Tranfusion risk: is "two-step'' vaginal delivery a risk for postpartum hemorrhage?

Objective: In the active management strategy of third stage of labor, the optimal timing for clamping the umbilical cord after birth has been a subject of controversy. We want to evaluate if "two-step'' delivery is a risk factor for postpartum hemorrhage (PPH), defined as need of transfusion, comparing to operative delivery, elective caesarean delivery and emergency caesarean delivery. Methods: This is a retrospective cohort study conducted in division of Perinatal Medicine, Policlinico Abano Terme. We evaluated the need of transfusion in all cases of PPH verified in all single deliveries between January 2011 and December 2012. The main outcome measure was blood loss and red blood cell transfusion. Results: We found 17 cases of PPH (0.88%). The distribution of PPH in relation to mode of delivery was 0.71%, 2.46% and 1.98% respectively for two-step vaginal delivery (RR = 0.81 (0.56-1.22)), emergency cesarean section (RR = 2.88 (1.27-7.77)) and operative vaginal delivery (RR = 2.88 (0.59-5.66)). In labor induction there is a stronger relative risk association between PPH and as emergency cesarean delivery (p<0.05) as operative vaginal delivery (p50.05). Conclusion: "Two-step'' delivery approach did not increase the risk of PPH with respect to operative delivery, elective caesarean section and emergency caesarean section.