing on third stage management The second component of active management is early has examined alternatives to oxytocin and syntometrine. cord clamping. In trials investigating active The majority of randomized controlled trials on the topic management, early cord clamping, occurring within published in the last 8 years have investigated use of 30-60 seconds of delivery, is undertaken regardless of misoprostol, a prostaglandin E1 analogue.42,43 whether of not cord pulsation has ceased. The benefits Misoprostol is inexpensive, stable, easily stored, and can of immediate cord clamping, and its impact on blood be given non-parenterally, and therefore has potential to be particularly useful in developing countries.13 Three systematic reviews have been completed on misoprostol When clamping is delayed until after pulsations have use since 2002.44,44,46 This work concludes that ceased, complete transfusion of blood from the placenta misoprostol results in higher blood loss than to the neonate occurs which leads to higher hemoglobin conventional prophylactic uterotonics and is associated and additional iron stores in infants.49 These effects in with significant increases in rates of shivering and fever. newborns are undetectable by 6 months after birth.29 On The efficacy, dose, and route of administration of the other hand, it is argued that early clamping is misoprostol for prophylactic use in third stage continue beneficial because reduced placental blood transfer to be investigated and it is not recommended for use in decreases the incidence of neonatal jaundice.29,50 the prevention of PPH at this time.13,29,44,45,46 Seven trials have compared the timing of cord clamping. Injectable prostaglandins are another alternative to Statistically non-significant findings from clinical trials conventional uterotonics. Mean blood loss does appear have suggested that there may be risks inherent in the to be reduced with injectable prostaglandins compared intervention of early cord clamping, including retained to conventional injectable uterotonics (weighted mean placenta, and increased bleeding,29 but there is not difference -70 ml, 95% CI -73 to -67), but these agents sufficient evidence to establish whether or not such risks have more side effects.45 Injectable prostaglandins exist. Methodological weakness, small sample size and appear to be more appropriate for use in the treatment variation in outcomes measured make interpretation difficult. Evidence published to date has not clearly established the impact of the timing of cord clamping on An additional issue of debate related to the postpartum blood loss,29,51 and further investigation is administration of prophylactic uterotonics is the ideal needed. Until such time as studies reveal the effect of timing of this intervention. It has been variously this component of active management on blood loss and suggested that oxytocin be given after the anterior its ideal timing, clamping of the cord may be done shoulder, after the birth of the baby or after delivery of the placenta. Other midwifery and obstetrical guidelines argue for delivery after the anterior shoulder, Recommendation #5: When active management is
and within one minute of delivery of the baby employed, clamping of the cord may be done
respectively.14,27 Earlier work47 which proclaimed that 5 March 2006

immediately after delivery of the infant or when
During controlled cord traction, the mother may be pulsation ceases. (I-C)
asked to push to assist expulsion. This may be of particular use in situations where the cord is beginning C) Controlled Cord Traction
to separate, and the practitioner wishes to use minimal Controlled cord traction is a component of active traction in facilitating expulsion. As the placenta begins management that is somewhat overlooked in the to appear at the introitus, the non-dominant hand research on third stage management. Two older trials continues to guard the uterus by applying suprapubic suggest that controlled cord traction is associated with pressure slightly toward the umbilicus until the placenta lower mean blood loss and shorter third stages compared to less active approaches.29 These findings are supported by a recent RCT which found a reduction of Recommendation #6: Controlled cord traction may
postpartum hemorrhage in the controlled cord traction be used to decrease blood loss, and should be used
group (5.8% vs. 11%; OR 0.50, 95% CI 0.15-0.63).52 The in combination with uterine guarding above the
results of this trial may be confounded by differences in pubic bone on a contracted uterus. (I)
the timing and route of administration of oxytocin between the study groups. Expectant Management
Expectant management is a low intervention approach
Another small RCT (n=239) adds the element of cord wherein the placenta is expelled spontaneously while drainage to the issue of cord traction. This study being aided by maternal effort, positioning or nipple investigated the use of controlled cord traction in stimulation. The umbilical cord is clamped and cut after combination with cord drainage and found that the placenta is delivered.28,29 Typically, the cord ceases to compared to expectant management, the length of third pulsate between 1-3 minutes after the birth, which may stage and amount of blood loss was significantly be considered “physiologic clamping”.56 Skin to skin reduced in the cord traction/drainage group.53 A contact between the mother and infant may support systematic review of trials involving placental cord physiological processes that contribute to separation and drainage as an investigated variable identified two relevant studies. The reviewers concluded that there appears to be potential benefit from the use of cord Worldwide, expectant management is frequently drainage in terms of reducing the third stage of labour, practiced. The Global Network for Perinatal and but more research is needed to fully investigate its Reproductive Health conducted an observational, cross impact.54 This practice is not typically included as a sectional survey in 10 countries and concluded that the rate of active management was 24.6%.58 This low rate may be accounted for by women’s desire for a more Overall the evidence shows that controlled cord traction “natural” childbirth, a philosophy that active results in a statistically significant decrease in the management is unnecessary, and a preference to avoid incidence of PPH. Further investigation into the role of the potentially unpleasant effects of uterotonic agents.59 controlled cord traction from larger trials with The lack of availability of uterotonics also limits the use comparable study groups would be useful. When performing controlled cord traction, it is A variation of expectant management that is used by important to observe some key principles in order to many practitioners who may consider their management avoid the potential danger of uterine inversion. style to be physiologic rather than active is the Brandt- Controlled cord traction should not be attempted prior Andrews manoeuvre. This manoeuvre involves no to separation of the placenta, and should only be done in administration of oxytocin, and controlled cord traction the presence of a well-contracted uterus. While with or without early clamping. There currently is no performing cord traction, the non-dominant hand of the research that compares the Brandt-Andrews manoeuvre practitioner should rest on the abdomen with the heel of to physiologic management of third stage. Both the hand at the symphysis pubis, and the fingertips approaches seem to be reasonable variations to offer resting on the fundus. In addition to allowing the when a woman has chosen physiological management, practitioner to confirm that the uterus is contracted and given the evidence discussed earlier in this guideline to guard the uterus, this hand position allows detection that suggests that controlled cord traction decreases the of any “dipping” in the fundus, which would indicate that the placenta is still attached and that traction should be discontinued until separation occurs.55 6 March 2006
Another component of third stage requiring The three main principles of management of PPH are: consideration with respect to physiologic management is the duration. There is some debate regarding the maximum duration of a normal third stage. Third stage usually lasts from 5-15 min, but may last up to an hour.4 After 30 minutes duration, there is an increase in the rates of postpartum hemorrhage.
Table 4 shows a clinical pathway for management of out the association between prolonged third stage and PPH. When PPH is identified, the likely cause must be complications. It has been suggested that the most determined so that appropriate action may be taken. important aspect of third stage management is Subsequent actions should take place as simultaneously minimizing its duration, and that how this is and as quickly as possible. While the uterus and genital accomplished is secondary. For example, in two trials tract are explored to identify cause of bleeding, demonstrating active management to be the superior measures such as monitoring vital signs, catheterization, approach, 26% and 16.4% of women in the physiologic administering oxygen and placing an IV, may be groups had third stages exceeding 30 minutes commenced.9 The order in which steps are taken may (compared to 2.9% and 3.3% of women in the active vary depending on the specific circumstances and the demonstrated no benefit to active management, third Table 3: Clinical findings with various degrees of shock stage duration was less than 20 minutes in 93% of the physiologically managed and 95% of the actively Systolic
Signs and Symptoms

Recommendation #7: Either expectant management
or the Brandt-Andrews manoeuvre is an acceptable
option for women who decline active management.
The majority of the existing research on PPH focuses on the prevention of PPH, while evidence regarding the safety and efficacy of treatments for primary PPH is (Source: In SOGC Alarm manual from ACOG Bulletin #235) more varied and controversial.61 The subsequent discussion of the management of PPH is based primarily Recommendation #8: When PPH occurs, the cause
on established protocols that have been developed based of bleeding should be identified and directed
on the experience of clinicians. While in some cases the treatment undertaken promptly. (III)
clinical benefits of interventions are clearly apparent, there is room for further research on the efficacy of Prompt decision making and communication are the various components of the emergency measures cornerstones of management of PPH.62 Informing the woman, her partner and other health care providers assisting the midwife of the situation initially and in an Following careful identification of risk factors, and the ongoing manner is an important aspect of management. use of active management of the third stage, the third key aspect in preventing PPH is early recognition of Recommendation #9: In addition to controlling
blood loss. Careful assessment in the immediate bleeding, the initial steps in treatment of PPH
postpartum and prompt intervention when indicated include treating shock and communicating with the
can help to reduce blood loss. Post delivery, the fundus client and other health care providers assisting the
should be assessed at regular intervals. Signs and midwife. (III)
symptoms that are associated with PPH include visible bleeding, pallor, rising pulse rate, falling blood pressure, Options for treatment of PPH include drugs to increase altered level of consciousness, restlessness, or enlarged uterine contraction and surgical techniques.61 Treatment uterus. Table 3 outlines the clinical findings associated is directed based on the identification of the cause of hemorrhage. The most common cause of PPH is uterine atony which can be treated by uterine massage and/or 7 March 2006
compression and administration of uterotonics.9 It is within the midwife’s pharmacopeia to give oxytocin, ergonovine and carboprost for the treatment of PPH. See Table 5 for a summary of these medications. Current research shows promising developments in the potential use of rectal misoprostol as a first line drug for the treatment of primary PPH; however, more research is needed.42,61 8 March 2006
9 March 2006
Hemorrhage unresponsive to these actions requires the between 2-8 degrees Celsius.62 Oxytocin is ideally stored immediate assistance of a physician with obstetric between 15-30C and should be protected from freezing.27 surgical skills. As with any emergency, careful attention Midwives should not store these drugs in their cars to communication and documentation is required. where large temperature fluctuations can adversely Uterine packing, artery ligation, x-ray guided embolization, hysterectomy and the use of blood replacement products are all further interventions in the It is important to acknowledge that there is variation in management of PPH that may be performed by an the preferences of both midwives and women regarding third stage management. Woman and midwives who participated in the Bristol trial on active management of Table 5: Properties of uterotonic medications third stage both regarded the longer length of third stage with physiologic management as a negative feature,63 Mechanism
Side Effects
and research suggests there is a tendency to favour of Action
active management.29 Others favour physiologic management because it is “less interventive,” though it has been suggested that the label of interventive medicine should be removed from the evidence based practice of active management.64 Midwives are in a position to preserve choice by respecting that some women neither want or need active management while presenting evidence based information to all clients.20,65 It is the role of midwives simultaneously to support birth as a natural physiological practice and to acknowledge the research that supports interventions such as active management in decreasing postpartum When a primary PPH occurs, early recognition, communication, and attention to resuscitative measures and cause of bleeding66 will assist the midwife in managing this rare but potentially life threatening ADDITIONAL MI DW IF E R Y IM PLIC AT IO NS
situation. With careful management, third stage can remain an anti-climatic and uneventful part of one of the The topic of third stage management should be most important days of a woman’s life. discussed with each client during the course of her prenatal care. Women need to be informed of the RECOMMENDATIONS
benefits and risks of management options and made aware of any factors particular to their situation worthy 1. Identification of risk factors for PPH should occur in of consideration. Access to previous obstetrical records an ongoing manner throughout the course of care. and continuing evaluation of risk factors will help midwives to identify women to whom active management should be recommended. Midwives 2. Active management should be offered to all should endeavour to minimize any existing barriers to the implementation of active management. 3. Active management is strongly recommended for women with an identified increased risk of One concern for midwives is the storage of ergonovine, carboprost and oxytocin for women planning homebirths. Storage and refrigeration is essential to the 4. When active management is employed, prophylactic efficacy of ergometrine. Ergometrine loses 21-27% of oxytocin (given as 10 IU IM or 5 IU IV slow push) active ingredients after 1 month and 90% after 1 year of should be given after delivery of the anterior storage exposed to light and at 21-25 degrees Celsius. shoulder within up to one minute after delivery of For most effective long-term storage, ergonovine must be kept between 2-8 degrees Celsius and protected from light.43 Similarly, carboprost must also be stored at 10 March 2006
5. When active management is employed, clamping of without the intervention; dramatic results in uncontrolled the cord can occur immediately after delivery of the Opinions of respected authorities, based on clinical experience; descriptive studies or reports of expert 6. Controlled cord traction may be used to decrease blood loss, and should be used in combination with Levels of Evidence - Quality (Internal Validity) Rating
counter traction above the pubic bone on a contracted uterus. (I-B) Good A study (including meta-analyses or systematic reviews) that
meets all design-specific criteria* well.
Fair A study (including meta-analyses or systematic reviews) that
7. Either expectant management or the Brandt- does not meet (or it is not clear that it meets) at least one Andrews manoeuvre is an acceptable option for design-specific criterion* but has no known “fatal flaw.” women who decline active management. (III) Poor A study (including meta-analyses or systematic reviews) that
has at least one design-specific* "fatal flaw,” or an accumulation of lesser flaws to the extent that the results of 8. When PPH occurs, the cause of bleeding should be the study are not deemed able to inform recommendations.
identified and directed treatment undertaken REFERENCES
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