Hemorragia Postparto

SOGC CLINICAL PRACTICE GUIDELINE
It is the Society of Obstetrician and Gynaecologists of Canada (SOGC) policy to review the content 5 years after publication, at which
time the document may be revised to reflect new evidence or the document may be archived
No. 431, December 2022 (Replaces No. 235, October 2009 & No. 115, June 2002)
Guideline No. 431: Postpartum

Hemorrhage and Hemorrhagic Shock
(En français : Directive clinique no 431 : Hémorragie post-partum et choc hémorragique)
The English document is the original version. In the event of any discrepancy between the English and French content, the English version prevails.
This clinical practice guideline was prepared by the authors and SOGC Clinical Practice e Obstetrics Committee (2022):
overseen by the SOGC Clinical Practice Obstetrics committee. It Douglas Black (past-Chair), Mélina Castonguay, Cynthia Chan,
was reviewed by the SOGC Obstetrical Content Review Elissa Cohen (co-Chair), Christine Dallaire, Kirsten Duckitt,
committee and approved by the SOGC Guideline Management Sebastian Hobson (co-Chair), Isabelle Létourneau, Amy Metcalfe,
and Oversight Committee and SOGC Board of Directors. J. Larry Reynolds, debbie Robinson, Marie-Ève Roy-Lacroix,
This clinical practice guideline supersedes No. 235, published in Katherine Tyndall, Kathryn Versteeg
October 2009 and No. 115, published in June 2002.
Acknowledgements: The authors would like to acknowledge
Authors and thank special contributor Dr. Stephanie Cooper, MD, Calgary,
AB, for her extensive contribution to the appended PPH
debbie Robinson, MD, Winnipeg, MB
Appendices.
Melanie Basso, RN, MSN, Vancouver, BC
Cynthia Chan, MD, London, ON Disclosures: Statements were received from all authors.
Kirsten Duckitt, MD, Campbell River, BC Dr. Ryan Lett has previously given lectures on intravenous iron
Ryan Lett, MD, Regina, SK and received an unrestricted educational honorarium from Pfizer;
he also sits on the National Advisory Committee on Blood and
Blood Products as a representative for Saskatchewan. No other
relationships or activities that could involve a conflict of interest
were declared.
All authors have indicated that they meet the journal’s
requirements for authorship.
Keywords: postpartum hemorrhage; therapeutics; hemorrhagic
J Obstet Gynaecol Can 2022;44(12):1293-1310 shock; obstetric delivery; preventive medicine
https://doi.org/10.1016/j.jogc.2022.10.002 Corresponding author: debbie Robinson,
ª 2022 The Society of Obstetricians and Gynaecologists of Canada/La [email protected]
Société des obstétriciens et gynécologues du Canada. Published by
Elsevier Inc. All rights reserved.
This document reflects emerging clinical and scientific advances as of the publication date and is subject to change. The information is not
meant to dictate an exclusive course of treatment or procedure. Institutions are free to amend the recommendations. The SOGC suggests,
however, that they adequately document any such amendments.
Informed consent: Patients have the right and responsibility to make informed decisions about their care in partnership with their health care
provider. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally
appropriate, and personalized. The values, beliefs and individual needs of each patient in the context of their personal circumstances should be
considered and the final decision about care and treatment options chosen by the patient should be respected.
Language and inclusivity: The SOGC recognizes the importance to be fully inclusive and when context is appropriate, gender-neutral lan-
guage will be used. In other circumstances, we continue to use gendered language because of our mission to advance women’s health. The
SOGC recognizes and respects the rights of all people for whom the information in this document may apply, including but not limited to
transgender, non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with their
patients about their gender identity and preferred gender pronouns and to apply these guidelines in a way that is sensitive to each person’s
needs.
DECEMBER JOGC DÉCEMBRE 2022 l 1293

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assessment should include a calculation of the maximum allow-

RECOMMENDED CHANGES IN PRACTICE able blood loss (good practice point).
2. Both antenatal and postnatal anemia should be identified and
1. Quantitative blood loss measurement should replace
treated aggressively (strong, high).
estimated blood loss for all deliveries.
3. Quantitative blood loss measurement should replace estimated
2. Maximum single dose oxytocin doses should be 3 IU IV rapid
blood loss in all patients whenever possible (strong, moderate).
injection, or 10 IU intramuscular
4. Staging and management of postpartum hemorrhage should be
3. In cases of severe obstetrical hemorrhage, the calculated
based on quantitative blood loss (strong, high).
maximum allowable blood loss and lab-based (or point-of-
5. Active management of the third stage of labour should be offered
careebased) factor replacement should guide treatment
to all women (strong, high).
whenever possible.
6. Prophylactic intramuscular oxytocin can be used for patients at low
4. Misoprostol should only be used sublingually or orally for the
risk for postpartum hemorrhage (strong, high).
prevention and treatment of postpartum hemorrhage.
7. For patients at high risk of postpartum hemorrhage, prophylactic
intravenous oxytocin should be used (conditional, moderate).
8. When given intravenously, oxytocin can be given either as a rapid
infusion (max rate 1 IU/min) for 4 minutes, followed by 7.5e15 IU/h
KEY MESSAGES or as a 3 IU intravenous rapid injection (strong, moderate)
1. Reducing the risk of postpartum hemorrhage begins 9. If there is inadequate response to oxytocin within 4 minutes, a
antenatally and continued vigilance is needed throughout second-line uterotonic should be administered (strong, high).
labour to recognize abnormal postpartum bleeding early. 10. Carbetocin can be considered as a first-line agent for postpartum
2. Appropriate recognition and treatment of postpartum hemorrhage prophylaxis at cesarean delivery (strong, moderate).
hemorrhage can prevent serious morbidity while reducing 11. Bimanual uterine compression and bladder emptying should be
costs to the health care system by minimizing costly performed as first-line measures while waiting for pharmacologic
interventions and length of hospital stays. agents to take effect (good practice point).
3. Simulation training followed by formal debriefing will improve 12. Misoprostol (sublingual/oral) is an effective adjunct to prophylactic
outcomes in the clinical setting. or therapeutic oxytocin in high-risk individuals (strong, high)
13. Intramuscular ergotamine and intramuscular or intramyometrial
carboprost, can both be used to treat active postpartum hemor-
rhage (strong, high).
14. Rectal misoprostol is inferior to other routes (both in onset and in
bioavailability) and should not be used (strong, moderate).
ABSTRACT 15. Tranexamic acid can be used in all patients as an adjunct to ute-
rotonics in the setting of postpartum hemorrhage, and can be used
as a prophylactic agent in patients at high risk for postpartum
Objective: This guideline aims to provide evidence for prevention,
hemorrhage (strong, high).
recognition, and treatment of postpartum hemorrhage including
16. Uterine tamponade is an effective tool and should be considered
severe hemorrhage leading to hemorrhagic shock.
for ongoing mild to moderate bleeding (conditional, moderate).
Target population: All pregnant patients. 17. If the placenta has not been expelled spontaneously in the 30
minutes following delivery, measures should be taken to expedite
Benefits, harms, and costs: Appropriate recognition and treatment of delivery of the placenta (strong, high).
postpartum hemorrhage can prevent serious morbidity while 18. When there is ongoing bleeding, examine the patient for the
reducing costs to the health care system by minimizing more costly presence of clots, retained placental tissue, or genital tract lacer-
interventions and length of hospital stays. ations (good practice point).
19. In the case of uterine inversion, if immediate reversion is not
Evidence: Medical literature, PubMed, ClinicalTrials.gov, the
possible, transfer the patient to an operating room for uterine
Cochrane Database, and grey literature were searched for articles,
relaxation and patient stabilization, as required (good practice
published between 2012 and 2021, on postpartum hemorrhage,
point)
uterotonics, obstetrical hemorrhage, and massive hemorrhage
20. If pharmacologic interventions have not controlled
protocols.
bleeding, surgical intervention should be undertaken promptly
Validation methods: The authors rated the quality of evidence and (strong, high)
strength of recommendations using the Grading of 21. Compression sutures, ligation of uterine or internal iliac arteries,
Recommendations Assessment, Development and Evaluation and uterine artery embolization are all effective interventions that
(GRADE) approach. See online Appendix A (Tables A1 for can be considered; however, hysterectomy should not be delayed
definitions and A2 for interpretations of strong and conditional in an unstable patient (strong, high).
[weak] recommendations). 22. Severe obstetrical hemorrhage should be managed by a multi-
disciplinary team consisting of obstetrics, anaesthesia, nursing,
Intended Audience: All members of the health care team who care for and transfusion medicine (strong, high).
labouring or postpartum women, including, but not restricted to, 23. An obstetrical massive hemorrhage protocol, including defined
nurses, midwives, family physicians, obstetricians, and roles and responsibilities of each team member, should be used
anesthesiologists. (strong, moderate).
24. Initial resuscitative and monitoring measures should include
RECOMMENDATIONS intravenous access 2, electrocardiography, oxygen saturation,
1. An individualized risk assessment for postpartum hemorrhage blood pressure, placement of an indwelling urethral catheter,
should be documented in a checklist upon arrival to a labour unit euthermia, and volume replacement with balanced crystalloid
and updated throughout labour and delivery (strong, high). The risk (good practice point).
1294 l DECEMBER JOGC DÉCEMBRE 2022

PPH and Hemorrhagic Shock
25. Four units red blood cells should be given prior to other blood 27. A massive hemorrhage protocol with ratios of red blood cells
products in an actively bleeding patient who is approaching the to fresh frozen plasma to platelets of 1:1:1: or 2:1:1 can
maximum allowable blood loss, unless the patient has a coagu- be used in the absence of timely lab results (strong,
lation defect (strong, moderate) moderate).
26. Fibrinogen levels should be measured in every moderate to severe 28. Simulation training with all members of the multidisciplinary team
case of postpartum hemorrhage, and if <2 g/L, should be replaced should occur on a regular basis, ideally by a trained facilitator
accordingly (strong, high). (strong, high).

INTRODUCTION 5. RESUSCITATE
6. REVIEW
P ostpartum hemorrhage (PPH) continues to be a sig-
nificant contributor to maternal morbidity and mor-
tality, even in developed countries.1 Between 2003 and 2010, RISK ASSESSMENT
the incidence of PPH in Canada was 5.6 per 100 deliveries.
International data from high resource countries suggest the Causes and Risk Factors
rate is closer to 10% when blood loss is actually measured,2 The four Ts (tone, tissue, trauma, thrombin) are well
and this rate continues to rise, with uterine atony being the known. Evaluation of risk factors in each of these cate-
primary cause.3,4 The traditional definition of blood loss as gories is important to determine a potential cause of PPH
500 mL with vaginal delivery or 1000 mL with cesarean (Table 1). Individualized risk should be documented in a
delivery (CD) is no longer sufficient, as visual estimates have checklist upon arrival to a labour unit and updated
been found to be inaccurate, even for experienced pro- throughout labour and delivery (Appendix B). Patients at
viders.5,6 In addition, many women of reproductive age high risk for PPH deliver in a facility with easy access to a
maintain normal vital signs despite blood loss beyond these massive hemorrhage protocol (MHP) that takes into
amounts. Since these factors can lead to delays in treatment consideration local blood product supply, transport, and
causing adverse maternal outcomes,7,8 accurate and cumu- access to specialist advice.
lative measurement of blood loss has emerged as the new
standard of care.9 Anemia
Women with anemia (Hb <110 g/L) have less reserve to
Prevention is key to reducing maternal morbidity from cope with PPH. Anemia may also reduce oxygen delivery
PPH, as 60% of these patients have at least one identifiable to myometrial muscles resulting in uterine atony.12 In
antepartum or intrapartum risk factor.10 Assessment for addition, iron is a necessary cofactor for adenosine
these risk factors, as well as early intervention, are integral triphosphate (ATP) production in muscle cells, and iron
to mitigating potential adverse outcomes. deficiency itself may contribute to uterine atony.13
This guideline provides a new approach to the early Iron deficiency anemia is a significant health problem for
identification and management of PPH. Recommenda- women worldwide.14 The prevalence of iron deficiency
tions are based on emerging data that highlight the suc- anemia in pregnancy is estimated at 41%, with higher rates
cesses of obstetrical hemorrhage toolkits and care bundles in low socioeconomic populations.14 A study, conducted in
in reducing maternal morbidity and mortality. Toronto, Canada, of pregnant women screened for iron
deficiency anemia found that 91% of participants were iron
The California Maternal Quality Care Collaborative deficient (ferritin <50 mg/L), with most having severe iron
implemented a quality improvement initiative that led to a deficiency with a ferritin < 20 mg/L despite only 25% of
reduction in PPH of 20.8%, compared with 1.2% in non- participants having a hemoglobin level <110 g/L.15 These
participating hospitals.11 This guideline presents an findings highlight the fact that by the time a low hemoglobin
adapted model to prevent and manage PPH and com- is detected, the iron deficiency is profound. Both hemo-
prises the following categories: globin and ferritin should be measured antenatally.
1. RISK ASSESSMENT Anemia and iron deficiency should be assessed and treated
2. RISK REDUCTION at or before 28 weeks gestation. Ferrous salts, taken daily
or every other day, on an empty stomach is the ideal
3. RECOGNIZE AND RE-EVALUATE method of iron supplementation.16 There is insufficient
4. REACT evidence to routinely co-administer ascorbic acid (vitamin
C).17 Intravenous iron should be given if there is no
response (increase in Hb of 10 g/L) within 2 weeks.18
ABBREVIATIONS
CD cesarean delivery Postpartum anemia contributes to fatigue, postpartum
MABL maximum allowable blood loss depression, poor bonding, and poor lactation.19,20 Oral
MHP massive hemorrhage protocol iron supplementation should continue for at least 3
PPH postpartum hemorrhage months postpartum and intravenous (IV) iron considered
TXA tranexamic acid
with hemoglobin <80 g/L, regardless of symptoms.16

Table 1. Postpartum hemorrhage risk factors

Etiology Risk Factors
Tone (uterine atony) Uterine overdistension Polyhydramnios
Multiple gestation
Macrosomia
Uterine exhaustion Precipitous or prolonged labour
Prolonged oxytocin use
High parity
General anaesthesia
Anemia
Infection Prolonged rupture of membranes
Chorioamnionitis
Dysfunctional uterine activity Fibroids
Placenta previa
Tissue Retained products of conception Incomplete placental delivery (succenturiate lobe,
morbidly adherent placenta)
Trauma Laceration of cervix, vagina, perineum Precipitous or operative delivery
Episiotomy extension
Fetal malposition
Extension/lacerations at cesarean Deep engagement
Prolonged second stage
Fetal malposition
Uterine rupture Previous uterine surgery
Uterine inversion Nulliparity with fundal placenta
Excessive cord traction
Thrombin Pre-existing states Hereditary coagulopathies (von Willebrand disease, hemophilia)
Idiopathic thrombotic purpura
Acquired in pregnancy Preeclampsia
Disseminated intravascular coagulopathy
Fetal demise
Severe infection
Abruption
Amniotic fluid embolism
Iatrogenic Therapeutic anticoagulation
RISK REDUCTION can be accessed at any time to properly evaluate blood loss
in any patient. Measuring amniotic fluid in the drape (cali-
The California Collaborative found that underestimating brated cones are available) and wiping the fluid off the floor
blood loss and relying on vital signs led to health care before active bleeding begins will distinguish it from any
providers underestimating the severity of PPH and, more postpartum bleeding. Whenever possible, suction the am-
importantly, led to delays in treatment.11 Denial is delay niotic fluid at CD prior to delivering the infant and docu-
should be the new theme for PPH management strate- ment its volume. Everything suctioned after this point
gies.11 The benefit of one or more PPH bundles (con- should be considered blood loss. Sponges, towels, and
taining key medications, instruments, tamponade devices, drapes should be collected and weighed. A record of cu-
sponges, sutures, etc.) can decrease the time to treatment mulative blood loss for the first 24 hours should be kept.
by having all potentially needed materials readily available. Estimated blood loss should be replaced by quantitative
(measured) blood loss (Appendices C, D, E, F).
Accurate Measurement of Blood Loss
Since visual estimates grossly underestimate the true volume
of blood loss, it is recommended that labour units begin to Classification and Management Protocols for
accurately monitor and record ongoing bleeding. Dry Stages of Postpartum Hemorrhage
weights of sponges, towels, sheets, and other commonly A staging system based on quantitative blood loss,
soaked surfaces should be recorded on a standard form that regardless of vital signs, with detailed management

Table 2. Classification and management of PPH by stage

Blood loss, mL BP, mm Hga HR, bpma Signs/symptoms Initial managementb
Stage 0 <500 vaginal Normal <100 Asymptomatic Active or physiologic management
<1000 CD of the third stage
Stage 1 (mild) 500-1000 vaginal Normal <110 Often asymptomatic, or may Therapeutic first-line uterotonic
1000 CD have signs of severe PPH
Stage 2 1000-1500 Postural >110 May be asymptomatic, or Second-line uterotonic
(moderate) hypotension may have signs of Look for other causes
(SBP 80-100) severe PPH
Stage 3 >1500 SBP <80 >120 Diaphoresis Full resuscitation protocol
(severe) Delayed capillary refill time
Tachypnea
Pallor
Oliguria/anuria
Decreased level of
consciousness
Agitation
Cool extremities
a
BP and HR may be variable.
b
Expanded in Appendix G.
BP: blood pressure; CD: cesarean delivery; HR: heart rate; PPH: postpartum hemorrhage; SBP: systolic blood pressure.
protocols for each stage should be implemented.21 (Clas- should be given the necessary information regarding the
sification in Table 2, for a more detailed table including benefits and risks of active management of the third stage of
expanded management protocols see Appendix G) labour in order to make informed choices about their care.
Skin to skin contact may independently reduce the length of
Active Management of the Third Stage of Labour the third stage.30
The SOGC first commented on the active management of
the third stage of labour in 2000.22 Three elements were Oxytocin Free Interval Prior to Cesarean Delivery
originally included: a uterotonic after delivery of the The longer oxytocin is used for the induction or
anterior shoulder, early cord clamping, and cord traction to augmentation of labour, the less responsive the uterus
deliver the placenta. Since that time, delayed cord clamping becomes to it. Tran et al. showed a statistically significant
has become the standard of care as it improves neonatal association between the length of the oxytocin free interval
outcomes without increasing the incidence of PPH.23 prior to CD and the total estimated blood loss with the
Furthermore, in multiple trials and reviews, controlled greatest benefit after 1 hour.31 While the reduction in
cord traction has been shown to only decrease the length blood loss in patients with a low BMI was not clinically
of the third stage by 4-6 minutes and blood loss by significant (7 mL/10-min recovery interval), the greatest
<30 mL.24e28 Since there is limited evidence to suggest benefit was seen in women with a BMI >40 kg/m2, where
that expediting delivery of the placenta before 30 minutes blood loss was reduced by 45 mL per 10-minute recovery
reduces the risk of PPH in an uncomplicated delivery,22 interval up to a maximum of 450 mL at 99 minutes. In
the definition of active management of the third stage of these women, higher amounts and longer durations of
labour should be confined to the use of a uterotonic. oxytocin use were associated with an increased need for a
Providers choosing to employ controlled cord traction second-line uterotonic agent. When maternal and fetal
should only do so after signs of placental separation, and conditions are stable, providing an oxytocin wash-out in-
traction should be performed with uterine contraction as terval may be beneficial, particularly when the patient’s
these measures reduce the risk of uterine inversion, cord BMI is >40 kg/m2.
avulsion, and partial detachment of the placenta.
Prophylactic Uterotonics (Table 3)
Although prophylaxis with oxytocin for all patients has been Oxytocin
common practice, a 2019 Cochrane review found no clear Numerous trials over more than 2 decades continue to
benefit to routine uterotonics in terms of PPH or hemo- show that oxytocin is the drug of choice for both the
globin in women at low risk of PPH, based on low quality prevention and treatment of PPH.32 Compared with pla-
evidence.29 They concluded that women at low risk for PPH cebo, ergometrine, carboprost, or misoprostol, oxytocin is

Table 3. Prophylactic and first-line therapeutic uterotonics

Oxytocin (Syntocinon, Pitocin) Carbetocin (Duratocin)
Use Prophylaxis Prophylaxis AND first-line therapeutic Prophylaxis
Mechanism of action Uterotonic, direct stimulation of Uterotonic, direct stimulation of Stimulation of oxytocin
oxytocin receptorsa oxytocin receptorsa receptors
Dose and route 3 IU IV rapid injection 20e40 IU/L infusion e rapid 4þ min, 100 mg slow IV injection
10 IU IM then 7e15 IU/h once tone achieved (30 s)
100 mg IM
Onset of clinical action 1e2 min (IV) 4 min with rapid infusion 1e2 min IV
3e7 min (IM) 3e4 min IM
Half-life 4e10 min (IV) Ongoing 40 min
15e30 min (IM)
Duration of action 15e20 min (IV) Ongoing 1h
1e2 h (IM)
Adverse effects IV: Water retention 100 mg dose side effects
o <1 IU e none Note: rate above 15 IU/h ineffective equivalent to 5 IU slow
o 1e3 IU e minimal after 3 IU in circulation IV rapid injection oxytocin
o >3 IU e dose-related
increase ST depression,
increase in HR, drop in BP
IM: minimal
Note: misoprostol and TXA may be given concurrently with these first-line uterotonics for patients at high risk for PPH.
a
Decreased effect with prolonged use. Increased effect after oxytocin free interval.
either more effective, has fewer adverse effects, or higher infusion rate or additional IV boluses will not
both.33e35 While the uterus is increasingly responsive to provide any additional benefit. For high-risk patients, or
oxytocin as pregnancy progresses, there are fewer re- ongoing bleeding, a second-line agent should be added.
ceptors in the lower uterine segment than in the fundus,
and oxytocin has no direct effects on the cervix.36 Oxytocin has known hemodynamic and cardiac side ef-
Oxytocin is most commonly given by IV or intramus- fects (mainly ST depression from vasoconstriction of
cular injection, though some research has been done on coronary arteries) that are seldom recognized after vaginal
the inhaled and intramyometrial routes.37,38 For low-risk birth, primarily because patients are not monitored to
patients, prophylaxis via any route is sufficient; for high- detect them and because the clinical signs are attributed to
risk patients, the IV route is preferred.39 other causes. Fortunately, these side effects are short lived;
however, they have contributed to maternal death in
Much research has been done on the effects of IV oxytocin developed countries.43,44 When oxytocin is given quickly,
at the time of CD. In an elective CD (no labour), as little as hypotension and ST changes begin to appear after as little
1 IU of oxytocin can achieve uterine tonus. While similar as 1 IU is administered but do not become noticeable until
studies have not been done in the context of a vaginal 3 IU is administered; these signs are significant at
birth, it is reasonable to assume that the uterus will be at 5 IU.40 At 10 IU, 50% of women will experience ST
least as responsive after vaginal delivery than after an depression, even non-pregnant, non-anesthetized control
intrapartum CD, where studies show an IV bolus of 3 IU patients.45 These effects disappear when the 5 IU bolus
is sufficient to cause maximal uterine tonus by 4 minutes.40 is given over 5 minutes. Rapid IV bolus should therefore
Interestingly, a rapid IV infusion will provide the same be restricted to 3 IU or less, and an IV infusion is
benefit at 4 minutes, when approximately 3e4 IU of preferred.
oxytocin has entered the circulation.41,42
Carbetocin
In order to avoid overdosing oxytocin, the infusion should Carbetocin is a synthetic, long-acting, heat stable, analogue
be put through a pump, hung as a separate mini-infusion of oxytocin with equivalent affinity for the oxytocin re-
with only 4 IU in 100 mL. At this point, an infusion of ceptor. A single prophylactic 100 mg dose given IV over 30
7.5e15 IU/h is sufficient to maintain uterine tone; a seconds to 1 min provides similar or better clinical effects

Table 4. Pharmacokinetics of misoprostol

AUC ranka Onset of action,b min Tmax,c min Cmax,d pg/mL (averaged) Duration of action,e h
Sublingual 1 11 30 500 3
Vaginal 2 20 75 300 4
Oral 3 8 30 300 2
Buccal 4 20 75 200 4
Rectal 5 100 75 100 4
a
AUC: area under the (concentration vs time) curve; reflects bioavailability from highest (1) to lowest (5)
b
How rapidly clinical effect is seen.
c
Tmax: how rapidly the drug is completely absorbed.
d
How completely the drug is absorbed.
e
How long clinical effect is seen.
and similar side effects as a 5 IU IV bolus of oxytocin Special Agents

given at the same rate,46,47 and some studies have shown Misoprostol
smaller doses to be equally effective.48 In addition, its long PGE1 is available in 100 and 200 mg tablets and can be given
half-life of 40 minutes reduces the need for additional sublingually, orally, buccally, vaginally, and rectally. However,
uterotonics when compared with oxytocin. The product an understanding of the pharmacokinetics of misoprostol,
monograph states that severe preeclampsia/eclampsia is a borne out in clinical trials, will quickly eliminate most of
contraindication to its use; however, clinical trials in these routes for treatment of PPH52 (Table 4).
women delivering vaginally or by cesarean found carbe-
tocin to be both safe and effective in this setting.49,50 While The 2018 Cochrane review of all uterotonic agents found
carbetocin has not been studied as a therapeutic agent for misoprostol alone was superior to placebo but inferior to
active PPH, it should be considered a first-line agent for oxytocin for preventing PPH; however, adding miso-
prophylaxis at CD. Emerging evidence suggests the use of prostol to oxytocin prevented the need for additional
carbetocin may also be considered as a first-line prophy- uterotonics.47,53 When used as an adjunctive treatment,
lactic uterotonic at vaginal delivery.51 misoprostol should be given sublingually as this route
offers the highest bioavailability with a rapid onset and a
RECOGNIZE AND RE-EVALUATE moderate duration of action. Doses above 400 mg are not
needed, and, in fact, 200 mg may be sufficient.54 Miso-
It is crucial for care providers to rapidly recognize when prostol should not be given rectally as this route offers the
initial measures have not adequately controlled bleeding. lowest bioavailability and is associated with a maximum
Failure to discern both the extent and source of bleeding serum concentration that may not reach clinically signifi-
will needlessly delay appropriate intervention. Recording cant levels.52,55 While misoprostol is a valuable adjunct to
quantitative blood loss and vital signs for every post- both prophylactic and therapeutic uterotonics, the inject-
partum patient will help health care providers recognize able agents (oxytocin, ergometrine, carboprost, and TXA)
when blood loss has moved between stages and can have a more rapid onset and may be more useful as an
prompt intervention (Appendix G) independent agent in active PPH. The main side effects of
misoprostol, which are dose dependent, are shivering and
RE-EVALUATE TONE
fever, nausea, vomiting, and diarrhea.
Bimanual Uterine Compression and Bladder
Emptying Tranexamic Acid
The basic manoeuvre of manually compressing the uterus TXA is an antifibrinolytic agent that inhibits the activation
simultaneously through the abdomen and the vagina can of plasminogen to plasmin. Given intravenously, it has a
be life-saving and should be actively used until the phar- half-life of 2 hours.56 Side effects include nausea, vomiting,
macologic agents take effect, or surgical intervention is diarrhea, seizures, deep vein thrombosis, and pulmonary
initiated. The lower uterine segment must be cleared of embolism, though seizures and thrombosis have not been
clots to allow the uterus to contract. Catheterization demonstrated in clinical trials of PPH.57 Two separate
should be an initial step in management of PPH as a full randomized trials showed prophylactic IV TXA (after cord
bladder can impair the uterus’ ability to contract. clamping in 1 trial, and preoperatively in the other)

Table 5. Special agents

Misoprostol (Cytotec) Tranexamic acid (TXA)
Indication Adjunct for prophylaxis with first-line agents in Adjunct for prophylaxis with first-line agents in very high-
high-risk patients risk patients
Adjunct for treatment with second-line uterotonics Adjunct for treatment with second-line uterotonics in
in all patients with active PPH all patients with active PPH
Mechanism of action Uterotonic; binds prostaglandin receptors Antifibrinolytic; inhibits activation of plasminogen to plasmin
Dose/route/rate 200e400 mg sublingual 1 g IV over 30e60 s
200e400 mg oral
Onset of action 11 min (sublingual) d
8 min (oral)
o both peak at 30 min
Half-life 2 h (sublingual) 2h
1.5 h (oral)
Duration of action 3 h (sublingual) d
2 h (oral)
Repeat dosing d Every 30 min; max 2 doses
Adverse effects Fever (especially with doses 600 mg) Nausea/vomitingdiarrhea, Headache
Shivering, nausea/vomiting, diarrhea
Caution d VTE has not been seen in obstetrical clinical trials
IV: intravenous; PPH: postpartum hemorrhage; VTE: venous thromboembolism.
reduced the blood loss at CD,58,59 and 2 separate large precipitate coronary artery vasospasm and myocardial
meta-analyses, as well as one randomized controlled trial ischemia, even in patients without pre-existing cardiovascular
showed that 1g of IV TXA given in the setting of ongoing risk factors.65 Ergometrine should not be used in patients
PPH after vaginal delivery decreases blood loss, rate of with essential or gestational hypertension,66 or in patients on
hysterectomy, and mortality.60e62 In particular, when given HIV protease inhibitors.47,67,68 Though undisputedly
over 30e60 seconds, there was no difference in systolic or extremely effective, potential adverse effects limit ergome-
diastolic blood pressures compared with placebo.61 TXA trine to a second-line agent.
should be given whenever a second-line uterotonic is
administered. Every 15-minute delay results in a 10% Carboprost
reduction of TXA efficacy and immediate treatment im- Carboprost is a prostaglandin F2a that causes contractions
proves survival by over 70% (P < 0.0001).63 Prophylactic in myometrial and intestinal smooth muscle cells.69 It can
use (in addition to a prophylactic uterotonic agent) in in- be given by intramuscular or intramyometrial injection but
dividuals at high risk of PPH (cesarean or vaginal delivery) cannot be given intravenously. Its efficacy is equivalent to
is a reasonable option. For a summary of special agents, oxytocin after either cesarean or vaginal delivery but
see Table 5. common adverse effects, including nausea, vomiting,
diarrhea, and fever limit its use to a second-line agent.34,70
Uterotonics for Treatment of Postpartum Loperamide should be given concurrently with carboprost
Hemorrhage to counteract its diarrheal effects. As a member of the F
Additional agents should be used whenever the initial class of prostaglandins, carboprost can cause broncho-
agent has not produced sufficient uterine tone by 4 mi- spasm and should not be used in patients with asthma.71
nutes, or concurrently with a prophylactic agent in patients
with increased risk for PPH based on the ongoing Mechanical Options
checklist (Table 6). Tamponade
Intrauterine compression may control mild to moderate
Ergometrine blood loss. The Bakri balloon was designed for this pur-
Ergometrine, or ergonovine is an ergot alkaloid which directly pose and its use prevents the need for further non-
stimulates uterine and vascular smooth muscle to contract. It pharmacologic intervention in 75%e95% of cases.72,73 It
can be given intramuscularly or, in life-saving circumstances, should be filled with 300e500 mL of sterile solution, left
as a slow IV injection.64 It is a potent uterotonic, but in the in situ for 8e48 hours and then gradually deflated. Anti-
setting of anemia and hypovolemia, ergometrine can rarely biotics should be considered if they have not already been

Table 6. Second-line uterotonics for treatment of postpartum hemorrhage

Ergometrine/ergonovine Carboprost (Hemabate, PGF2a)
Mechanism of action Uterotonic; non-specific activation of adrenergic and Uterotonic; binds prostaglandin receptors
dopaminergic receptors in uterine and vascular
smooth muscle
Dose and route 250 mg IM (preferred) 250 mg IM or IMM
250 mg IV over 1 min (only in life-saving circumstances)
Onset of action 2e5 min (IM) 5 min
1e2 min (IV)
Half-life T1/2a ¼ 10 mina 30 min
T1/2b ¼ 2 hb
Duration of action 120 min 60 min
Repeat dosing Every 2 h, max 5 doses Every 15 min, max 5 doses
Adverse effects Nausea/vomiting, hypertension, vasoconstriction causing ST Diarrhea
depression and chest pain
Caution Hypertension Can cause bronchospasm in patients
HIV medications (NNRTIs or protease inhibitors) with asthma
Macrolide antibiotics
a
T1/2a ¼ time for the drug to redistribute to other tissues;
b
T1/2b ¼ time for the drug to re-enter and then be cleared from the circulation
IM: intramuscular; IMM: intramyometrial; IV: intravenous; NNRTI: non-nucleoside reverse transcriptase inhibitors; PGF2a: prostaglandin F2a.
given, and a pack can be placed in the vagina if the balloon waiting more than 30 minutes for placental separation
is hourglassing through the cervix. If a Bakri balloon is not increased the risk of blood transfusion more than three-
available, any balloon device can be used. Alternatively, fold.76 More studies need to be done to be able to
systematically packing the uterus from cornua to cornua recommend the ideal time for manual removal of the
with laparotomy packs tied end to end may be considered; placenta in a stable patient.
however, this procedure requires more experience, more
anaesthesia, and a second procedure to remove. It may Intraumbilical oxytocin (20 IU in 30 mL saline), miso-
also mask blood loss and increase the risk of infection. prostol (800 mg in 30 mL saline), or ergometrine (0.2 mg in
Packing should be used as a last resort until more defini- 30 mL saline), as well as IV carbetocin (100 mg), or sub-
tive treatment can be initiated. A running record of lingual misoprostol (400 mg) all have similar efficacy for
accumulated quantitative blood loss and interventions expelling the placenta within 30 minutes of administration
should be easily accessible and visible to all members of (62%e72%).77,78 In the presence of heavy bleeding,
the care team (Appendix E, F, H, I). transfer to an operating room for manual removal of the
placenta should be expedited and curettage with a large
RE-EVALUATE SOURCE curette may be needed. There is insufficient evidence to
recommend routine treatment with antibiotics.74
Retained Placenta
Retained placenta occurs in 1%e3% of vaginal deliveries Lacerations
and is the second leading cause of PPH.74 Risk factors are Lacerations of the vagina or cervix, or disruption of a
uterine atony, an adherent placenta, succenturiate lobe, and uterine scar should be ruled out by a formal examination
a trapped placenta behind a closed cervix. Internationally, under anaesthesia, and surgical repair of the injury should
recommendations for manual removal of the placenta vary be completed. Vaginal packing may be required when
between 30 and 60 minutes, based on studies from the generalized bleeding from a deep venous plexus pre-
1990s showing no increase in PPH until at least 30 minutes cludes proper repair. Re-opening the abdominal incision
had passed.74 The majority of placentas (95%) will deliver after CD to look for surgical bleeding should not be
spontaneously by 18 minutes. A 2012 randomized delayed.
controlled trial confirmed a previous observational study
that found patients who had manual removal of the Uterine Inversion
placenta earlier than 30 minutes had less blood loss.75 This rare but potentially life-threatening condition is
Similarly, a large retrospective study (n >28 000) showed thought to be caused by excessive cord traction on a

fundal placenta or fundal pressure without a uterine lower uterine segment or cervical branches, a second stitch
contraction; however, there are no risk factors in most placed 3 cm inferior to the first can be used to compress
cases.79 Clinical diagnosis is based on the presence of brisk descending branches of the uterine artery. This location
vaginal bleeding, a mass in the vagina, and vasovagal increases the risk of ureteric entrapment, and further
syncope. If still attached, the placenta should not be bladder dissection should be performed. Radiologic or
removed prior to reversion. Prompt replacement may be cystoscopic evaluation of ureteral patency is recommended.
attempted; however, hypovolemic shock occurs rapidly,
and the patient should be urgently transferred to an Bilateral Internal Iliac Artery Ligation
operating room if reversion cannot be accomplished Bilateral internal iliac artery ligation is extremely effective
immediately. Uterine relaxation with IV nitroglycerine in at controlling obstetrical hemorrhage (including following
addition to vasopressors may be required to revert the hysterectomy), with numerous case series reporting suc-
uterus and reverse hemodynamic instability. If reversion is cess rates of 75% or higher.83e85 Unfortunately, bilateral
unsuccessful, laparotomy may be required. Antibiotics and internal iliac artery ligation requires more skill and expe-
oxytocin should be given after reversion. rience. Retroperitoneal dissection to identify the bifurca-
tion of the common iliac artery is followed by ligation of
REACT the internal branch at least 2 cm distal to the bifurcation
with an absorbable suture. Bilateral internal iliac artery
If previous measures fail to control bleeding, urgent ligation reduces pelvic blood flow by 49% but immediate
abdominal surgical exploration is required. Bimanual increased retrograde flow in collateral vessels prevents
compression should be continued while preparations in pelvic ischemia. Resumption of menses and demonstration
the operating room are being made and surgery is about to of flow in distal uterine arteries in 90% of women within 6
begin. Uterine compression sutures (B-Lynch, Cho), months suggests that fertility is preserved.86
uterine artery ligation, internal iliac artery ligation, embo-
lization, and hysterectomy are possible interventions. This Uterine or Internal Iliac Artery Embolization
guideline is not an instruction manual for those not skilled Embolization of either uterine or internal iliac arteries is
at performing these procedures. Additional expertise highly effective and fertility sparing. When compared with
should be sought urgently if the necessary procedure is hysterectomy, blood loss and operative time are
beyond the skill set of the care provider. significantly less.87,88 The main drawbacks of embolization
are the availability of an interventional radiology
Compression Sutures department and a patient with a stable blood pressure. If
The B-Lynch technique uses an absorbable suture on a these conditions are met and bleeding is ongoing, uterine
large needle to create compression “suspenders,” which artery embolization can be considered before proceeding
successfully treat intractable uterine atony 75% of the to hysterectomy. Uterine artery embolization can also be
time.80 Adding a second suture can further decrease the considered post-hysterectomy for ongoing bleeding,
need for hysterectomy.81 Cho square compression sutures, where a contributing vessel can be identified. Uterine
incorporating both anterior and posterior walls of the artery embolization is particularly useful for cases
uterus, have similar efficacy.82 where bleeding is expected to be high and/or surgical
treatment is expected to be difficult (e.g., placenta previa,
Uterine Artery Ligation accreta, severe obesity, or suspected intra-abdominal
The purpose of uterine artery ligation is not to obliterate adhesions). In these cases, an interventional radiology
blood flow to the uterus, but to temporarily slow it. Key consult should be obtained pre-delivery and a plan
aspects include bladder retraction (to prevent traction on established, including the possibility of pre-delivery
both bladder and ureters caused by the suture) and use of placement of arterial balloons.
an absorbable suture on a large needle to secure the uterine
artery at the level of the isthmus (or 2e3 cm below the Hysterectomy
uterine incision at CD). Ensuring 2 cm of myometrium is In cases of massive obstetric hemorrhage, hysterectomy
incorporated into the suture will bundle the uterine artery can be life-saving, and the biggest risk is waiting too long
and vein and prevent complete occlusion of the uterine to perform it. Successive clamping of pedicles without
artery. A second suture can be used superiorly to further tying them until the uterine arteries have been secured will
compress ascending branches of the uterine artery. Alter- allow faster control of bleeding. Conflicting opinions on
natively, if bleeding is predominantly coming from the subtotal versus total hysterectomy preclude a

recommendation, and clinical judgment on the source of occur. The equation assumes that volume losses have been
bleeding and type of hysterectomy is required.89 replaced with balanced crystalloid. In a healthy pregnancy,
the total circulating blood volume is 100 mL/kg (range
Abdominal Packing 90e200 mL/kg.) In obesity, or volume-contracted states
When surgical hemostasis has been achieved, but ongoing such as severe preeclampsia, total blood volume should be
bleeding persists, disseminated intravascular coagulation, estimated at 70 mL/kg.92
acidosis, and hypothermia are often contributing factors.
Packing the pelvis tightly with warm, moist packs and The actual calculation is:
leaving them in place for 24e48 hours can provide the ðHbi-Hbf Þ Pt’s Weight ðkgÞ Total Blood Volume ðmL=kgÞ
necessary time to reverse these factors. ½ðHbi þ Hbf Þ 0:5
RESUSCITATE
The following simplified and more user-friendly version of
Resuscitation requires ongoing communication and this formula can be used to calculate MABL:
teamwork involving the obstetrical care provider and
anaesthesia and nursing teams. An algorithm, including Wt ðkgÞ 100 ½Hbi-70
MABL ¼
clinical signs and symptoms of PPH and hypovolemic ðHbi þ 70Þ 0:5
shock and their treatments, should clearly outline the re-
sponsibilities of various team members in order to opti-
Hypotension, tachycardia, oliguria, and altered mental
mize maternal outcome11 (Appendix G).
status indicate hypovolemic shock and should be treated
aggressively. The “lethal triad” of coagulopathy, acidosis,
PPH is an active, ongoing process; lab results represent a
and hypothermia, which occurs in hemorrhagic shock,
point in time that has invariably passed. While formal lab
compounds the loss of volume and blood components.8
tests can help tailor therapy, waiting for results to initiate
(Appendix J)
treatment can worsen patient outcomes.90 Most parturi-
ents are able to maintain hemodynamic stability despite
Initial Steps
considerable blood loss. The recommended hemoglobin
Establish the following:
level at which to transfuse has decreased over time. In
2003, the threshold was 80 g/L, and as of 2021 the
Two large bore IV catheters
consensus is 70 g/L; however, with many patients able to
tolerate hemoglobin as low as 50 g/L, this threshold may Frequent BP monitoring (consider arterial line)
change in the future. Patients with pre-existing anemia Continuous EKG
may tolerate lower hemoglobin levels better than those O2 saturation monitor
with acute anemia. Current recommendations suggest
Temperature probe
that vital sign changes and accurate measurements of
ongoing blood loss should trigger resuscitation efforts. Foley catheter
Escalation of care (with or without transfusion) should
occur at blood loss intervals of 500, 1000, and 1500 mL Oxygen, Temperature, Volume
(mild/moderate/severe blood loss) so the team can Oxygen supplementation of 8e10 L/min will slow the
respond appropriately if the patient is not tolerating the onset of tissue hypoxia. Hypothermia increases the risk of
blood loss. mortality; keeping the patient dry, using warmed blankets
or forced air warmers, and warming all fluids will help
Maximum allowable blood loss (MABL)91 is an invaluable maintain euthermia.93 Initial volume resuscitation should
tool to customize treatment of PPH and should be use Ringer’s lactate in a ratio of 1e2 mL per 1 mL blood
calculated for each individual patient and documented on loss.94 Higher volumes of crystalloid have been
the risk assessment form. This formula uses the patient’s associated with poor maternal outcomes due to dilutional
most recent hemoglobin level as the initial hemoglobin coagulopathy. At this time, there is no evidence to promote
(Hbi) and the hemoglobin at which transfusion may occur, the use of colloids over crystalloids, as colloids are also
if clinically indicated, as the final hemoglobin (Hbf); it in- associated with impaired coagulation. In the setting of
corporates the patient’s weight and total circulating blood ongoing massive hemorrhage, red blood cell (RBC)
volume and provides an individualized estimate of the administration should occur before total blood loss equals
patient’s tolerable blood loss before transfusion should MABL.

Blood Products hemorrhage.100 Each dose should raise the platelet count
Red Blood Cells by 15e25 109/L.
RBCs are the first step in the transfusion process, unless
the patient has a known coagulation defect. Transfusing Fresh Frozen Plasma
RBCs is not without risk, and ongoing transfusion medi- The goal of transfusion is to keep the INR <1.8. Donor
cine trials continue to demonstrate that the decision to plasma has less fibrinogen than the 5 g/L typically seen in
transfuse must take into account the potential for harm.92 the plasma of healthy parturients and is not the first choice
Patients at high risk for PPH should have a blood type and for its replacement.19 Although plasma provides additional
screening on admission to cross match blood, if needed. O clotting factors, most healthy women with moderate ob-
negative, Kell negative emergency blood is the next best stetric hemorrhage do not require these factors. However,
alternative to cross-matched blood. There is no absolute using plasma in a ratio to RBCs of 1:2 or 1:1, as a global
hemoglobin level at which transfusion must occur, but replacement, may improve outcomes in severe hemor-
maintaining a level between 70 and 90 g/L during active rhage in trauma patients, particularly if timely lab values
hemorrhage is recommended.95 are not available. Large volumes of plasma increase the
incidence of transfusion-related acute lung injury (TRALI)
Transfusion should occur when hemorrhage is unre- and transfusion-associated cardiorespiratory overload
sponsive to uterotonic measures and blood loss exceeds (TACO).101
150 mL/min or total loss is rapidly approaching the
calculated MABL or when the patient develops symptoms Fibrinogen
of inadequate perfusion, such as shortness of breath or Fibrinogen levels <2 g/L are associated with poor out-
tachycardia unresponsive to fluid in the presence of he- comes and direct replacement below these levels is rec-
moglobin less than 90 g/L. ommended. Testing for fibrinogen levels when blood loss
is <1500 mL is not predictive of severe PPH, and routine
Fatigue alone is not a symptom that warrants trans- administration of fibrinogen in the absence of hypofi-
fusion.96 Each unit of packed RBCs should increase the brinogenemia does not improve outcomes. Levels will
hemoglobin by 10 g/L. If 4 units of RBCs have been drop more rapidly in the setting of abruption and amniotic
given, and blood loss is ongoing, activation of a MHP fluid embolism than in the setting of atony.94,96,97
should be considered. Hemorrhage caused by uterine
atony or birth-related trauma rarely requires additional Each unit of cryoprecipitate contains 150e350 mg of
coagulation factors or platelets, unless the volume of blood fibrinogen and a typical dose is 8e10 U. Thawing is
loss is significantly greater than the MABL and/or dilu- required prior to use, and multiple donors are required for
tional coagulopathy occurs. Hemorrhage due to placental sufficient amounts, which increases the risk of transfusion
abruption, amniotic fluid embolism, or disseminated reactions.102,103
intravascular coagulation consumes platelets and factors
rapidly and replacement may be beneficial earlier in Fibrinogen concentrates (RiaSTAP and FIBRYGA) do not
resuscitation.97 Cell salvage does not increase the risk of require thawing, provide accurate dosing, and decrease
amniotic fluid embolism and should be considered when both the requirement for other blood products and the
the risk for severe PPH is high.19 Intravenous iron is an incidence of circulatory overload.104 Fibrinogen concen-
important adjuvant for a hemoglobin level <80 g/L once trates also undergo viral inactivation and removal of an-
bleeding has settled.16,98,99 tigens and antibodies. Four grams of fibrinogen
concentrate is equivalent to 10 units of cryoprecipitate and
Platelets typically raises plasma fibrinogen levels by 1 g/L (60 mg/
Platelet transfusion is necessary if blood loss is severe or if kg dosing).102,103
a consumptive coagulopathy develops. During active
hemorrhage, platelets should be transfused at a level Massive Hemorrhage Protocol
of 75 109/L in order to maintain a level above Originally designed for trauma patients, MHP is now often
50 109/L.19 There is no evidence to support a fixed ratio used in the setting of obstetrical hemorrhage. In the
of platelets in obstetric hemorrhage; however, it is trauma literature, transfusing fixed ratios of RBCs to fresh
acceptable to give 1 pooled dose of adult platelets frozen plasma to platelets of either 1:1:1 or 2:1:1 after the
(4 U platelets, or 5 U in Québec) per 8e10 U of RBCs, first 4 units of packed RBCs has been shown to decrease
transfused in the absence of lab data and with ongoing mortality.94,96,97,105,106 Therapy based on lab values

(including viscoelastography, where available [rotational Prothrombin Complex Concentrate

thromboelastometry, thromboelastography]) is superior to Prothrombin complex concentrate contains vitamin
ratio-based approaches as it reduces the number of Kedependent clotting factors and is indicated for reversal
products transfused, reduces transfusion overload and of vitamin K antagonists (warfarin). Apart from patients
transfusion-related complications, and tailors therapy to with known factor II or X deficiencies, in which case, a
the underlying coagulopathy.107,108 hematologist should be consulted, there is currently no
role for prothrombin complex concentrate in the treat-
The amount of blood loss that should trigger an MHP can ment of PPH.96,97,105
be markedly different based on the patient’s size, etiology
of hemorrhage, and underlying health issues (i.e., pre- Recombinant Activated Factor VII
eclampsia). Using a single blood loss volume to initiate an Recombinant activated factor VII (rFVIIa) provides a
MHP may result in some patients being transfused too thrombin burst and stabilizes clots, and should only be
early and others too late. Whenever the blood loss is administered to patients with a fibrinogen level >1g/L,
approaching the MABL and there is ongoing bleeding, platelets >20 109/L, and a near normal pH (7.4) and
RBCs should be considered first.94,96,97,105,106 Canadian temperature (35.9 C). Given the absence of strong evi-
standard of care recommendations indicate that an MHP dence of benefit and the serious risk of thrombosis, rFVIIa
should be able to be mobilized and products delivered should only be used in PPH as a last resort and in
within 10 minutes.109 If local resources cannot reliably consultation with a transfusion medicine specialist or
meet this timeline, consider initiating an MHP sooner. hematologist.96,97,105
If the patient is stable and the bleeding is controlled after
the initial 4 units of RBCs, the MHP products can be
REVIEW
returned.
Quality care initiatives in many centres have clearly shown
Coagulopathy does not occur in every PPH including that strong teamwork and communication, along with
massive PPH. When there is no coagulopathy, there is no simulation training and debriefing after any significant
benefit to transfusion of coagulation products. The etiology PPH, improve outcomes. Key components of teamwork
of the bleed matters, as atony and trauma are less likely to include a process for standard and structured communi-
require coagulation factor replacement than abruption, cation, effective use of clear language, psychological safety
abnormal placentation, or amniotic fluid embolism. Testing where team members are not fearful of speaking up,
for coagulopathy rarely demonstrates abnormalities when situational awareness, and effective leadership111
the blood loss is <1.5e2 L. When coagulopathy is present (Appendix K).
in PPH, hypofibrinogenemia is the most common etiol-
ogy,102,103 and commonly coexists with hypocalcemia. Debriefing after simulation led by a trained facilitator
Ionized calcium less than 1.16 mmol/L (rather than routine promotes improved learning outcomes and enhances
or corrected calcium which may be normal) is the most future performance in the clinical setting.112 Debriefing is
accurate way to measure calcium status in a hemorrhaging more than feedback, it is “an interactive, bidirectional and
patient and may be at least as important as fibrinogen in reflective conversation,”113 which will foster better
terms of risk reduction.110 Calcium chloride is the agent of communication and teamwork in subsequent clinical sce-
choice to replace calcium as it contains 3 times the narios. As experiencing PPH can be traumatic, care pro-
elemental calcium of calcium gluconate and does not viders should have a conversation with the patient and
require liver metabolism. Fresh frozen plasma and platelets their family to explain the events and answer any questions
are less commonly needed, but may be included in the they have. Debriefing after a significant PPH should occur
MHP, particularly after 4 to 8 units of RBCs, respectively. and should include all involved members of the health care
team, as well as a separate discussion with the patient and
Frequent monitoring of all these components (CBC, PTT, her family.
INR, fibrinogen, ionized calcium), as well as magnesium,
electrolytes, hypothermia, and overall volume status are
necessary components of any MHP. Tailoring therapy as CONCLUSION
early as feasible results in a patient-centred approach that is
in keeping with the most up-to-date recommendations in Although the acute treatment of PPH is key for any single
transfusion medicine. patient, the ongoing review practices is most important for

future patients. While standardized approaches for the 10. Kramer MS, Berg C, Abenhaim H, et al. Incidence, risk factors and
temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol
identification and management of PPH may need to vary 2013;209:449.e1e7.
between sites based on the availability of resources, best 11. California Maternal Quality Care Collaborative. Obstetric hemorrhage.
practices include: Available at: https://www.cmqcc.org/content/obstetric-hemorrhage-0.
Accessed on June 1, 2021.
a risk assessment for every patient, including calculation 12. Kavle JA, Stoltzfus RJ, Witter F, et al. Association between anaemia during
pregnancy and blood loss at and after delivery among women with vaginal
of the MABL births in Pemba Island, Zanzibar, Tanzania. J Health Popul Nutr
a standardized approach for collecting, weighing, and 2008;26:232e40.
13. Dziegala M, Josiak K, Kasztura M, et al. Iron deficiency as energetic insult
reporting blood loss to skeletal muscle in chronic diseases. J Cachexia Sarcopenia Muscle
stage-based management strategies, including protocols 2018;9:802e15.
specifically designed for massive blood loss 14. Mawani M, Ali SA, Bano G, et al. Iron deficiency anemia among women of
reproductive age, an important public health problem: situation analysis.
‘hemorrhage carts’ for storing medications and supplies Reprod Syst Sex Disord 2016;5:187.
regular multidisciplinary staff training and simulation 15. Tang G, Lausman A, Abdulrehman J, et al. Prevalence of iron deficiency
and iron deficiency anemia during pregnancy: a single centre Canadian
debriefing with formal review of adverse events. study. Blood 2019;134(Suppl 1):3389.
16. Munoz M, Pena-Rosas J, Robinson S, et al. Patient blood management in
obstetrics: management of anaemia and hematinic deficiencies in pregnancy
Templates for all these recommendations can be found in and in the post-partum period: NATA consensus statement. Transfus Med
the supplementary toolkit. 2018;28:22e39.
17. Li N, Zhao G, Wu W, et al. The efficacy and safety of vitamin c for
SUPPLEMENTARY TOOLKIT iron supplementation in adult patients with iron
deficiency anemia: a randomized clinical trial. JAMA Netw Open 2020;3:
e2023644.
A supplementary toolkit related to this article can be 18. Pavord S, Daru J, Prasannan N, et al. UK guidelines on the management of
found in the Online Appendix. iron deficiency in pregnancy. Br J Haematol 2020;188:819e30.
19. Munoz M, Stensballe J, Bucloy-Bouthors A-S, et al. Patient blood
management in obstetrics: prevention and treatment of postpartum
haemorrhage. A NATA consensus statement. Blood Transfus
2019;17:112e36.
REFERENCES
20. Khalafallah AA, Dennis AE, Ogden K, et al. Three-year follow-up of a
randomised clinical trial of intravenous versus oral iron for anaemia in
1. Grobman WA, Bailit JL, Rice MM, et al. Frequency of and factors pregnancy. BMJ Open 2012;2:e000998.
associated with severe maternal morbidity. Obstet Gynecol
2014;123:804e10. 21. Cooper S. Alberta Health Services. PPH staging and management guidelines.
Available at: https://extranet.ahsnet.ca/teams/policydocuments/1/klink/et-
2. Deneux-Tharaux C, Bonnet MP, Tort J. Épidémiologie de l’hémorragie du klink-ckv-post-partum-hemorrhage-adult-inpatient.pdf. Accessed on June 1,
post-partum [Epidemiology of post-partum haemorrhage]. J Gynecol 2021.
Obstet Biol Reprod (Paris) 2014;43:936e50.
22. Leduc D, Senikas V, Lalonde A. Active management of the third stage of
3. Mehrabadi A, Liu S, Bartholomew S, et al. Temporal trends in postpartum labour: prevention and treatment of post partum hemorrhage. J Obstet
hemorrhage and severe postpartum hemorrhage in Canada from 2003 to Gynaecol Can 2018;40:e841e55.
2010. J Obstet Gynaecol Can 2014;36:21e33.
23. Delayed Umbilical Cord Clamping After Birth: ACOG Committee
4. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage Opinion, Number 814. Obstet Gynecol 2020;136:e100e6.
in high resource countries: a review and recommendations from the
International Postpartum Hemorrhage Collaborative Group. BMC 24. Hanafi S, El-Shehawy H, Meshmesh K. Impact of controlled cord traction
Pregnancy Childbirth 2009;9:55. in the management of the third stage of labor on postpartum hemorrhage:
a randomized controlled trial. EBWHJ 2014;4:78e81.
5. Al Kadri HM, Al Anazi BK, Tamim HM. Visual estimation versus
gravimetric measurement of postpartum blood loss: a prospective cohort 25. Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM. Controlled cord traction
study. Arch Gynecol Obstet 2011;283:1207e13. for the third stage of labour. Cochrane Database Syst Rev
2015;1:CD008020.
6. Patel A, Goudar SS, Geller SE, et al. Drape estimation vs. visual
assessment for estimating postpartum hemorrhage [published erratum 26. Gülmezoglu AM, Lumbiganon P, Landoulsi S, et al. Active
appears in Int J Gynaecol Obstet 2006;95:312]. Int J Gynaecol Obstet management of the third stage of labour with and without controlled
2006;93:220e4. cord traction: a randomised, controlled, non-inferiority trial. Lancet
2012;379:1721e7.
7. Della Torre M, Kilpatrick SJ, Hibbard JU, et al. Assessing preventability for
obstetric hemorrhage. Am J Perinatol 2011;28:753e60. 27. Bartlett L, Cantor D, Lynam P, et al. Facility-based active management of
the third stage of labour: assessment of quality in six countries in sub-
8. Seacrist MJ, VanOtterloo LR, Morton CH, et al. Quality improvement Saharan Africa. Bull World Health Organ 2015;93:759e67.
opportunities identified through case review of pregnancy-related deaths
from obstetric hemorrhage. J Obstet Gynecol Neonatal Nurs 28. Althabe F, Alemán A, Tomasso G, et al. A pilot randomized controlled trial
2019;48:288e99. of controlled cord traction to reduce postpartum blood loss. Int J Gynaecol
Obstet 2009;107:4e7.
9. Rubenstein AF, Zamudio S, Al-Khan A, et al. Clinical experience with the
implementation of accurate measurement of blood loss during cesarean 29. Begley CM, Gyte GML, Devane D, et al. Active versus expectant
delivery: influences on hemorrhage recognition and allogeneic transfusion. management for women in the third stage of labour. Cochrane Database
Am J Perinatol 2018;35:655e9. Syst Rev 2019;(2):CD007412.

30. Karimi FZ, Heidarian Miri H, Salehian M, et al. The effect of mother-infant 50. Reyes OA, Gonzalez GM. Carbetocin versus oxytocin for prevention of
skin to skin contact after birth on third stage of labor: a systematic review postpartum hemorrhage in patients with severe preeclampsia: a double-
and meta-analysis. Iran J Public Health 2019;48:612e20. blind randomized controlled trial. J Obstet Gynaecol Can
2011;33:1099e104.
31. Tran G, Kanczuk M, Balki M. The association between the time from
oxytocin cessation during labour to Cesarean delivery and postpartum 51. Chao YS, McCormack S. Carbetocin for the prevention of post-partum
blood loss: a retrospective cohort study. Can J Anesth 2017;64:820e7. hemorrhage: a review of clinical effectiveness, cost-effectiveness, and
guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in
32. Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third Health. Available at: https://www.ncbi.nlm.nih.gov/books/NBK546425/.
stage of labour to prevent postpartum haemorrhage. Cochrane Database Accessed on July 29, 2019.
Syst Rev 2013;10:CD001808.
52. Tang OS, Gemzell-Danielsson K, Ho PC. Misoprostol: pharmacokinetic
33. Bilgin Z, Kömürcü N. Comparison of the effects and side effects of
profiles, effects on the uterus and side effects. Int J Gynecol Obstet
misoprostol and oxytocin in the postpartum period: a systematic review. 2007:S160e7.
Taiwan J Obstet Gynecol 2019;58:748e56.
53. Chaudhuri P, Majumdar A. Sublingual misoprostol as an adjunct to
34. Sunil Kumar KS, Shyam S, Batakurki P. Carboprost versus oxytocin for oxytocin during cesarean delivery in women at risk of postpartum
active management of third stage of labor: a prospective randomized hemorrhage. Int J Gynaecol Obstet 2015;128:48e52.
control study. J Obstet Gynaecol India 2016;66(Suppl 1):229e34.
54. Ugwu IA, Oluwasola TA, Enabor OO, et al. Randomized controlled
35. McDonald S, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin trial comparing 200mg and 400mg sublingual misoprostol for prevention
versus oxytocin for the third stage of labour. Cochrane Database Syst Rev of primary postpartum hemorrhage. Int J Gynaecol Obstet
2004;1:CD000201.
2016;133:173e7.
36. DrugBank Online. Oxytocin pharmacokinetics. Available at: https://go.
55. Barbieri R. Stop using rectal misoprostol for the treatment of
drugbank.com/drugs/DB00107. Accessed on June 1, 2021. postpartum hemorrhage caused by uterine atony. OBG Manag 2016;28.
37. Mangla D, Goel JK, Goel R. Prophylactic intramyometrial oxytocin before 8-10,12.
placenta delivery during cesarean section prevents postpartum hemorrhage: 56. Pharmacokinetics of tranexamic acid. Available at: https://go.drugbank.
a prospective randomized study of 150 women. J South Asian Feder Obst com/drugs/DB00302. Accessed on June 1, 2021.
Gynae 2012;4:93e6.
57. Chauncey J, Wieters J. Tranexamic acid - Stat Pearls. Available at: https://
38. Fernando D, Siederer S, Singh S, et al. Safety, tolerability and www.ncbi.nlm.nih.gov/books/NBK532909/. Accessed on June 1, 2021.
pharmacokinetics of single doses of oxytocin administered via an inhaled
route in healthy females: randomized, single blind, phase 1 study. Lancet 58. Della Corte L, Saccone G, Locci M, et al. Tranexamic acid for treatment of
2017;22:249e55. primary postpartum hemorrhage after vaginal delivery: a systematic review
and meta-analysis of randomized controlled trials. J Matern Fetal Neonatal
39. Oladapo OT, Okusanya BO, Abalos E, et al. Intravenous versus Med 2020;33:869e74.
intramuscular prophylactic oxytocin for the third stage of labour. Cochrane
Database Syst Rev 2020;(11):CD009332. 59. Ray I, Bhattacharya R, Chakraborty S, et al. Role of intravenous tranexamic
acid on cesarean section blood loss: a prospective randomized study.
40. Heesen M, Carvalho B, Carvalho JCA, et al. International consensus J Obstet Gynaecol India 2016;66(Suppl 1):347e52.
statement on the use of uterotonic agents during caesarean section.
Anaesthesia 2019;74:1305e19. 60. Xia Y, Griffiths BB, Xue Q. Tranexamic acid for postpartum hemorrhage
prevention in vaginal delivery: a meta-analysis. Medicine (Baltimore)
41. George RB, McKeen D, Chaplin AC, et al. Up-down determination of the 2020;99:e18792.
ED(90) of oxytocin infusions for the prevention of postpartum uterine
atony in parturients undergoing Cesarean delivery. Can J Anesth 61. Sentilhes L, Senat MV, Le Lous M, et al. Tranexamic acid for the
2010;57:578e82. prevention of blood loss after cesarean delivery. N Engl J Med
2021;384:1623e34.
42. Lavoie A, McCarthy RJ, Wong CA. The ED90 of prophylactic oxytocin
infusion after delivery of the placenta during Cesarean delivery in laboring 62. Brenner A, Shakur-Still H, Chaudhri R, et al. The impact of early outcome
compared with nonlaboring women: an up-down sequential allocation events on the effect of tranexamic acid in post-partum haemorrhage: an
dose-response study. Anesth Analg 2015;121:159e64. exploratory subgroup analysis of the WOMAN trial. BMC Pregnancy
Childbirth 2018;18:215.
43. Lewis G, ed. Why mothers die 1997e99. The confidential enquiry into
maternal deaths in the United Kingdom. London (UK): RCOG Press; 2001. 63. Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay
on the effectiveness and safety of antifibrinolytics in acute severe
44. Farina Z, Fawcus S. Oxytocineensuring appropriate use and balancing
haemorrhage: a meta-analysis of individual patient-level data from 40 138
efficacy with safety. S Afr Med J 2015;105:271e4.
bleeding patients. Lancet 2018;391:125e32.
45. Svanström MC, Biber B, Hanes M, et al. Signs of myocardial ischaemia
64. Pharmacokinetics of ergotamine. Available at: https://go.drugbank.com/
after injection of oxytocin: a randomized double-blind comparison of drugs/DB01253. Accessed on June 1, 2021.
oxytocin and methylergometrine during Caesarean section. Br J Anaesth
2008;100:683e9. 65. Spencer SPE, Lowe SA. Ergometrine for postpartum hemorrhage and
associated myocardial ischemia: two case reports and a review of the
46. Mörtl MG, Friedrich S, Kraschl J, et al. Haemodynamic effects of literature. Clin Case Rep 2019;7:2433e42.
carbetocin and oxytocin given as intravenous bolus on women undergoing
caesarean delivery: a randomised trial. Int J Obstet Gynaecol 66. Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al. Prophylactic use of
2011;118:1349e56. ergot alkaloids in the third stage of labour. Cochrane Database Syst Rev
2018;6:CD005456.
47. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing
postpartum haemorrhage: a network meta-analysis. Cochrane Database 67. Recommendations for the use of antiretroviral drugs during pregnancy and
Syst Rev 2018;12:CD011689. interventions to reduce perinatal HIV transmission in the United States.
Available at: https://clinicalinfo.hiv.gov/en/guidelines/perinatal/
48. Khan M, Balki M, Ahmed I, et al. Carbetocin at elective Cesarean delivery: intrapartum-antiretroviral-therapyprophylaxis. Accessed on June 1, 2021.
a sequential allocation trial to determine the minimum effective dose. Can J
Anaesth 2014;61:242e8. 68. Chelmow D. Postpartum haemorrhage: prevention. BMJ Clin Evid
2008;2008:1410.
49. Nucci B, Aya A, Aubry E, et al. Carbetocin for prevention of postcesarean
hemorrhage in women with severe preeclampsia: a before-after cohort 69. Bygdeman M. Pharmacokinetics of prostaglandins. Best Pract Res Clin
comparison with oxytocin. J Clin Anesth 2016;35:321e5. Obstet Gynaecol 2003;17:707e16.

70. Bai J, Sun Q, Zhai H. A comparison of oxytocin and carboprost 90. Ballas J, Roberts S. Hypovolemic shock. In: Phelan JP, editor. Critical care
tromethamine in the prevention of postpartum hemorrhage in high-risk obstetrics. 6th ed. Oxford (UK): John Wiley & Sons Ltd; 2019. p. 535e45.
patients undergoing cesarean delivery. Exp Ther Med 2014;7:46e50.
91. Gross J. Estimating allowable blood loss: corrected for dilution.
71. Minigh J. Carboprost - an overview. The Comprehensive Pharmacology Anesthesiology 1983;58:277e80.
Reference; Science Direct Topics. Available at: https://www.sciencedirect.com/
topics/nursing-and-health-professions/carboprost. Accessed on June 1, 2022. 92. Blood, still saving lives but.there are risks (video). Available at: https://
www.blood.gov.au/health-professionals. Accessed on June 1, 2021.
72. Likis FE, Sathe NA, Morgans AK, et al. Management of postpartum
hemorrhage. Comparative effectiveness review no. 151. AHRQ 93. Cohen WR. Obstetric hemorrhage and hypothermia: chilling facts. Open J
publication no. 15-EHC013-EF. Rockville (MD): Agency for Healthcare Obstet Gynecol 2018;8:2160e270.
Research and Quality; 2015. 94. Henriquez DDCA, Bloemenkamp KWM, Loeff RM, et al. Fluid
resuscitation during persistent postpartum haemorrhage and maternal
73. Brown H, Okeyo S, Mabeya H, et al. The Bakri tamponade balloon as an
outcome: a nationwide cohort study. Eur J Obstetr Gynecol Reprod Biol
adjunct treatment for refractory postpartum hemorrhage. Int J Gynaecol
Obstet 2016;135:276e80. 2019;235:49e56.
74. Perlman NC, Carusi DA. Retained placenta after vaginal delivery: 95. Lotterman S, Sharma S. Blood transfusion. Treasure Island (FL): StatPearls
risk factors and management. Int J Womens Health 2019;11:527e34. Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK4
99824/. Accessed on June 1, 2021.
75. Magann EF, Niederhauser A, Doherty DA, et al. Reducing hemodynamic
compromise with placental removal at 10 versus 15 mins: a randomized 96. Prick BW, Jansen AJ, Steegers EA, et al. Transfusion policy after
clinical trial. Am J Perinatol 2012;29:609e14. severe postpartum haemorrhage: a randomised non-inferiority trial. BJOG
2014;121:1005e14.
76. Shinar S, Schwartz A, Maslovitz S, et al. How long is safe? Setting the cutoff
97. Collis R, Guasch E. Managing major obstetric haemorrhage:
for uncomplicated third stage length: a retrospective case-control study.
pharmacotherapy and transfusion. Best Pract Res Clin Anaesthesiol
Birth 2016;43:36e41.
2017;31:107e24.
77. Maher MA, Sayyed TM, Elkhouly NI. Different routes and forms of
uterotonics for treatment of retained placenta: a randomized clinical trial. 98. Chua S, Gupta S, Curnow J, et al. Intravenous iron vs blood for acute post-
J Matern Fetal Neonatal Med 2017;30:2179e84. partum anaemia (IIBAPPA): a prospective randomised trial. BMC
Pregnancy Childbirth 2017;17:424.
78. Harara R, Hanafy S, Zidan MS, et al. Intraumbilical injection of three
different uterotonics in the management of retained placenta. J Obstet 99. Holm C, Thomsen LL, Norgaard A, et al. Single-dose intravenous iron
Gynaecol Res 2011;37:1203e7. infusion versus red blood cell transfusion for the treatment of severe
postpartum anaemia: a randomized controlled pilot study. Vox Sang
79. Thakur M, Thakur A. Uterine inversion. Treasure Island (FL): StatPearls 2017;112:122e31.
Publishing. Available at: https://www.ncbi.nlm.nih.gov/books/NBK525
100. Jones RM, de Lloyd L, Kealaher EJ, et al. Platelet count and transfusion
971/. Accessed on June 1, 2022.
requirements during moderate or severe postpartum haemorrhage.
80. Kaya B, Tuten A, Daglar K, et al. B-Lynch uterine compression sutures in Anaesthesia 2016;71:648e56.
the conservative surgical management of uterine atony. Arch Gynecol
Obstet 2015;291:1005e14. 101. Ontario Regional Blood Coordinating Network (ORBCoN). Bloody easy 4:
blood transfusions, alternatives and transfusion reactions. A guide to
81. Şahin H, Soylu Karapınar O, Şahin EA, et al. The effectiveness of transfusion medicine. 4th ed. ORBCON. Available at: file:///C:/Users/
the double B-lynch suture as a modification in the treatment cgreen/Downloads/EN_BE4-JULY11_FINAL.pdf. Accessed on June 1,
of intractable postpartum haemorrhage. J Obstet Gynaecol 2021.
2018;38:796e9.
102. Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, et al. Coagulation
82. Kwong LT, So PL, Wong SF. Uterine compression sutures with additional management in obstetric anesthesia. Curr Anesthesiol Rep
hemostatic procedures for the management of postpartum hemorrhage. 2022;12:266e76.
J Obstet Gynaecol Res 2020;46:2332e9.
103. Ducloy-Bouthors AS, Mercier FJ, Grouin JM, et al. Early and systematic
83. Joshi VM, Otiv SR, Majumder R, et al. Internal iliac artery ligation for administration of fibrinogen concentrate in postpartum haemorrhage
arresting postpartum haemorrhage. BJOG 2007;114:356e61. following vaginal delivery: the FIDEL randomised controlled trial. BJOG
2021;128:1814e23.
84. Wang CY, Pan HH, Chang CC, et al. Outcomes of hypogastric
artery ligation and transcatheter uterine artery embolization in 104. Sahin AS, Ozkan S. Treatment of obstetric hemorrhage with fibrinogen
women with postpartum hemorrhage. Taiwan J Obstet Gynecol concentrate. Med Sci Monit 2019;25:1814e21.
2019;58:72e6.
105. O’Brien KL, Shainker SA, Lockhart EL. Transfusion management of
85. Camuzcuoglu H, Toy H, Vural M, et al. Internal iliac artery ligation for obstetric hemorrhage. Transfus Med Rev 2018;32:249e55.
severe postpartum hemorrhage and severe hemorrhage after postpartum
hysterectomy. J Obstet Gynaecol Res 2010;36:538e43. 106. Bell SF, Collis RE, Bailey C, et al. The incidence, aetiology, and coagulation
management of massive postpartum haemorrhage: a two-year national
86. Singh A, Kishore R, Saxena SS. Ligating internal iliac artery: prospective cohort study. Int J Obstet Anesth 2021;47:102983.
success beyond hesitation. J Obstet Gynaecol India
2016;66(Suppl 1):235e41. 107. Ramler PI, Gillissen A, Henriquez D, et al. Clinical value of early
viscoelastometric point-of-care testing during postpartum hemorrhage
87. Liu Z, Wang Y, Yan J, et al. Uterine artery embolization versus for the prediction of severity of bleeding: a multicenter prospective
hysterectomy in the treatment of refractory postpartum hemorrhage: a cohort study in the Netherlands. Acta Obstet Gynecol Scand
systematic review and meta-analysis. J Matern Fetal Neonatal Med 2021;100:1656e64.
2020;33:693e705.
108. McNamara H, Kenyon C, Smith R, et al. Four years’ experience of a
88. Kim TH, Lee HH, Kim JM, et al. Uterine artery embolization for primary ROTEM -guided algorithm for treatment of coagulopathy in obstetric
postpartum hemorrhage. Iran J Reprod Med 2013;11:511e8. haemorrhage. Anaesthesia 2019;74:984e91.
89. Zhang Y, Yan J, Han Q, et al. Emergency obstetric hysterectomy for life- 109. Callum J, Yeh CH, Petrosoniak A, et al. A regional MHP
threatening postpartum hemorrhage: a 12-year review. Medicine developed through a modified Delphi technique. CMAJ Open
(Baltimore) 2017;96:e8443. 2019;7:E546e61.

110. Epstein D, Solomon N, Korytny A, et al. Association between ionized 112. Cheng A, Eppich W, Kolbe M, et al. A conceptual framework for the
calcium and severity of postpartum hemorrhage: a retrospective cohort development of debriefing skills: a journey of discovery, growth and
study. Brit J Anaesth 2021;126:1022e8. maturity. Simul Healthc 2020;15:55e60.
111. Leonard MW, Frankel AS. Role of effective teamwork and 113. Sawyer T, Eppich W, Brett-Fleegler M, et al. More than one way to debrief:
communication in delivering safe, high-quality care. Mt Sinai J Med a critical review of healthcare simulation debriefing methods. Simul Healthc
2011;78:820e6. 2016;11:209e17.

APPENDIX A
Table 1. Key to Grading of Recommendations, Assessment, Development and Evaluation Quality of Evidence
Grade Definition
Strength of recommendation
Strong High level of confidence that the desirable effects outweigh the undesirable effects (strong recommendation
for) or the undesirable effects outweigh the desirable effects (strong recommendation against)
a
Conditional Desirable effects probably outweigh the undesirable effects (weak recommendation for) or the undesirable
effects probably outweigh the desirable effects (weak recommendation against)
Quality of evidence
High High level of confidence that the true effect lies close to that of the estimate of the effect
Moderate Moderate confidence in the effect estimate:
The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially
different
Low Limited confidence in the effect estimate:
The true effect may be substantially different from the estimate of the effect
Very low Very little confidence in the effect estimate:
The true effect is likely to be substantially different from the estimate of effect
a
Do not interpret conditional recommendations to mean weak evidence or uncertainty of the recommendation.
Adapted from GRADE Handbook (2013), Table 5.1.
Table 2. Implications of Strong and Conditional recommendations, by guideline user

Perspective Strong Recommendation Conditional (Weak) Recommendation
“We recommend that.” “We suggest.”
“We recommend to not.” “We suggest to not.”
Authors The net desirable effects of a course of action outweigh the It is less clear whether the net desirable consequences of
effects of the alternative course of action. a strategy outweigh the alternative strategy.
Patients Most individuals in the situation would want the The majority of individuals in the situation would want the
recommended course of action, while only a small suggested course of action, but many would not.
proportion would not.
Clinicians Most individuals should receive the course of action. Recognize that patient choices will vary by individual and
Adherence to this recommendation according to the that clinicians must help patients arrive at a care
guideline could be used as a quality criterion or decision consistent with the patient’s values and
performance indicator. preferences.
Policymakers The recommendation can be adapted as policy in most The recommendation can serve as a starting point for
settings. debate with the involvement of many stakeholders.
Adapted from GRADE Handbook (2013), Table 6.1.
DECEMBER JOGC DÉCEMBRE 2022 l 1310.e1


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SOGC CLINICAL PRACTICE GUIDELINE

Guideline No. 431: Postpartum

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assessment should include a calculation of the maximum allow-

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Table 1. Postpartum hemorrhage risk factors

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Table 2. Classiﬁcation and management of PPH by stage

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Table 3. Prophylactic and ﬁrst-line therapeutic uterotonics

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Table 4. Pharmacokinetics of misoprostol

and similar side effects as a 5 IU IV bolus of oxytocin Special Agents

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Table 5. Special agents

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Table 6. Second-line uterotonics for treatment of postpartum hemorrhage

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(including viscoelastography, where available [rotational Prothrombin Complex Concentrate

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Table 2. Implications of Strong and Conditional recommendations, by guideline user

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