WHO Guidelines for Management of PPH and Retained Placenta

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WHO guidelines
for the management of
postpartum haemorrhage
and retained placenta

WHO guidelines
for the management of
postpartum haemorrhage
and retained placenta

WHO Library Cataloguing-in-Publication Data:
WHO guidelines for the management of postpartum haemorrhage and retained placenta.
1.Placenta, Retained - therapy. 2.Postpartum hemorrhage - diagnosis. 3.Postpartum hemorrhage - therapy.
4.Obstetric labor complications. 5.Guidelines. I.World Health Organization.
ISBN 978 92 4 159851 4
(NLM classification: WQ 330)
(c) World Health Organization 2009
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Scope of the guidelines
Evidence and recommendations
A. Diagnosis of PPH

1. Should blood loss be routinely quantified during management of the third stage of

labour for the purpose of diagnosing PPH?
B. Management of atonic PPH

1. Medical interventions for management of PPH

2. Non-medical interventions for management of PPH

3. Surgical interventions in the treatment of PPH
C. Management of retained placenta

1. Should uterotonics be offered as treatment for retained placenta?

2. Should intra-umbilical vein injection of oxytocin with or without saline be offered

as treatment for retained placenta?

3. Should antibiotics be offered after manual extraction of the placenta as part of the

treatment of retained placenta?
D. Choice of fluid for replacement or resuscitation

1. Should crystalloids be offered for fluid replacement in women with PPH?
E. Health systems and organizational interventions

1. Should health care facilities have a protocol for management of PPH?

2. Should health care facilities have a formal protocol for referral of women

diagnosed as having PPH?

3. Should simulation of PPH treatment be part of training programmes for

health care providers?
PPH care pathways
Research Implications
Plans for local adaptation of the recommendations
Plans for supporting implementation of these recommendations
GRADE tables

A. Diagnosis of PPH

B. Management of atonic PPH

C. Management of retained placenta

D. Choice of fluid for replacement or resuscitation
Annex 1. Scoping document with average scores
Annex 2. Search strategy
Annex 3. GRADE methodology
Annex 4. List of participants

WHO guidelines for the management of postpartum haemorrhage and retained placenta
This document was prepared by Dr A. Metin Gulmezoglu, Dr Joao Paulo Souza and Dr Doris Chou (WHO Department
of Reproductive Health and Research), Dr Matthews Mathai (WHO Department of Making Pregnancy Safer),
Dr Suzanne Hill (WHO Essential Medicines and Pharmaceutical Policies) and Dr Edgardo Abalos (Centro Rosarino
de Estudios Perinatales, Rosario, Argentina), on the basis of discussions at the WHO Technical Consultation on
the Management of Postpartum Haemorrhage and Retained Placenta, held in Geneva on 18-21 November 2008.
The document was finalized after consideration of all comments and suggestions from the participants of the
Consultation to earlier drafts and an internal WHO review.
WHO gratefully acknowledges the contributions of the Chair of the Consultation (Dr Pisake Lumbiganon) and of
the international panel of experts who provided input to the Consultation. The assistance of Centro Rosarino de
Estudios Perinatales, Rosario, Argentina, and of Ms Mary Ellen Stanton are also gratefully acknowledged.
The process leading to the preparation of these guidelines was financially supported by the WHO Department of
Reproductive Health and Research and the United States Agency for International Development (USAID).
WHO Secretariat will review the questions below in the update of this guideline planned for 2010-2011.
Declarations of interest
Six temporary advisors (Hany Abdel-Aleem, Jennifer Blum, Richard Derman, Justus Hofmeyr, Pisake Lumbiganon
and Tran Son Thach) and one observer (Beverly Winikoff) declared that they had received grants for conducting
research and made presentations on the research they conducted regarding the use of misoprostol and other
aspects of PPH prevention and management which were reviewed during the meeting. None of these grants was
from commercial entities. One observer, Ms Mary Ellen Stanton, declared that she may present an organization's
position (USAID) if required in this field.
The interests declared reflect the academic interest and opinions of the experts and the Secretariat does not
believe that there are any undeclared commercial or financial interests among the guideline review group.
The two observers did not participate in the voting processes and were not asked to approve or provide comments
to the document.

WHO guidelines for the management of postpartum haemorrhage and retained placenta
One of the Millennium Development Goals set by the United Nations in 2000 is to
reduce maternal mortality by three-quarters by 2015. If this is to be achieved,
maternal deaths related to postpartum haemorrhage (PPH) must be significantly
reduced. In support of this, health workers in developing countries need to have
access to appropriate medications and to be trained in relevant procedures. But
beyond this, countries need evidence-based guidelines on the safety, quality,
and usefulness of the various interventions. These will provide the foundation for
the strategic policy and programme development needed to ensure realistic and
sustainable implementation of appropriate interventions.
PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours
after birth, while severe PPH is blood loss greater than or equal to 1000 ml within
24 hours. PPH is the most common cause of maternal death worldwide. Most cases of
morbidity and mortality due to PPH occur in the first 24 hours following delivery and
these are regarded as primary PPH whereas any abnormal or excessive bleeding from
the birth canal occurring between 24 hours and 12 weeks postnatally is regarded as
secondary PPH.
PPH may result from failure of the uterus to contract adequately (atony), genital
tract trauma (i.e. vaginal or cervical lacerations), uterine rupture, retained placental
tissue, or maternal bleeding disorders. Uterine atony is the most common cause and
consequently the leading cause of maternal mortality worldwide.
In practice, blood loss after delivery is seldom measured and it is not clear whether
measuring blood loss improves the care and outcome for the women. In addition,
some women may require interventions to manage PPH with less blood loss than
others if they are anaemic.
Risk factors for PPH include grand multiparity and multiple gestation. However,
PPH may occur in women without identifiable clinical or historical risk factors. It
is therefore recommended that active management of the third stage of labour be
offered to all women during childbirth, whenever a skilled provider is assisting with
the delivery (1). Active management should include: (i) administration of a uterotonic
soon after the birth of the baby; (ii) clamping of the cord following the observation
of uterine contraction (at around 3 minutes); and (iii) delivery of the placenta by
controlled cord traction, followed by uterine massage.
Even with these efforts to prevent PPH, some women will still require treatment for
excessive bleeding. Multiple interventions (medical, mechanical, invasive non-surgical
and surgical procedures), requiring different levels of skill and technical expertise,
may be attempted to control bleeding. For the purposes of these guidelines, it is
assumed that the patient with PPH is being treated by a health-care worker in a
medical facility. Efforts in the community to prevent and treat PPH are not covered
Effective treatment of PPH often requires simultaneous multidisciplinary
interventions. The health care provider needs to begin resuscitative efforts quickly,

WHO guidelines for the management of postpartum haemorrhage and retained placenta
establish the cause of the haemorrhage, and possibly obtain the assistance of other
care providers, such as an obstetrician, anaesthetist or radiologist. Avoiding delays
in diagnosis and treatment will have a significant impact on sequelae and chance
of survival. These guidelines therefore include "care pathways" (or algorithms) for
management of PPH, as a practical guide for clinicians. (A loose-leaf insert of these
care pathways has been included for use as a wall chart.)
This document is not intended to be a comprehensive guide on management of PPH
and retained placenta. Rather, it reflects the questions that were regarded as high
priority by a multidisciplinary panel of international health workers and consumers.
Staff from the WHO Departments of Reproductive Health and Research, Making
Pregnancy Safer, and Essential Medicines and Pharmaceutical Policies drafted
questions on interventions and a list of possible outcomes in the treatment of atonic
postpartum haemorrhage and retained placenta (Annex 1).
These questions and outcomes were sent by email to an international panel of
experts (midwives, obstetricians, neonatologists, researchers, methodologists,
consumers and programme experts). Members of the panel were invited to comment
on the relevance of the questions and outcomes, and were asked to rate each of
them on a scale of 1 to 9. A critical outcome was defined as an outcome with an
average score between 7 and 9. Questions and outcomes that scored between 4 and
6 were considered important but not critical, while those that scored less than 4
were considered not important (2). Panel members were also encouraged to revise
the questions or suggest new questions and outcomes.
Two reminders were sent to the members of the panel. The results of the scoping
exercise were sent to all respondents for review. All of the responses were reviewed
by WHO staff. The responses and scores are presented in Annex 1. In the preparation
of the care pathways for management of PPH and retained placenta, questions that
scored lower than critical points in the scoping exercise were included in the search
for evidence and appraisal process.
Centro Rosarino de Estudios Perinatales (CREP), a WHO Collaborating Centre in
Maternal and Perinatal Health, was commissioned to search, review and grade the
evidence to answer the questions, using the GRADE (Grading of Recommendations,
Assessment, Development and Evaluation) methodology (Annex 3). The initial search
for evidence was conducted in November 2007. Records were searched in the
Cochrane library, Pubmed, Embase, and Lilacs. The search terms used are given
in Annex 2. Ad hoc searches in Pubmed were also conducted before the Technical
Consultation to make sure that relevant studies were not missed and that studies
identified by experts in the field were included.
GRADE tables were prepared for the highest level of evidence available; systematic
reviews and randomized controlled trials (RCTs) or, in their absence, observational
studies were used. When RCTs were available, observational study data were not

WHO guidelines for the management of postpartum haemorrhage and retained placenta
summarized in the GRADE tables. However, they were mentioned in the evidence
summary and taken into account in the recommendation. GRADE tables were not
prepared for case series or reports.
The draft GRADE tables were reviewed by the WHO Secretariat together with CREP
staff. Recommendations relating to the questions and outcomes proposed were then
drafted ahead of the Technical Consultation. A draft of the methodology, results, and
recommendations was sent for review to a subgroup of the experts participating in
the Technical Consultation before the meeting.
Decision-making during the technical consultation
For each question, the participants in the Technical Consultation discussed the draft
text prepared by the Secretariat, with the aim of reaching a consensus. Consensus
was defined as agreement by the majority of participants, provided that those who
disagreed did not feel strongly about their position. Any strong disagreements were
recorded as such.
During the meeting, in addition to the documentation prepared by the Secretariat,
preliminary results from four unpublished trials were made available. While the
presentation of the most recent data from large trials was welcomed and used to
inform the recommendations, some participants expressed a need for more time
to review these results before making recommendations. The GRADE tables in this
document include evidence from the search as well as the data presented and
discussed during the Technical Consultation.
The system used to establish the strength and ranking of the recommendations
involved assessing each intervention on the basis of: (i) desirable and undesirable
effects; (ii) quality of available evidence; (iii) values and preferences related to
interventions in different settings; and (iv) cost of options available to health care
workers in different settings.
Scope of the guidelines
The draft questions and list of outcomes related to the treatment of PPH and
management of retained placenta were sent to 144 experts from all parts of the
world. Responses were received from 60 of these experts: 46 physicians,
7 midwives, and 7 non-clinicians (policy-makers, researchers and consumers),
representing all 6 WHO regions.
There were 39 questions in 6 domains:
assessment of blood loss (1 question);
drugs for atonic PPH (13 questions);
non-drug interventions for atonic PPH:
- mechanical (6 questions);
- radiological (1 question);
- surgical (8 questions);

WHO guidelines for the management of postpartum haemorrhage and retained placenta
retained placenta (4 questions);
organizational and educational interventions (5 questions);
crystalloid versus colloid fluids for resuscitation (1 question). This question was
included following a suggestion from the respondents during the survey.
The average scores for questions and outcomes are shown in Annex 1.
It should be noted that not all outcomes are applicable to all questions. As mentioned
above, questions that scored less than 7 are also included in the guidelines.
Evidence and recommendations
A. Diagnosis of PPH
1. Should blood loss be routinely quantified during management of
the third stage of labour for the purpose of diagnosing PPH?
Several related studies that looked at measurement of blood loss following childbirth,
with the objective of ensuring timely diagnosis of PPH and improving health
outcomes, were assessed. No study was found that directly addressed the question.
Summary of evidence
Visual versus quantitative methods for estimating blood loss after vaginal delivery
One RCT (3) compared visual estimation of blood loss with measurement of
blood collected in a plastic drape. Six observational studies (4-9), with a total of
594 participants, compared visual estimation with known values in the delivery
room or in simulated scenarios. Three studies (10-12) compared visual or quantified
estimations with laboratory measurement in 331 vaginal deliveries.
In the RCT (3), visual estimation underestimated blood loss when compared with
drape measurement (mean difference 99.71 ml) (page 27, GRADE Table A1). Visual
methods underestimated blood loss when compared with known simulated volumes.
Training courses on estimating blood loss after vaginal delivery
One RCT (13) compared the accuracy of estimation of blood loss by 45 nurses
attending a course on blood loss estimation and 45 nurses not attending the course.
In this small RCT (13), with seven simulated scenarios, blood loss was accurately
estimated by 75.55% of the nurses attending a training course compared with 24.44%
without training (relative risk (RR) 3.09; 95% confidence interval (CI) 1.80-5.30)
(page 27, GRADE Table A2).
In three studies (14-16), a total of 486 staff members of maternity services visually
estimated blood loss in simulated scenarios before and after training courses. The
three uncontrolled studies (14-16) show results in the same direction as the RCT.