WHO guidelines for the management of postpartum haemorrhage and retained placenta
This appraisal relates to WHO guidelines for the management of postpartum haemorrhage and retained placenta, 2009, which has been replaced by new guidelines entitled WHO recommendations for the prevention and treatment of postpartum haemorrhage, 2012
The document below is included in RHL for archival purposes only. It may be cited as: Kumar S, Dadhwal V, Sharma J, Mittal S. WHO guidelines for the management of postpartum haemorrhage and retained placenta: RHL guideline (last revised: 1 February 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL guideline appraisal by Kumar S, Dadhwal V, Sharma J, Mittal S
Postpartum haemorrhage (PPH) continues to be the leading cause of maternal mortality, accounting for at least 30% of all maternal deaths, almost all of which occur in developing countries (1). In a great majority of cases, PPH is caused by atony of uterus, although retained placenta or injury to any part of the birth canal during delivery can also be the cause.
A large proportion of pregnant women in developing countries deliver at home under the care of birth attendants who are not medically trained and who are not well equipped to manage PPH. Once a woman experiences PPH, the way she is managed varies from centre to centre, depending on the training level and skills of the health-care professionals in each centre. A clear and uniform policy of managing PPH can be of immense help in reducing maternal deaths from this condition.
In 2009, WHO published the “WHO Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta” (2). These guidelines include: recommendations on assessment of blood loss after child birth; medical interventions for the management of PPH; and non-medical interventions for management of PPH, including surgical interventions. They also include issues related to the management of retained placenta, such as choice of uterotonics and their route of administration and antibiotic prophylaxis after manual removal of the placenta. There is also a recommendation on the choice of fluids for fluid replacement in women diagnosed with PPH. Finally, the guidelines include health system-related guidance – for example, how to develop protocols for the management and referral of cases of PPH. The objective of this appraisal is to determine the usefulness of the recommendations in the guidelines in terms of improving management of PPH in under-resourced settings.
The authors independently applied the AGREE instrument (Appraisal of Guidelines for Research and Evaluation, 2001) (3) to the guidelines. A standardized score for each domain of the AGREE instrument was obtained by combining the scores awarded by all the authors for each item within the domains as per the methodology described in the AGREE document. The domains included scope and purpose, stakeholders’ involvement, rigour of development, clarity and presentation, applicability and editorial independence.
The standardized domain scores were as follows: scope and purpose – 94; stakeholders’ involvement – 42; rigour of development – 77; clarity and presentation – 81; applicability – 58. All of the four commentators agreed that the scope and purpose of the guidelines was well timed and covered areas for which guidance is highly needed. With regard to stakeholders' involvement, there was variation in the scores allocated by each commentator, especially under the headings patient’s views and preferences and piloting the guidelines among target users. The score for rigour of development varied according to each author's perception about the criteria for selecting evidence and methods used in formulating the recommendations. All four commentary writers gave a high score to the guidelines for clarity and presentation. The authors had some reservations about the claim in the guidelines that the guidance presented "is supported with tools for application". As to applicability, the authors agreed overall that the guidance can be applied by well trained child birth attendants and those working in large secondary and tertiary level health-care facilities. Not all authors were able to evaluate the editorial independence aspect of the guidelines. Hence, no score was attributed to that domain.
Commenting on the overall assessment of the guidelines, the authors noted that there was a need for specific guidance for managing PPH and retained placenta in settings where a large proportion of women deliver at home under the care of semi-skilled and unskilled birth attendants.
Overall, the WHO guidelines for the management of PPH and retained placenta are of high quality and based on the best available evidence in the published literature. All available methods of controlling PPH have been considered in the recommendations. The guidelines include recommendations for each of the critical issue related to management of PPH.
4.1 Scope and coverage of the guidelines
Since a large number of drugs have been used for controlling PPH, a specific recommendation for best agent for managing PPH is not possible. However, recommendations are of high standard based upon best evidence available. The authors were unable to score the editorial independence of the guidelines because of lack of pertinent information in the printed report. Regarding conflict of interest reported by members of the panel that developed the recommendations, the authors noted that a formal process of declaration of conflict of interest had taken place. A total of six out 24 temporary advisers had declared that they had received grants for conducting research on misoprostol and presenting their findings, although none of the grants were from commercial entities. With regard to the influence of external funding sources on guideline development, the authors noted that USAID had provided partial financial support towards the development of the guidelines and had one observer in the consultation meeting. However, this observer did not participated in the voting process and neither approved nor provided documents for the guidelines. In view of these factors it can assumed that the recommendations are independent of external influences and editorial bias.
4.2 Implementation of the recommendations
The guidelines note that there is a need for new primary research projects in different contexts to study the implementation of the recommendations. Birth attendants trained in clinical skills needed to care for women during pregnancy and childbirth (doctors, nurses and midwives) can easily adopt these guidelines in their practice. However, semi-skilled birth attendants or those without clinical skills who often care for woman in labour at small health-care facilities in under-resourced settings may not be able to benefit from these guidelines.
4.3 Recommendations for further updates of the guidelines
WHO collaborated with international agencies such as FIGO in developing these guidelines. The process of dissemination of recommendations has been clearly stated. The effectiveness of the dissemination strategies included in the guidelines should be evaluated. Future updates of the guidelines should include separate guidance for semi-skilled or non-medically trained birth attendants.
- Khan KS, Wojdyla D, Say L, Gulmezogh AM, Van Look PFA. WHO analysis of causes of maternal death: a systematic review. The Lancet 2006;367:1066-1074
- Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Practice & Research: Clinical Obstetrics and Gynaecology 2008; 22:999-1012.
- The AGREE Collaboration. Appraisal of Guidelines for Research and Evaluation. AGREE Instrument. Available at: http://www.agreecollaboration.org/instrument/
This document should be cited as: Kumar S, Dadhwal V, Sharma J, Mittal S. WHO guidelines for the management of postpartum haemorrhage and retained placenta: RHL guideline (last revised: 1 February 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.