CLINICAL PRACTICE GUIDELINE17 POSTPARTUM HEMORRHAGE CONTRIBUTORS PPH CPG Work Group Clinical Practice Guidelines Committee Quality, Insurance and Risk Management Program AOM Staff Suzannah Bennett, MHSc Sara Chambers, RM Kim Cleland, RM Abigail Corbin, RM Liz Darling, RM, PhD Stephanie Gingerich, RM Jenny Gilbert, MA Jenni Huntly (chair), CPM, LM Cathy Kipp, RM Natalie Kirby, RM Tasha MacDonald, RM, MHSc Sarah McNiven-Scott Anna Meuser, MPH Linda Ngo, RM Catherine Pestl, IBCLC Jenna Robertson, RM, MA Christine Sandor, RM Dianne Smith, RM Genia Stephen, RM, IBCLC Dana Wilson-Li, midwifery student Sarilyn Zimmerman, RM ACKNOWLEDGEMENTS Ryerson University Midwifery Education Program The Association of Ontario Midwives respectfully acknowledges the financial support of the Ministry of Health and Long-Term Care in the development of this guideline. The views expressed in this guideline are strictly those of the Association of Ontario Midwives. No official endorsement by the Ministry of Health and Long-Term Care is intended or should be inferred. This document may be cited as: PPH CPG Work Group. Association of Ontario Midwives. Postpartum Hemorrhage. 2016. The AOM is committed, through our statement on Gender Inclusivity and Human Rights, to reflect and include trans, genderqueer and intersex communities in all aspects of our work. In this document, there are references to sources that use gendered language to refer to populations of pregnant and birthing people. In order to accurately represent these sources, we may have maintained gendered language. We support research and knowledge translation that engages and reflects the entire childbearing population. TABLE OF CONTENTS Introduction ............................................................................................................................................. 3 Statement of purpose ................................................................................................................................... 3 Objectives ..................................................................................................................................................... 3 Abbreviations ................................................................................................................................................ 3 Outcomes of interest .................................................................................................................................... 4 Methods ....................................................................................................................................................... 4 Literature search ........................................................................................................................................... 5 Review .......................................................................................................................................................... 5 Background ............................................................................................................................................. 5 Definition and assessment of PPH ................................................................................................................ 5 Summary statements .................................................................................................................................... 6 Recommendations ........................................................................................................................................ 6 Incidence of PPH .......................................................................................................................................... 6 Complications of PPH ................................................................................................................................... 7 Causes of PPH .............................................................................................................................................. 8 Risk factors associated with PPH ........................................................................................................ 8 Selected and emerging risk factors for PPH ............................................................................................... 10 Previous CS and future risk of placenta accreta ................................................................................. 10 Parity .................................................................................................................................................. 10 Gestational Diabetes Mellitus ............................................................................................................ 10 Body mass index (BMI) ....................................................................................................................... 10 Previous PPH ...................................................................................................................................... 10 Antidepressant use ............................................................................................................................ 11 Induction and augmentation of labour .............................................................................................. 11 Maternal position during the second stage ....................................................................................... 12 Place of birth and risk of PPH ..................................................................................................................... 12 Summary statements .................................................................................................................................. 13 Recommendation ....................................................................................................................................... 13 Prevention of PPH ................................................................................................................................ 14 Management of the third stage of labour .................................................................................................. 14 Physiologic management ................................................................................................................... 14 Active management ........................................................................................................................... 14 Effects of active management compared to physiologic management ..................................................... 16 Third-stage management and place of birth .............................................................................................. 16 Active management of the third stage of labour and global health .......................................................... 17 Which uterotonic agent is most effective to prevent PPH? ........................................................................ 17 Oxytocin vs no oxytocin/placebo ....................................................................................................... 17 Oxytocin vs ergot alkaloids ................................................................................................................ 17 Syntometrine vs oxytocin ................................................................................................................... 17 Other uterotonic agents ..................................................................................................................... 18 Should misoprostol be used to prevent PPH? ............................................................................................ 18 Misoprostol vs oxytocin ..................................................................................................................... 20 Misoprostol vs other injectable uterotonics ....................................................................................... 20 Should tranexamic acid be used to prevent PPH? ..................................................................................... 20 Components of the active management package ....................................................................... 21 What is the best time to administer a prophylactic uterotonic? ................................................................. 21 What route is most effective for administration of prophylactic oxytocin? ................................................. 21 How does timing of cord clamping affect PPH and neonatal outcomes? .................................................. 21 What is the effect of umbilical cord drainage? ........................................................................................... 21 What are the effects of uterine massage? .................................................................................................. 21 What are the effects of controlled cord traction? ....................................................................................... 22 Active management and controlled cord traction ............................................................................. 22 Expectant management and controlled cord traction ....................................................................... 22 Summary statements .................................................................................................................................. 23 Recommendations .....................................................................................................................................