Postpartum Hemorrhage: A Comprehensive Review of Guidelines

Abstract

Importance: Postpartum hemorrhage (PPH) is a common complication of childbirth and the leading cause of maternal deaths worldwide, also associated with important secondary sequelae.

Objective: The aim of this study was to review and compare the most recently published influential guidelines on evaluation, management, and prevention of this severe, life-threatening obstetric complication.

Evidence acquisition: A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the Network for the Advancement of Patient Blood Management, Hemostasis and Thrombosis in collaboration with the International Federation of Gynecology and Obstetrics, the European Board and College of Obstetrics and Gynecology and the European Society of Anaesthesiology, and the World Health Organization on PPH was carried out.

Results: There is a consensus among the reviewed guidelines that once PPH occurs, it is important to identify the underlying cause (4 T's), estimate the blood loss, and immediately initiate a resuscitation protocol with fluid replacement, blood transfusion, and close monitoring of the woman. In case of uterine atony, all the reviewed medical societies recommend uterine massage, bimanual uterine compression, and administration of uterotonics, although minor discrepancies are observed regarding the optimal regimens. If these measures fail, the use of intrauterine balloon tamponade or other surgical interventions is unanimously recommended. There is also agreement regarding the management of PPH due to retained placenta, placenta accreta, obstetric trauma, uterine rupture or inversion, and acute coagulopathy. Massive transfusion protocols are not consistent in the reviewed guidelines. Finally, all guidelines highlight the importance of the active management of the third stage of labor for the prevention of PPH, suggesting several interventions, with the administration of oxytocin being the criterion standard.

Conclusions: Postpartum hemorrhage is a significant contributor of maternal morbidity and mortality. Thus, the development of consistent international practice protocols for the effective management and prevention of this major complication seems of paramount importance and will hopefully improve obstetric outcomes and especially maternal mortality rate.