MATERNAL AND EARLY CHILD HEALTH

Health Evidence Bulletins - Wales

Date of Completion: 23.6.97

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


16. Postpartum Haemorrhage (prevention and management)

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
16a. In comparing active and passive management of the third stage of labour, routine administration of oxytocics results in an important reduction in blood loss and the risk of postpartum haemorrhage (by 60%)(i).
(Health gain notation - 2 "likely to be beneficial")
caveat: Routine administration of oxytocics increases the risk of rare but serious morbidity and of retained placenta. This latter finding might reflect selective presentation of outcome data or be an effect of chance
i. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management of the third stage of labour. Cochrane database of systematic reviews. Cochrane Library. 1997 Issue 4.
(Type I evidence - systematic review)
16b. Syntometrine (Ergot + oxytocin) remains the most effective oxytocic in active management of the third stage(i).

(Health gain notation - 1 "beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 pp. 1151-1157
(Type I evidence - systematic review. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 238)
16c. Optimum management of postpartum haemorrhage depends on rapid assessment and prompt arrest of the bleeding. Oxytocic drugs remain the traditional first line approach(i,ii).

(Health gain notation - 2 "likely to be beneficial")

i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 1146
(Type III evidence - non-randomised studies. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 241);
ii. Department of Health and Others. Guidelines for the Management of massive obstetric haemorrhage in Confidential Enquiries into Maternal Deaths 1988-1990. London: HMSO, 1994
(Type V evidence - expert opinion)
16d. Prostaglandins (Carboprost) are effective in severe postpartum haemorrhage due to uterine atony, which is unresponsive to ergometrine and oxytocin (i).
(Health gain notation - 2 "likely to be beneficial")
caveat: This should be used with caution in women with a history of asthma, epilepsy, glaucoma and hypertension.
i. British National Formulary. March 1997, p.328

(Type V evidence - expert opinion)

16e. In the management of retained placenta in the absence of haemorrhage expectant care should be considered as an alternative to anaesthesia and manual removal, with appropriate consideration to alternative strategies after 60 minutes (i). i. Chalmers I, Enkin M, Keirse MJNC. Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989 p. 1146
(Type II evidence - single trial. Summary in Enkin M, Keirse MJNC, Renfrew M, Neilson J. A guide to effective care in pregnancy and childbirth. 2nd ed. Oxford: Oxford University Press. 1995. p. 241)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk