section name header

Evidence summaries

Prophylactic Oxytocin to Prevent Postpartum Haemorrhage

Prophylactic oxytocin at any dose or carbetocin is effective for decreasing both postpartum haemorrhage greater than 500 mL and the need for therapeutic uterotonics compared to placebo alone. Intravenous oxytocin is more effective than intramuscular oxytocin. Level of evidence: "A"

Oxytocin IV or IM as part of the active management of the third stage of labour is recommended for preventing postpartum haemorrhage.

Summary

A Cochrane review [Abstract] 1 included 24 studies with a total of 10 018 subjects. Prophylactic oxytocin compared with placebo reduced the risk of postpartum haemorrhage (PPH) greater than 500 mL or 1000mL, and the need for therapeutic uterotonics (table T1). The benefit of prophylactic oxytocin to prevent PPH greater than 500 mL was seen in all subgroups. There was no difference in preventing PPH greater than 500 mL with prophylactic oxytocin compared to ergot alkaloids (RR 0.84, 95% CI 0.56 to 1.25; 10 trials, n=3082). Use of prophylactic oxytocin was associated with fewer side effects compared with use of ergot alkaloids.

Oxytocin compared to no uterotonics or placebo for the third stage of labour to prevent postpartum haemorrhage

OutcomeRelative effect (95% CI)Risk with no uterotonicsRisk with oxytocin (95% CI)№of participants (studies)
Blood loss 500 mL or more after deliveryRR 0.51 (0.37 to 0.72)239 per 1000122 per 1000 (89 to 172)4162 (6)
Need for additional uterotonicsRR 0.54 (0.36 to 0.80)114 per 100062 per 1000 (41 to 91)3135 (4)
Blood loss 1000 mL or more after deliveryRR 0.59 (0.42 to 0.83)48 per 100029 per 1000 (20 to 41)4123 (5)
Third stage greater than 30 minutesRR 2.55 (0.88 to 7.44)6 per 100016 per 1000 (5 to 45)1947 (1)

Another Cochrane review and meta-analysis [Abstract]2 included 196 studies with a total of 135 559 subjects. All agents were effective for preventing PPH 500 mL or greater when compared with placebo or no treatment. The three highest ranked uterotonic agents were ergometrine plus oxytocin combination, misoprostol plus oxytocin combination and carbetocin. There is evidence that ergometrine plus oxytocin (RR 0.70, 95% CI 0.59 to 0.84, moderate certainty), carbetocin (RR 0.72, 95% CI 0.56 to 0.93, moderate certainty) and misoprostol plus oxytocin (RR 0.70, 95% CI 0.58 to 0.86, low certainty) may reduce PPH ≥ 500 mL compared with oxytocin. All agents except ergometrine and injectable prostaglandins were effective for preventing PPH 1000 mL or greater when compared with placebo or no treatment. Ergometrine plus oxytocin and misoprostol plus oxytocin make little or no difference compared with oxytocin.

A third Cochrane review [Abstract] 3 included 7 studies with a total of 7 817 subjects. Compared to intramuscular administration, intravenous administration of oxytocin in the third stage of labour carried a lower risk for postpartum haemorrhage (PPH) ≥ 500 mL (average risk ratio (RR) 0.78, 95% CI 0.66 to 0.92; 6 trials; n=7731), blood transfusion (aRR 0.44, 95% CI 0.26 to 0.77; 4 trials; n=6684), and PPH ≥ 1000 mL (aRR 0.64, 95% CI 0.43 to 0.94; 2 trials; n=1512).

Clinical comments

Note

Date of latest search: 2019-05-24

    References

    • Salati JA, Leathersich SJ, Williams MJ et al. Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev 2019;(4):CD001808. [PubMed]
    • Gallos ID, Williams HM, Price MJ et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev 2018;(4):CD011689. [PubMed]
    • Oladapo OT, Okusanya BO, Abalos E et al. Intravenous versus intramuscular prophylactic oxytocin for the third stage of labour. Cochrane Database Syst Rev 2020;(11):CD009332. [PubMed]

Primary/Secondary Keywords