Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: Dr. Grethe Heitmann and Dr. Justus Hofmeyr.
COSTR Citation
Anna Maria Subic, Heba Shahaed, Jestin Carlson, Matthew Douma, Therese Djarv, Amy Kule, G Justus Hofmeyr, Teruko Kishibe, Annette Aronsson, Grethe Heitmann, Trude Thommesen, Aaron Orkin, on behalf of the International Liaison Committee on Resuscitation First Aid Task Force.
Lay provider administration of manual external uterine massage for the prevention or treatment of post-partum hemorrhage Consensus on Science with Treatment Recommendations [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, date. Available from: http://ilcor.org
Methodological Preamble and Link to Published Systematic Review
The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of basic life support (Subic, 2024, CRD42024572048 – PROSPERO citation) conducted at the Dalla Lana School of Public Health at the University of Toronto in Ontario, Canada with involvement of clinical content experts. Evidence for literature was sought and considered by the First Aid Task Force.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: People with a uterus/women experiencing post-partum hemorrhage
Intervention: Manual external uterine massage administered by a lay provider
Comparators: Any other first aid intervention to treat PPH, compared with uterine massage; No intervention done to treat PPH, compared with uterine massage
Outcomes: The following is the TF approved outcomes rated into critical/important:
- Maternal survival (critical)
- Blood loss (critical)
- Future fertility
- Surgical intervention
- Organ dysfunction
- Pain
- Blood transfusion
Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) are excluded. All relevant publications in any language are included as long as an English abstract is available.
Timeframe: All years.
PROSPERO Registration: CRD42024572048
Consensus on Science
For the critical outcome of maternal survival, and other outcomes including organ failure, neonatal survival, surgical intervention, and quality of life, we identified no eligible studies specifically involving external uterine massage involving lay providers or a prehospital setting. For the outcomes of blood transfusion and blood loss, we identified a single RCT involving self-administered external uterine massage in-hospital, as a preventive measure for postpartum hemorrhage.
Only one study (Ngichabe 2012, 128) was found to for the systematic review, that only reported on two important outcomes: blood loss and blood transfusion, with the quality of evidence being low and very low, respectively. As such, meta-analysis was not possible for this review.
Treatment Recommendations
We suggest external uterine massage, including self-massage, in the immediate postpartum period (I) in comparison with no intervention (c) to prevent postpartum hemorrhage, which can lead to maternal death (weak recommendation, very low certainty of evidence).
Technical remarks: In the sole included study (Ngichabe 2012, 128), people who recently gave birth were advised to perform self-massage queued by an alarm every 15 minutes for the first 120 minutes after birth. The details of how participants were taught to perform the external uterine massage was not reported. This study occurred in an in-hospital setting.
The immediate postpartum period, or fourth stage of labour, refers to the first three hours after birth.
Justification and Evidence to Decision Framework Highlights
This topic was prioritized by the FA Task Force based on the observation that (a) many systematic reviews and international guidelines recommend external uterine massage as a part of active management of the third stage of labour for the prevention and management of PPH (Saccone 2018, 778; Escobar 2022, 3; Giouleka 2022, 665; Hofmeyr 2013, CD006431; Likis 2015, 1; Prata 2013, 737; Tuncalp 2013, 254; Weeks 2015, 202), (b) external uterine massage is a simple and safe physical maneuver equivalent to many manual interventions taught to first aid and lay providers, (c) that PPH is a major cause of global morbidity and mortality and gender-based health inequity, (d) that attendants at most births worldwide have limited professional health education and may be considered lay or first aid providers (Bazirete 2020, 66), (e) that intrapartum and postnatal care has traditionally been omitted from the first aid corpus, and that (f) first aid interventions designed to serve low-resource settings and particularly people giving birth in these settings may therefore do substantial good by reducing morbidity and mortality.
In making this recommendation, the FA Task force considered:
- That external uterine massage is a ubiquitous standard for professional birth attendants and first responders for the prevention and management of PPH.
- That external uterine massage is a simple and safe physical maneuver, equivalent to other physical interventions routinely taught to first aid providers (e.g.: moving a patient, splinting an injured limb, applying direct pressure or a tourniquet to a bleeding wound).
- That PPH is a major source of global morbidity and mortality, especially in settings with limited or no access to professional healthcare providers, professional prehospital care, hospital care, or professional birth attendants. Therefore, recommendations that limit external uterine massage to professionalized contexts would potentially compound health inequities.
- We considered that first aid includes self-management for the prevention and treatment of time-sensitive conditions.
- In making a weak recommendation, we considered the certainty of evidence was interpreted as very low, as only a single lower-quality RCT was identified where postnatal patients were taught to administer self-external uterine massage and that the study did not demonstrate a statistically significant reduction in the volume of postpartum hemorrhage or transfusion. It did however demonstrate that external uterine massage can be taught to lay providers.
- We also considered that the only available study involving lay providers occurred in hospital.
Knowledge Gaps
Current knowledge gaps include the following:
- There were a few excluded studies which reported on manual uterine external massage done by trained health professionals, extrapolating that it could be an effective intervention for lay provider use. As such, more studies with robust methodology examining lay provider use of manual uterine external massage, particularly in out of hospital settings, are needed.
- More studies examining non-self lay providers, such as traditional birth attendants, are needed.
- Pressure/firmness of the uterine massage may affect the effectiveness of the intervention, the included study could not measure or regulate the strength/firmness of the uterine massage by study participants, and did not describe if or how this was controlled or taught.
- As primary PPH can occur up to 24 hours after the birth of a baby, it is possible that symptoms of PPH occurred after the intervention, as patients in the included study were only monitored for 120 minutes, and did not receive follow-up.
- Aspects of equity were not well reported in the included study, and may affect the care received by people experiencing PPH.
EtD: FA 7336 PPH Uterine Massage ETD v3
References
Bazirete O, Nzayirambaho M, Uwimana MC, Umubyeyi A, Marilyn E. Factors affecting the prevention of postpartum hemorrhage in Low-and Middle-Income Countries: A scoping review of the literature. Journal of Nursing Education and Practice. 2020;11(1):66.
Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2022;157 Suppl 1:3-50.
Giouleka S, Tsakiridis I, Kalogiannidis I, Mamopoulos A, Tentas I, Athanasiadis A, et al. Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv. 2022 Nov;77(11):665–82
Hofmeyr, G. J., Abdel‐Aleem, H., & Abdel‐Aleem, M. A. (2013). Uterine massage for preventing postpartum haemorrhage. The Cochrane Database of Systematic Reviews, 2013(7), CD006431. https://doi.org/10.1002/146518...
Likis FE, Sathe NA, Morgans AK, Hartmann KE, Young JL, Carlson-Bremer D, et al. Management of Postpartum Hemorrhage [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 [cited 2023 Aug 13]. (AHRQ Comparative Effectiveness Reviews). Available from: http://www.ncbi.nlm.nih.gov/bo...
Ngichabe, S. K., Gatinu, B. W., Nyangore, M. A., Karuga, R., Wanyonyi, S. Z., & Kiarie, J. N. (2012). REMINDER SYSTEMS FOR SELF UTERINE MASSAGE IN THE PREVENTION OF POSTPARTUM BLOOD LOSS. East African Medical Journal.
Prata N, Bell S, Weidert K. Prevention of postpartum hemorrhage in low-resource settings: current perspectives. International journal of women's health. 2013;5:737-752.
Saccone G, Caissutti C, Ciardulli A, Abdel-Aleem H, Hofmeyr GJ, Berghella V. Uterine massage as part of active management of the third stage of labour for preventing postpartum haemorrhage during vaginal delivery: a systematic review and meta-analysis of randomised trials. BJOG Int J Obstet Gynaecol. 2018 Jun;125(7):778–81.
Tuncalp O, Souza JP, Gulmezoglu M. New WHO recommendations on prevention and treatment of postpartum hemorrhage. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2013;123(3):254-256.
Weeks A. The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next? BJOG Int J Obstet Gynaecol. 2015;122(2):202–10.