From the Research
Postpartum hemorrhage (PPH) after a cesarean section (C-section) is typically defined as a blood loss of more than 1000mL within the first 24 hours post-delivery. The expected duration of PPH can vary, but according to the World Health Organization, it is generally considered to occur within the first 24 hours after delivery 1.
Key Points to Consider
- PPH is a major cause of maternal mortality due to obstetric hemorrhage, and its incidence is still increasing in both vaginal delivery and C-section 1.
- The most recent and highest quality study on this topic, a network meta-analysis published in 2022, found that carbetocin is probably the most effective agent in reducing blood loss and the need for additional uterotonics after C-section 2.
- The study also found that oxytocin appears to be more effective when initiated as a bolus, and that the combination of oxytocin and misoprostol may be inferior to oxytocin alone in reducing blood loss and the need for additional uterotonics 2.
- Another study published in 2020 found that oxytocin used as first-line treatment of PPH probably is more effective than misoprostol with less side-effects, and that adding misoprostol to oxytocin probably makes little or no difference to effectiveness outcomes, but is associated with more side-effects 3.
Recommendations
- Carbetocin should be considered as the first-line uterotonic agent for preventing PPH after C-section, due to its effectiveness in reducing blood loss and the need for additional uterotonics, as well as its favorable side-effect profile 2.
- Oxytocin should be initiated as a bolus, and the combination of oxytocin and misoprostol should be used with caution due to its potential inferiority to oxytocin alone 2.
- It is essential to monitor patients closely for signs of PPH, such as excessive bleeding, and to be prepared to administer additional uterotonics or other interventions as needed to prevent morbidity and mortality.