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fewer at day 14 than at day 7. This ob-servation suggests that in some partic-ipants, pain returned after the pressneedles had been removed. Thus, it isimportant for future investigators toexplore whether extended continuous

auricular acupuncture is needed to havea sustained effect, as well as the charac-teristics of acupuncture responders vsnonresponders.

Because we did not observe any majorlocal irritation, infection, or adverse out-come, we are confident that 1 week ofauricular acupuncture can be safely ad-ministered to women with low back andposterior pelvic pain in the last trimesterof pregnancy. For a majority of partici-pants receiving therapeutic acupunc-

ture, pain relief was substantial and ledto improvement of functional status.Thus, this study supports that use of acu-puncture at specific auricular points is asafe and effective nonpharmacologictreatment of an important clinical entity

for which few, if any, effective treatmentsare currently available.In summary, women who received 1

week of continuous acupuncture treat-ment at 3 specific auricular points expe-rienced significantly greater reduction inpain than those receiving sham acu-puncture or no treatment, although thetreatment effect was not sustained in all.Although the long-term efficacy of au-ricular acupuncture as a treatment forPRLP remains inconclusive, it clearly

shows promise. A future, large-scale ran-domized control study is indicated.

CLINICAL IMPLICATIONS

Auricular acupuncture using retained

press needles for 1 week can reducethe pain and disability caused bylower back and posterior pelvic painduring pregnancy.

Once the intervention was removed,pain returned in some study partici-pants.

Future studies shouldbe conducted todetermine whether extensive auricu-lar acupuncture treatment can de-crease the development of chroniclow back pain after delivery. f

Effects of onset of labor and mode of delivery

on severe postpartum hemorrhageIqbal Al-Zirqi, MD, MRCOG; Siri Vangen, MD, PhD; Lisa Forsn, PhD, MSc; Babill Stray-Pedersen, MD, PhD

OBJECTIVE:Our purpose was to study the impact of labor onset anddelivery mode on the risk of severe postpartum hemorrhage.STUDY DESIGN: This was a population-based study of 307,415 mothers who

were registered in the Medical Birth Registry of Norway from 1999-2004.RESULTS: Severe postpartum hemorrhage occurred in 1.1% of allmothers and in 2.1% of those mothers with previous cesarean sectiondelivery (CS). Compared with spontaneous labor, hemorrhage risk washigher for induction (odds ratio [OR], 1.71; 95% confidence interval

[CI], 1.561.88) and prelabor CS (OR, 2.05; 95% CI, 1.842.29). Therisk was 55% higher for emergency CS and half that for vaginal deliv-eries (OR, 0.48; 95% CI, 0.430.53), compared with prelabor CS. The

highest risk was for emergency CS after induction in mothers withprevious CS (OR, 6.57; 95% CI, 4.2510.13), compared with sponta-neous vaginal delivery in mothers with no previous CS.CONCLUSION:Induction and prelabor CS should be practiced with cau-tion because of the increased risk of severe postpartum hemorrhage.

Cite this article as: Al-Zirqi I, Vangen S, Forsn L, et al. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol

2009;201:273.e1-9.

BACKGROUND AND OBJECTIVESevere postpartum hemorrhage is a ma-

jor cause of maternal death worldwide.The morbidity that is associated with se-vere hemorrhage remains a major prob-lem. The onset of labor and mode of de-

livery, especially delivery by cesarean

section (CS), is a prominent risk factor

that is associated with severe postpartumhemorrhage. However, it has been pro-

posed that the induction of labor and the

underlying indications of CS delivery

might be the real causes of hemorrhagerather than the procedure itself. The es-

timation of hemorrhage risk for CS de-liverythat is performedbefore labor afteradjustment for other risk factors may re-veal the risk of severe hemorrhage that isrelated to the procedure itself.

Our aim was to study the impact oflabor onset anddeliverymode on the riskof severe postpartum hemorrhage.

MATERIALS AND METHODSWe used data from the Medical Birth

Registry of Norway on 307,415 womenwith pregnancies from 16 weeks of ges-

From the Division of Obstetrics and Gynecology, Faculty of Medicine (Dr Al-Zirqi), the

Division of Obstetrics & Gynecology, National Resource Center for Womens Health (Dr

Vangen), Rikshospitalet, theNorwegian Institute of Public Health (Dr Forsn), and the

Division of Obstetrics & Gynecology, Faculty of Medicine, University of Oslo (Dr Stray-

Pedersen), Rikshospitalet, Oslo, Norway.

This study was supported by the Norwegian Foundation for Health and Rehabilitation and the

Norwegian Womens Public Health Association.

0002-9378/free 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.06.007

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tation who gave birth between Jan 1,1999-April 30, 2004.

Severe postpartum hemorrhage, which

is defined as a visually estimated bloodloss of1500 mL within 24 hours afterdelivery or the need for blood transfu-sion after delivery, regardless of the

amount of blood loss, coded as yes orno. Severe postpartum hemorrhagewas identified ina ticked box onthe birthregistration form.

The explanatory variables includedonset of labor, which was defined as spon-taneous labor onset, induced labor on-

set, and prelabor CS delivery (CS per-formed before labor onset) andmode of

delivery, which was defined as spontane-ous vaginal delivery, operative vaginal

delivery, emergency CS delivery (CSper-formed after labor onset), and prelaborCS delivery. Complete information on

the onset of labor and mode of deliverywas available.The confounding variables included

demographic,medical, and obstetricfac-

tors. The demographic variables wereage in years at thetime of delivery,parity,and ethnicity. The medical variables in-cluded medical diseases before preg-

nancy. The pregnancy-related variablesincluded multiple pregnancies, HELLP(hemolysis, elevated liver enzymes, andlow platelet count) syndrome, pre-

eclampsia, gestational diabetes mellitus,polyhydramnios, and gestational age

that was calculated by ultrasound mea-surements at 18 weeks of gestation. Thelabor-related variables included pro-longed labor, augmentation by oxytocin,macrosomia, intrapartum pyrexia, anduterine rupture.

Frequency analysis and cross tabula-tions were used to measure the preva-lence and causes of severe postpartumhemorrhage. The association betweensevere postpartum hemorrhage and la-bor onset was analyzed with the use of 3logistic regression models. The associa-tion between severe postpartum hemor-rhage and mode of delivery was analyzedwith the use of 4 logistic regression mod-els, with prelabor CS delivery asreference.

Finally, the association between severepostpartum hemorrhage and deliverymode after both spontaneous and in-duced labor was analyzed with the use oflogistic regression in 3 separate groups:(1) primiparous women, (2) multipa-rous women with no previous CS deliv-ery, and (3) mothers with previous CSdelivery.

RESULTSSevere postpartum hemorrhage was ob-served in 3333 mothers of the total pop-ulation, with a prevalence of 1.1%. Caseswere identified in 330 mothers (2.1%)

with previous CS delivery and in 3003mothers (1.0%) with no previous CS de-

livery. The prevalence was higher at pre-

labor CS delivery and induction than at

spontaneous labor onset (Figure). In-

duction of labor increased the preva-

lence of severe postpartum hemorrhage

at every mode of delivery.

Comparing all 3 types of labor onset inseparate models revealed that the risk of

severe postpartum hemorrhage was

higher for prelabor CS delivery and in-

duction than for spontaneous labor on-

set. Compared with spontaneous labor

onset in mothers with no previous CS

delivery, prelabor CS delivery doubled

the risk of severe postpartum hemor-

rhage, andinduced labor onset increased

the risk of severe postpartum hemor-

rhage by 75%. In mothers with previous

CS delivery, the risk of severe postpar-tum hemorrhage was 28% higher for

prelabor CS than for spontaneous labor

onset.

When modes of deliveries were com-

pared, the risk of severe postpartum

hemorrhage was significantly halved for

all vaginal deliveries, and emergency CS

delivery had 55% higher risk, compared

with prelabor CS delivery. Causes of

postpartum hemorrhage were not iden-

tified in60% of CS deliveries.

The lowest prevalence of severe post-partum hemorrhage was observed at

spontaneous vaginal delivery after spon-

taneous labor in multiparous women

with no previous CS delivery (0.6%), al-

thoughthehighestprevalencewasatemer-

gency CS delivery after induction in moth-

ers with previous CS delivery (4.7%). The

risk for severe postpartum hemorrhage

among primiparous women was higher

forprelaborCSdeliverythanforspontane-

ous vaginal delivery, but it was highest for

operative vaginal delivery after induction

followed by emergency CS delivery. The

risk among multiparous women with and

with no previous CS delivery was higher

for prelabor CS delivery than for vaginal

deliveries,butit washighest foremergency

CS delivery. Emergency CS delivery after

induction in motherswith previous CS de-

livery was associated with the highest risk

of severe postpartum hemorrhage (odds

ratio, 6.57), compared with spontaneous

vaginal delivery after spontaneous labor inmultiparous women with no previous CS.

FIGURE

Prevalence of severe postpartum hemorrhagefor the onset of different labor modes

2.01.8

0.81.0

2.32.4

1.82.1

0

1

2

3

All deliveries Spontaneous labor Induced labor Prelabor CS

Severehemorrhage(%)

No previous CS

Previous CS

n = 291,604 n = 241,889 n = 32,377 n = 17,338

n = 15,811 n = 8254 n = 1810 n = 5747

CS, cesarean section.

Al-Zirqi. Labor and delivery effects on severe postpartum hemorrhage. Am J Obstet Gynecol 2009.

Research Obstetrics www.AJOG.org

274 American Journal of Obstetrics &Gynecology SEPTEMBER 2009

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COMMENTPrelabor CS delivery andinduction of la-bor carried significantly higher risk of se-vere postpartumhemorrhage, comparedwith spontaneous labor onset. Emer-gency CS delivery, especially after induc-

tion, had the highest risk of severe post-partum hemorrhage.The strength of the current study lies

in the population-based design that in-cluded the total pregnant population ofNorway over a 5-year period. Weak-nesses of this study were the retrospec-tive andobservational design andthe ab-sence of objective measurement of bloodloss.

The finding that the risk of severepostpartum hemorrhage was higher for

prelabor CS delivery than for spontane-ous labor onset, even in those with pre-vious CS delivery, is supported by otherstudies. This confirms that major sur-gery, even when planned, is not risk free.In contrast to our findings, Landon et alfound that the rate of transfusion washigher among mothers having trial of la-bor than among those having elective re-peat CS delivery. To further address thistopic, we suggest additional large-scaleprospective studies that would use objec-

tive methods to measure blood loss atprelabor CS delivery and after spontane-ous and induced trial of labor.

Among all mothers, the risk of severepostpartum hemorrhage was signifi-cantly higher for induction than forspontaneous labor onset but was not sig-

nificantly different between induction

and prelabor CS delivery. This againconfirms that induction is an importantrisk factor that should not be underesti-mated in daily practice. Large random-ized controlled studies are needed to as-

sess the role of induction whereinformation about the ripeness of thecervix, induction method, and obstetrichistory are taken into account.

The finding that emergency CS deliv-

ery after labor onset had significantlyhigher risk of severe postpartum hemor-rhage than prelabor CS delivery is alsosupported by other studies. However, wefound that severe postpartum hemor-rhage was significantly lower for vaginal

deliveries than for prelabor CS delivery.

This is not surprising, because CS deliv-ery results in acute blood loss before theuterine musculature can contractaround the spiral arteries and the hyste-rotomy incision can be closed.

The high percentage of unidentifiedcauses of postpartum hemorrhage that

arerelated to delivery by CS delivery mayindicate that there were cases of uterineatonythat were not recognizedclinically.However, it may indicate that there wereundocumented surgical causes of bleed-

ing that were related to the procedure. Afuture prospective study that would doc-ument the exact causes of hemorrhage atCS delivery is needed.

There was noticeable risk of severepostpartum hemorrhage for operativevaginal delivery after induction among

primiparous women. This was due to thehigh prevalence of genital trauma anduterine atony at this delivery mode thatoccurred most among primiparouswomen. Multiparous women with noprevious CS delivery had the least prev-

alence of severe postpartum hemorrhagebecause of the significantly higher prev-alence of spontaneous vaginal deliveries.The finding that emergency CS deliveryafter induction in mothers with previousCS delivery had the highest risk of severepostpartum hemorrhage might result inconsidering prelabor CS delivery to be abetter option for this group. However,we have to emphasize that this deliverymode occurred at a very low rate. Vagi-nal deliveries, which are known to have

the lowest risk of hemorrhage, were themost frequent mode of delivery after trialof labor, even in mothers with previousCS.

CLINICAL IMPLICATIONS

In the absence of clear medical indica-tion, induction of labor and prelaborcesareansection(CS)deliveryshouldbeavoided because of the increased risk ofsevere postpartum hemorrhage.

Prelabor CS delivery might be a betteroption if the probability of emergencyCS delivery is high.

Large-scale prospective studies areneeded to document objectively theamount and precise causes of bloodloss at CS delivery. f

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