Saving womens lives: evidence-based recommendations for the prevention of postpartum haemorrhage.

Failure of the uterus to contract adequately after childbirth (atonicity) is the most common cause of postpartum haemorrhage (PPH), the leading cause of maternal death in Africa and Asia.1 Attempts to identify women at risk of atonic PPH have been unsuccessful. Numerically, more women without risk factors have atonic PPH compared to those with risk factors. To prevent atonic PPH, interventions should therefore be targeted at all women during childbirth. Active management of the third stage of labour has been described as a package comprising the following interlocking interventions: administration of a prophylactic uterotonic after birth of the baby, and usually also early cord clamping and cutting, and controlled cord traction.2 Other definitions in this package include uterine massage, but without reference to the timing of cord clamping.3 In contrast, expectant (also called physiological or conservative) management involves waiting for signs of separation and allowing the placenta to deliver spontaneously, or aided by gravity or nipple stimulation.2 While there is agreement on the beneficial effects of active management of the third stage of labour for prevention of PPH, there is less consensus on issues such as importance of the intervention’s individual components, the best methods and the requirements for safe administration of this intervention under conditions of limited resources. In particular, the choice of uterotonics has been the subject of discussion and debate. Injectable oxytocin has been recommended for routine use in the active management of the third stage of labour;3 however, a safe injection requires skills and sterile equipment. Oxytocin may be inactivated if exposed to high ambient temperatures.4 In contrast, misoprostol,