WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one?

Abstract

Obstetric haemorrhage, especially postpartum haemorrhage (PPH), was responsible for more than a quarter of the estimated 303 000 maternal deaths that occurred globally in 2015.1 PPH—commonly defined as a blood loss of 500 mL or more within 24 hours after birth—affects about 6% of all women giving birth.1 Uterine atony is the most common cause of PPH, but it can also be caused by genital tract trauma, retained placental tissue or maternal bleeding disorders. The majority of women who experience PPH have no identifiable risk factor, meaning that PPH prevention programmes rely on universal use of PPH prophylaxis for all women in the immediate postpartum period. Active management of the third stage of labour involves prophylactic administration of a uterotonic agent prior to delivery of the placenta, as well as delayed cord clamping and controlled traction of the umbilical cord (in settings where skilled birth attendants are available).2 The uterotonic is the most important component in terms of preventing PPH.3 4 In 2012, WHO recommended oxytocin (10 IU, intravenously or intramuscularly) as the uterotonic of choice for PPH prevention at birth for all women.5\n\nThere have been major new developments in PPH prevention and treatment in the last decade, including technological advancements (such as inhalational oxytocin and the non-pneumatic antishock garment), new treatment strategies (such as advance distribution of prophylactic misoprostol for self-administration after birth, administration of oxytocin via Uniiject and care bundles for PPH management), as well as large multicountry trials of tranexamic acid for PPH treatment and a heat-stable formulation of carbetocin for PPH prevention.6–12 The increasing number of PPH prevention and management options makes it challenging for providers and health system stakeholders to choose where and how to invest limited resources in order to optimise health outcomes.\n\nMultiple uterotonics have been …