Postpartum Hemorrhage Guidelines

Updated: Apr 01, 2022
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Guidelines Summary

FIGO guidelines

The International Federation of Gynecology and Obstetrics (FIGO) has published guidelines on the prevention and management of postpartum hemorrhage (PPH). Highlights of the guidelines include the following [84] :

Prevention of PPH

To prevent PPH, a uterotonic drug should be routinely administered during the third stage of labor in all births. The preferred choice is oxytocin (either intravenous [IV] or intramuscular [IM]); if oxytocin is unavailable, other injectable uterotonics (eg, ergometrine/methylergometrine), oral misoprostol, or carbetocin (IM or IV) can be used.

For the early detection of uterine atony, abdominal uterine tonus assessment is warranted after all births.

To prevent PPH after cesarean delivery, administration of oxytocin (IV or IM) and controlled cord traction are recommended for removal of the placenta.

Management of PPH

The first-line uterotonic drug for the management of PPH is IV oxytocin. IM ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin drug (eg, sublingual misoprostol) can be used if IV oxytocin is unavailable or if oxytocin fails to control the bleeding.

In addition, IV tranexamic acid should be administered as soon as PPH is diagnosed but within 3 hours of either vaginal birth or cesarean delivery. A second dose is recommended if bleeding continues after 30 minutes or if bleeding restarts within 24 hours of the first dose.

Uterine massage should be included in the management of PPH. In addition, bimanual uterine compression or external aortic compression can be used to treat PPH that results from uterine atony following vaginal birth.

Uterine balloon tamponade is a nonsurgical treatment option if PPH fails to respond to uterotonic drugs or if these drugs are not available. Another conservative management option is uterine artery embolization.

If uterotonic agents and conservative measures fail to control PPH, surgical interventions are recommended, such as the use of compression sutures, uterine and hypogastric artery ligation, and hysterectomy.