Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision. The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss. The effect of placental removal method at cesarean delivery on perioperative hemorrhage: a randomized clinical trial ISRCTN 49779257. Effects of placental delivery method and intraoperative glove changing on postcesarean febrile morbidity. Does manual removal of the placenta affect operative blood loss during cesarean section? The effect of placental management at cesarean delivery on operative blood loss. Manual removal of the placenta and postcesarean endometritis. The effect of placental removal method on the incidence of postcesarean infections. The effect of manual removal of the placenta on post-cesarean endometritis. Cesarean section intraoperative blood loss and mode of placental separation.
The current study was undertaken to determine if blood loss at the time of cesarean section is affected by method of placental removal (spontaneous versus extracted) or uterine position for repair (in situ versus exteriorized). This prospective randomized study involved 100 women who were undergoing a cesarean section. The patients were placed into one of four groups--1, spontaneous placenta detachment, in situ uterine repair; 2, spontaneous placental detachment, exteriorized uterine repair; 3, manual placental removal, in situ uterine repair, and 4, manual placental removal, exteriorized uterine repair. Patients with spontaneous placental separation (groups 1 and 2) compared with manual removal (groups 3 and 4) revealed a significant decrease in blood loss (p < 0.001). Uterine position did not significantly affect blood loss in the spontaneous group (1 and 2; p = 0.971) or the manual placental removal groups (3 and 4; p = 0.061). The hematocrit values for all groups were similar preoperatively, but postoperatively, were significantly lower in the manual removal groups when compared with the spontaneous placental separation groups (p < 0.001). The method of placental removal and not the position of the uterus at the time of its repair has a significant role in blood loss during cesarean birth. Our purpose was to determine whether blood loss during cesarean section and postoperative endometritis rate were associated with the method of placental removal and site of uterine repair.
                This prospective randomized study involved 840 women who underwent cesarean section. The patients were grouped into four: (1) manual placental delivery + exteriorized uterine repair; (2) spontaneous placental delivery + exteriorized uterine repair; (3) manual placental delivery + in situ uterine repair; (4) spontaneous placental delivery + in situ uterine repair. Patients were excluded if they had received intrapartum antibiotics, had chorioamnionitis, required an emergency cesarean hysterectomy, had rupture of membranes for more than 12 hr, had bleeding diathesis, and had abnormal placentation or prior postpartum hemorrhage. The main outcome measures were postoperative hemoglobin and hematocrit values, and postcesarean endometritis.
                There were no statistically significant differences in mean maternal age, parity, gestational age, presence and duration of membrane rupture and number of vaginal examinations between the four groups. The decrease in postoperative hemoglobin (P < 0.05) and hematocrit (P < 0.001) was significantly greater in the manual removal groups (groups 1 and 3) than in the spontaneous expulsion groups (groups 2 and 4) at 48 hr postoperatively. The incidence of postoperative endometritis was significantly higher in manual removal groups (15.2%) (groups 1 and 3) than in spontaneous groups (5.7%) (groups 2 and 4) (P < 0.05).
                Manual removal of the placenta at cesarean delivery results in more operative blood loss and a higher incidence of postcesarean endometritis. To evaluate whether the method of placental removal during cesarean section has an impact on perioperative hemorrhage and maternal infectious morbidity.
                Three hundred and two patients admitted for abdominal delivery were recruited in a prospective randomized clinical intention-to-treat trial. Participants were assigned to have their placenta removed either manually or spontaneously. The drop in hematocrit was the primary outcome; postpartum maternal infectious morbidity was also assessed.
                Two patients were excluded for incomplete data. One-hundred-fifty-one were randomized to the manual removal group and 149 to the spontaneous group. The demographic characteristics of the two populations were similar. The mean drop (%) in the manual removal group was greater than in the spontaneous group (5.57+/-3.86 and 2.65+/-2.67, respectively; P<0.01). the incidence of postpartum infectious morbidity was also significantly greater in the manual group (RR 15.8, 95% CI 2.19-117.5).
                Routine manual removal of placenta at cesarean section significantly increases perioperative blood loss and postpartum maternal infectious morbidity. This study was designed to evaluate the effects of the placental delivery methods and intraoperative glove changing on postcesarean febrile morbidity. In this randomized controlled trial, consenting patients were randomized to one of four management protocols: Group A (n = 26)--no glove change with manual placental delivery; Group B (n = 27)--no glove change with expressed placental delivery; Group C (n = 27)--glove change with manual placental delivery; and Group D (n = 28)--glove change with expressed placental delivery. Glove change was performed by removal of a second glove after delivery of the fetal head. Variables examined included febrile morbidity, endometritis, maximums and durations of elevated temperatures, as well as other demographic, intrapartum, and postpartum variables. Febrile morbidity and endometritis rates were not significantly different between the four groups. When the groups were combined so as to compare no glove change versus glove change (Groups A and B vs. C and D) and manual versus expressed placental delivery (Groups A and C vs. B and D), there were no significant differences in either febrile morbidity (relative risk: 0.7, 95% CI: 0.3-1.4 and relative risk: 1.4, 95% CI: 0.6-3.5) or endometritis (relative risk: 1.2, 95% CI: 0.5-2.8 and relative risk: 1.5, 95% CI: 0.6-3.6), respectively. There were no statistically significant differences in measures of postcesarean febrile morbidity based on placental delivery method or intraoperative glove change. To investigate whether manual removal of the placenta is associated with significantly more blood loss compared to spontaneous separation of the placenta during cesarean section.
                This was a randomised study of 200 women with normal pregnancies undergoing cesarean section. Patients were randomly assigned to the study group, manual removal (n=100) or the control group, spontaneous separation (n=100). Operative blood loss was measured using a volume and gravimetric method. Patients postoperative complications were recorded and hemoglobin levels measured at 24 and 48 h.
                The amount of blood loss associated with spontaneous and manual removal of the placenta was 626+/-253 ml and 589+/-272 ml, respectively. This difference was not significant. There was a decrease in the postoperative hemoglobin levels in both groups which was not significantly different. The incidence of endometritis, wound infection, and the need for blood transfusion was similar in the two groups.
                Manual delivery of the placenta is not associated with a significantly greater risk of operative blood loss, decreased postoperative hemoglobin levels or increased incidence of endometritis compared with spontaneous placental separation. The effect of alternative methods of placental delivery at cesarean section on blood loss has not been reported. The hypothesis of this study was that spontaneous expulsion of the placenta would reduce operative blood loss, compared with that of manual extraction during cesarean delivery.
                We prospectively randomized and compared outcomes of 62 gravid women with manual (n = 31) or spontaneous (n = 31) placental delivery at cesarean section. Operative blood loss was measured directly.
                Blood loss measured at cesarean delivery was greater in the manually delivered group (967 +/- 248 ml) than in the spontaneously delivered group (666 +/- 271 ml, p < 0.0001). The incidence of postpartum endometritis was sevenfold greater in the manual than the spontaneous group (23% vs 3%, respectively; p < 0.05).
                We conclude that spontaneous expulsion of the placenta at cesarean delivery results in less operative blood loss and a lower incidence of postoperative endometritis. To determine if manual vs. spontaneous delivery of the placenta at cesarean section affects the rate of postoperative endometritis and amount of blood loss.
                A prospective, randomized study was carried out on patients who had cesarean delivery assigned either to spontaneous delivery of the placenta (group 1) or manual removal (group 2). We excluded patients undergoing emergency cesareans and those with possible placenta accreta or evidence of preexisting infection. Outcome measures (frequency of endometritis and quantitative decrease in hemoglobin) were compared for the two groups.
                Study criteria were met for 375 subjects: 177 in group 1 and 198 in group 2. Endometritis was diagnosed in 1.7% of the former and 2.5% of the latter. The change in hemoglobin, reflecting operative blood loss, was similar in both groups (-1.81 and -1.72 g/dL, respectively).
                We found no significant difference in either postoperative endometritis or blood loss regardless of the means used to effect delivery of the placenta. The frequency of febrile morbidity in our study cases was considerably lower than heretofore reported. Our purpose was to determine whether the incidence of postoperative endometritis and wound infection is associated with the method of placental removal at the time of cesarean section.
                Parturients undergoing cesarean delivery were prospectively randomized to have the placenta removed manually or spontaneously. Patients were excluded from participation if they had received intrapartum prophylactic antibiotics or had been determined to have chorioamnionitis. After delivery of the infant women in the manual group had the placenta extracted by the primary surgeon, whereas women in the spontaneous group had the placenta delivered by gentle traction on the umbilical cord. All study subjects received perioperative prophylactic antibiotics. The primary outcome variable was a postcesarean infection, defined as postecsarean endometritis or wound cellulitis requiring drainage and antibiotic therapy.
                A total of 333 women were enrolled in the investigation, with 165 assigned to the manual removal group and 168 allocated to have spontaneous removal. There were no statistically significant differences in mean gestational age, frequency or duration of ruptured membranes, frequency or duration of labor, or mean number of vaginal examinations between the two study groups. Postoperative infections occurred in 25 of 168 (15%) women in the spontaneous delivery group compared with 44 of 165 (27%) women in which the placenta was manually extracted (relative risk 0.6, 95% confidence interval 0.4 to 0.9, p = 0.01). Subset analysis of patients delivered with ruptured membranes similarly demonstrated a statistically significant reduction in the incidence of postoperative infections with spontaneous placental removal compared with manual extraction (20% vs. 38%, relative risk 0.5, 95% confidence interval 0.3 to 0.9, p = 0.02). There was a similar trend toward a reduction in postdelivery infections associated with spontaneous placental removal in women with intact membranes; however, this difference did not attain statistical significance.
                Spontaneous delivery of the placenta after cesarean delivery is associated with a decrease in the incidence of postcesarean infections. To determine if intraoperative glove change and placental delivery method affect the post-cesarean endometritis rate.
                After informed consent, women who required cesarean were randomly assigned to one of four study groups: 1) no glove change plus manual placental extraction, 2) no glove change plus spontaneous placental delivery, 3) glove change plus manual extraction, and 4) glove change plus spontaneous delivery. Bilateral glove change by both primary and assistant surgeons occurred immediately after delivery of the newborn and before delivery of the placenta. External uterine massage and traction on the umbilical cord were performed to assist spontaneous delivery of the placenta. A first-generation cephalosporin was routinely administered after umbilical cord clamping for prophylaxis of post-cesarean endometritis.
                Of 760 women entered into the study, we included 643 who did not have intrapartum chorioamnionitis or cesarean hysterectomy. The four groups were comparable with respect to selected maternal and intrapartum characteristics, including maternal and gestational age, parity, presence of labor, and the presence and duration of membrane rupture. The postoperative endometritis rate was significantly higher in women whose placentas were extracted manually (31 versus 22%, P = .01). Operator glove change did not alter the incidence of endometritis (relative risk 1.0, 95% confidence interval 0.79-1.3).
                Manual extraction of the placenta is associated with a significantly greater risk of post-cesarean endometritis than that observed with assisted spontaneous placental delivery. Intraoperative glove change does not decrease post-cesarean endometritis. To investigate whether manual removal of the placenta is associated with significant blood loss compared with spontaneous separation of the placenta during cesarean delivery.
                A randomized prospective study of 400 women with normal pregnancies undergoing cesarean delivery at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Patients were randomly assigned to the study group, (manual placental removal, n=200) or the control group (spontaneous placental separation, n=200). Operative blood loss was assessed by the volumetric and gravimetric methods. Hemoglobin levels were evaluated the third postoperative day and patient's postoperative complications were recorded.
                The mean+/-S.D. amount of blood loss associated with manual and spontaneous removal of the placenta was 713+/-240 and 669+/-253 ml, respectively. This difference was statistically significant (P=0.04). There was a postoperative decrease in hemoglobin levels in both groups. Preoperative hemoglobin levels were 11.6+/-3 g/dl in the study group and 11.2+/-1.1 g/dl in the control group, and the difference was statistically significant (P=0.006). The postoperative hemoglobin levels at day 3 were 9.0+/-1.2 g/dl in the study group and 9.9+/-1.2 g/dl in the control group (P=0.003), also a statistically significant difference. The incidence of endometritis, wound infection, and need for blood transfusion was similar in the two groups.
                Manual delivery of the placenta was significantly associated with greater operative blood loss and greater decrease in postoperative hemoglobin levels, but with shorter operative time compared with spontaneous placental separation. No difference in postoperative complications was noted between the groups.