Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock. All pregnant patients. Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays. Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists. 1.An individualized risk assessment for postpartum hemorrhage should be documented in a checklist upon arrival to a labour unit and updated throughout labour and delivery (strong, high). The risk assessment should include a calculation of the maximum allowable blood loss (good practice point).2.Both antenatal and postnatal anemia should be identified and treated aggressively (strong, high).3.Quantitative blood loss measurement should replace estimated blood loss in all patients whenever possible (strong, moderate).4.Staging and management of postpartum hemorrhage should be based on quantitative blood loss (strong, high).5.Active management of the third stage of labour should be offered to all women (strong, high).6.Prophylactic intramuscular oxytocin can be used for patients at low risk for postpartum hemorrhage (strong, high).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 7.5–15 IU/h or as a 3 IU intravenous rapid injection (strong, moderate)9.If there is inadequate response to oxytocin within 4 minutes, a second-line uterotonic should be administered (strong, high).10.Carbetocin can be considered as a first-line agent for postpartum hemorrhage