Bibliographic information
GuidelineConsolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Administration of a uterotonic agent is recommended for the treatment of retained placenta after vaginal birth only in the presence of postpartum haemorrhage
Context specific recommendation
Only in specific contexts
Notes and Remarks
- The first-response treatment bundle for PPH includes rapid institution of uterine massage, administration of a uterotonic agent and tranexamic acid, intravenous fluids, examination of the genital tract and escalation of care as needed. The bundle should be applied to all women diagnosed with PPH, regardless of cause (including those with a retained placenta) (see Recommendation 29).
- The GDG found very limited evidence to support recommending routine use of uterotonics for the treatment of the retained placenta in the absence of PPH. Recommendation 30 was reached by consensus.
- Ergometrine and prostaglandin E2 alpha (dinoprostone or sulprostone) should be avoided in the presence of the retained placenta. Ergometrine may cause tetanic uterine contractions, which may delay the expulsion of the placenta and may increase a woman’s risk of adverse events, particularly cardiac events.
- If the placenta is not expelled spontaneously within 15 minutes after birth and PPH has not been diagnosed, health care workers should take steps to remove the placenta. These include controlled cord traction (CCT), mobilizing, squatting or emptying the bladder before manual removal of the placenta becomes clinically indicated. While undertaking these steps, health workers should monitor the woman for blood loss or other signs and symptoms consistent with PPH.
- If the placenta remains undelivered after 30 minutes and no PPH has been diagnosed, preparations for manual removal should be initiated. Delaying removal beyond 30 minutes has been associated in some studies with increased blood loss and higher rates of severe PPH; however, a longer wait time may also allow for more cases of spontaneous placental expulsion.
- In clinical practice, uterotonics are usually used immediately after manual removal of the placenta to support contraction of the uterus and reduce bleeding.