Joint Statement of Recommendation for the Use of Uterotonics for the Prevention of Postpartum Haemorrhage 

Postpartum haemorrhage (PPH) is a devastating but preventable condition that affects mothers and their children around the world. PPH occurs when a mother has serious bleeding after giving birth. When not treated quickly, it can be fatal. Most deaths from PPH could be avoided through active management of the third stage of labour, and prompt and effective application of the first response bundle (use of uterotonics, uterine massage, fluid replacement and tranexamic acid [TXA]). 

Preventing and treating PPH

As leading organisations representing specialists in midwifery, obstetrics and gynaecology, the International Federation of Gynaecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) draw attention to a range of aspects of care that are essential to the prevention and treatment of PPH. These include:

• organisation of care
• pre-service and in-service training of care providers
• identification and treatment of anaemia in women of childbearing age
• increased availability of contraception and family planning
• improved referral pathways
• development of clinical protocols for prevention and treatment of PPH.1

FIGO and ICM recommendations

In response to the availability of new evidence, FIGO and ICM strongly recommend the use of uterotonics during active management of third stage of labour to prevent PPH during vaginal birth or caesarean section. Our recommendations align with those made in the WHO 2018 recommendations on uterotonics for the prevention of postpartum haemorrhage.2

All health care providers should be trained and competent in both physiological and active management of third stage of labour.3 Women may choose physiological management of third stage of labour. In some settings, uterotonics may not be available or of good quality.

For active management of third stage of labour, it is recommended that one of the following uterotonics be used, preferably within one minute after birth. In settings where multiple uterotonic options are available, oxytocin (10IU, IM/IV) is the recommended uterotonic agent for the prevention of PPH for all births.4

In settings where oxytocin is unavailable (or its quality cannot be guaranteed), the use of other uterotonics (carbetocin, ergometrine/methylergometrine, oxytocin/ergometrine fixed-dose, misoprostol) are recommended for the prevention of PPH. Administration of uterotonics does not impede the delay of cord clamping.

Oxytocin 10IU, IM/IV

Oxytocin is relatively inexpensive and widely available. However, it requires refrigerated transport and storage (2–8°C). In settings where this cannot be guaranteed, the quality and effectiveness of oxytocin may be adversely affected. In these situations, alternative effective uterotonics may be considered.

Heat-stable Carbetocin 100mcg, IM/IV

Heat-stable carbetocin does not require refrigeration and therefore eliminates the costs associated with refrigerated storage and transport. This is a context-specific recommendation where its cost is comparable to other effective uterotonics.

Misoprostol 400mcg or 600mcg, PO

Misoprostol can be used in both hospital and community settings if no other injectable uterotonics is available. Its acceptability may be limited where providers have concerns regarding potential misuse, or need more information on its effectiveness, implementation and the management of side effects.

Ergometrine/methylergometrine 200mcg, IM/IV OR Oxytocin and ergometrine fixed-dose combination 5IU/500mcg, IM

Context-specific recommendations where hypertensive disorders can be safely excluded prior to the use of ergometrine.

Actions for midwives’ associations and OBGYN societies

FIGO and ICM recommend that national professional midwives’ associations and obstetrics and gynaecology societies have an important and collaborative role to play in:

• the dissemination and implementation of these recommendations for the use of uterotonics in the case of active management of third stage of labour
• advocacy to increase women’s access to quality maternal health care at all levels
• strengthening capacity at all levels of health care facilities to ensure the provision of high-quality services to all women giving birth
• translating recommendations into care packages and programmes at country and facility level, where appropriate to the context.

References

1. World Health Organization (WHO). Recommendation for the prevention and treatment of postpartum haemorrhage. 2012.
2. WHO. WHO recommendations Uterotonics for the prevention of postpartum haemorrhage. 2018.
3. ICM, FIGO. Prevention and Treatment of Post-partum Haemorrhage. New Advances for Low Resource Settings. 2006.
4. WHO. WHO recommendation routes of oxytocin administration for the prevention of postpartum haemorrhage after vaginal birth. 2020.