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PPH Prevention Protocol

updated 11/15/2018


Active Management of 3rd Stage of labor has been shown to reduce incidence of PPH by 30-40%, reduce number of uterotonics needed, and reduce maternal mortality. (WHO 2012)


1st line Oxytocin: a high alert med with half life of 1-6 minutes


When to Give:  IV piggy back or IM with the delivery of shoulders or baby

Active management should not interfere with delayed cord clamping

DO NOT GIVE IV PUSH.  Rapid IV administration causes hypotension, tachycardia, nausea and vomiting. 

TOXIC doses can cause myocardial ischemia 


Current Recommended administration: 

Use Premixed bag of Oxytocin 30 units in 500 cc of NS ( stocked in each OR anesthesia cart of Omnicell) infuse using a pump.  Initial bolus infusion of 10 units given over 30 minutes;

To be followed by infusion of another 20 unitsover 3.5 hours for a total dose of 30 units over 4 hours.

Continuation beyond 4 hours is recommended. Rate and duration titrated to uterine tone and bleeding.


L&D surgical technicians will now ensure that there is a pump in each OR as part of their set up.

if using a premixed bag of oxytocin  30 units in 500 mL NS


Infusion rates are:

1. Initial rate of  333 mL/hour of 166 mL (approximately 30 minutes ) followed by 

2. 95 mL/hr of 333 mL ( approx for 3.5 hours ) 

3. Infusion continues in Postpartum to prevent PPH


In an emergency when IV access is unavailable, 10 Units IM


2nd line Methergine 

Methergine 0.2 mg IM q2-4 hours; max doses 5

DO NOT GIVE IV and contraindicated in hypertensive patients due to risk of stroke/CVA


3rd line Cytotec (misoprostol) One time dosing

Preferred route is ORAL or Sublingual 600 mcg;

Onset of action 8 minutes ORAL and 11 min. Sublingual

Alternate 800 mcg RECTALLY but onset is 100 minutes

Duration is 2, 3, 4 hours respectively.

Side effects: Shivering, diarrhea, N&V, HA, Fever (6-30%) so use with caution in setting of elevated maternal temperature


4th line Hemabate

250 micrograms IM (deltoid) or Intra-myometrial every 15-90 minutes 

Max of 8 doses

Onset 5 min Peak in 15-30 min


Relative contraindication in Asthma patients


OB Related Communication


1.  The administration of uterotonic medications when treating uterine atony

  • Please use close loop communications whenever possible; 

  • Sometimes it is hard to verify if messages are heard in the OR setting especially when several conversations are occurring simultaneously

    • For example, prior to the administration of methergine, all care team must review & acknowledge the baseline maternal BP because methergine can cause an acute exacerbation of  preexisting hypertension.

    • Baseline core body temp before giving cytotec; cytotec can worsen pre-existing fever (eg chorioamniontis) 

    • Hemabate is contraindicated in patient with asthma.


2.  Pitocin administration after delivery by C/s

  • Pump settings when using premixed bag of 30 units in 500 mL ( supplied in anesthesia cart 2nd drawer)

  • 333 ml/hour (equates to 333 milliunits/min) until 166 mLinfused. This equals 10 unit bolus over 30 minutes

  • Followed by maintenance of 95-100 mL/hour for the remainder of 333 mL (20 units over approximately 3.5 hours)


3.  NICU request

  • Please relay to NICU team any additional medications(benzodiazepines for anxiety, extra narcotics, propofol or ketamine) given to the mother during the perioperative period before delivery so NICU staff are aware of their possible effects on the neonate.


4.  Blood Bank

  • Please help remind everyone on the care team to follow up all orders for blood products with a phone call from care team. This will help blood bank prioritize and process our orders first.

OB Stipends

The current department policy is a 1.0 hour credit applies if:


1. You are called by AIC to cover AND have to drive in from home (must meet both criteria)


The credit does NOT apply if:

1. You are on site or campus already 

2. You are either waiting to start your case OR are in-between cases


The 1 hour credit is intended to compensate an individual for their time to drive in and cover TOLAC while C/S finishes who otherwise may not get any compensation.


Please submit a billing sheet to ABEO with the following info:

1. AIC

2. OB anesthesiologist being covered

3. Name/label of TOLAC patient

4. Leave a copy in my mailbox

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