Rethinking our approach to postpartum haemorrhage and uterotonics

BMJ 2015; 351 doi: (Published 08 July 2015) Cite this as: BMJ 2015;351:h3251
  1. Andrew D Weeks, professor of international maternal health1,
  2. James P Neilson, professor of obstetrics and gynaecology1
  1. 1Department of Women’s and Children’s Health, University of Liverpool, Crown Street, Liverpool L8 7SS, UK
  1. Correspondence to: AD Weeks aweeks{at}
  • Accepted 30 March 2015

Andrew Weeks and James Neilson suggest that we have inappropriately generalised evidence on the use of uterotonics from uncomplicated births to all births. They call for stronger focus on women with complex births to reduce deaths from postpartum haemorrhage

Postpartum haemorrhage (defined as a bleed >500 mL) is estimated to affect 1-15% of vaginal births, depending on the definition used, the method of assessing blood loss, the setting, and the population studied. Risk factors include Asian ethnicity, obesity, previous postpartum haemorrhage, multiple pregnancy, anaemia, large baby, age over 40, induction of labour, prolonged labour, placental abruption, and caesarean delivery.1

Although global mortality from postpartum haemorrhage is falling, its incidence is increasing in high resource settings, the reasons for which are unclear.2 3 4 Many of those who survive have severe anaemia, renal failure, or psychological trauma, and the offspring may have difficulties in breast feeding and bonding.

Current best practice globally is for all pregnant women to receive a uterotonic drug at the time of childbirth to prevent postpartum haemorrhage. This recommendation has been in place since the 1980s when randomised trials showed that routine prophylaxis with oxytocin based uterotonic drugs reduced the rate of postpartum haemorrhage.5 The assumption that this would translate into fewer maternal deaths—based on the understanding that atony was the most common cause of haemorrhage related deaths—led to the promotion of active management of the third stage of labour, which comprises a prophylactic uterotonic drug, early cord clamping, and controlled cord traction.

Here we discuss the problems with generalising data from spontaneous vaginal (“normal”) births to complex births, and call for a change in global strategy on postpartum haemorrhage.

Rationale for universal prophylaxis

Atonic uterus is the failure of the uterine muscle to contract adequately to stop blood flow to the placental bed after detachment of the …

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