The rating schemes for the quality of the evidence (very low, low, moderate, high) and the strength of the recommendations (weak, strong) are defined at the end of the "Major Recommendations" field.
- Should active management of the third stage of labour be offered by skilled attendants for all women to prevent postpartum haemorrhage (PPH)? Should active management of the third stage be offered by non-skilled attendants to prevent PPH?
Recommendation
- Active management of the third stage of labour should be offered by skilled attendants to all women. (Strong recommendation, moderate quality evidence)
Recommendations on the individual components of active management are discussed below.
- The panel does not recommend active management by non-skilled attendants.
Remarks
Although no evidence was found for or against the use of active management by non-skilled providers, the group placed high value on the potential risks – such as uterine inversion – that may result from inappropriate cord traction.
Note: Questions 2−6 are related to the selection of the uterotonic and summary tables, including evidence derived from trials comparing different uterotonics within the context of active management of the third stage of labour, assuming there is no interaction between the other components of active management and the uterotonic.
- Should oxytocin (10 IU parenterally) or ergometrine/methylergometrine (0.25 mg parenterally) be offered to all women by skilled attendants to prevent PPH?
Recommendation
In the context of active management of the third stage of labour, if all injectable uterotonic drugs are available:
- Skilled attendants should offer oxytocin to all women for prevention of PPH in preference to ergometrine/methylergometrine. (Strong recommendation, low quality evidence)
If oxytocin is not available:
- Skilled attendants should offer ergometrine/methylergometrine or the fixed drug combination of oxytocin and ergometrine to women without hypertension or heart disease for prevention of PPH. (Strong recommendation, low quality evidence)
Remarks
These recommendations place a high value on avoiding adverse effects of ergometrine and assume similar benefit for oxytocin and ergometrine for preventing PPH.
- Should oral misoprostol (600 mcg) be offered to all women by skilled attendants to prevent PPH instead of oxytocin (10 IU intramuscular [IM])?
Recommendation
In the context of active management of the third stage of labour:
- Skilled attendants should offer oxytocin for prevention of PPH in preference to oral misoprostol (600 mcg). (Strong recommendation, high quality evidence)
Remarks
This recommendation places a high value on the relative benefits of oxytocin in preventing blood loss compared to misoprostol, as well as the increased adverse effects of misoprostol compared to oxytocin.
- Should sublingual misoprostol (600 mcg) be offered to all women by skilled attendants to prevent PPH instead of oxytocin (10 IU IM)?
Recommendation
In the context of active management of the third stage of labour:
- Skilled attendants should not offer sublingual misoprostol for prevention of PPH in preference to oxytocin. (Strong recommendation, very low quality evidence)
- Further research is needed to define the role of sublingual misoprostol administration for prevention of PPH.
- Should rectal misoprostol (600 mcg) be offered to all women by skilled attendants to prevent PPH instead of oxytocin (10 IU IM)?
Recommendation
In the context of active management of the third stage of labour:
- Skilled attendants should not offer rectal misoprostol for prevention of PPH in preference to oxytocin. (Strong recommendation, low quality evidence)
Remarks
This recommendation places a high value on the known benefits of oxytocin and notes the significant uncertainty about whether rectal misoprostol is equivalent. Misoprostol has more adverse effects and a higher purchase cost.
- Should carboprost (0.25 mg)/sulprostone (0.5 mg) be offered to all women by skilled providers to prevent PPH instead of oxytocin (10 IU IM)?
Recommendation
In the context of active management of the third stage of labour:
- Skilled attendants should not offer carboprost/sulprostone for prevention of PPH in preference to oxytocin. (Strong recommendation, very low quality evidence)
Remarks
This recommendation is based on the paucity of the evidence comparing the two treatments and the known effectiveness of oxytocin.
- In the absence of active management, should uterotonics be used alone for prevention of PPH?
Recommendation
- In the absence of active management of the third stage of labour, a uterotonic drug (oxytocin or misoprostol) should be offered by a health worker trained in its use for prevention of PPH. (Strong recommendation, moderate quality evidence)
Remarks
For misoprostol, this recommendation places a high value on the potential benefits of avoiding PPH and ease of administration of an oral drug in settings where other care is not available, but notes there is only one study.
The only trial relevant to this recommendation used 600 mcg of misoprostol. The efficacy of lower doses has not been evaluated. There is still uncertainty about the lowest effective dose and optimal route of administration.
- When should the cord be clamped to maximize benefits for mother and baby?
Recommendation
- Because of the benefits to the baby, the cord should not be clamped earlier than is necessary for applying cord traction in the active management of the third stage of labour. (Weak recommendation, low quality evidence)
- For the sake of clarity, it is estimated that this will normally take around 3 minutes.
- Early clamping may be required if the baby is asphyxiated and requires immediate resuscitation.
- Should the placenta be delivered by controlled traction in all women?
Recommendation
Given the current evidence for active management includes cord traction, the panel does not recommend any change in the current practice. Further research is needed. (Strong recommendation, very low quality evidence)
Definitions:
GRADE Quality Assessment Criteria
| Quality of Evidence |
Study Design |
Lower If* |
Higher If* |
| High |
Randomized trial |
Study Quality:
-1 Serious limitations
-2 Very serious limitations
-1 Important inconsistency
Directness:
-1 Some uncertainty
-2 Major uncertainty
-1 Sparse data
-1 High probability of Reporting Bias
|
Strong Association:
+1 Strong, no plausible confounders, consistent and direct evidence**
+2 Very strong, no major threats to validity and direct evidence***
+1 Evidence of a Dose response gradient
+1 All plausible confounders would have reduced the effect
|
| Moderate |
|
| Low |
Observational study |
| Very Low |
Any other evidence |
*1 = move up or down one grade (for example, from high to intermediate); 2 = move up or down two grades (for example, from high to low)
**A statistically significant relative risk of >2 (<0.5), based on consistent evidence from two or more observational studies, with no plausible confounders.
***A statistically significant relative risk of >5(<0.2) based on direct evidence with no major threats to validity.
Strength of the Recommendations
Strong recommendation: One for which the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects.
Weak recommendation: One for which the panel concludes that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is not confident about these trade-offs.
