Manual removal versus spontaneous delivery of the placenta at cesarean section in developing countries: a randomized controlled trial and review of literature

Purpose: Cesarean section (CS) rates have increased; this is especially concerning in developing countries. The mode of placental delivery contributes to morbidity associated with CS and determines blood loss during CS. We aimed to compare manual removal versus spontaneous delivery of the placenta at CS.Methods: In a randomized controlled trial, 574 women admitted for primary or repeat elective CS were randomized into two groups. In group A, the placenta was manually removed, whereas in group B, the placenta was left for spontaneous delivery. Blood loss, operative and postoperative data were recorded.Results: Blood loss was 875.2524.2ml in group A versus 731.8 +/- 426.7ml in group B (p=.001), with a significant drop in postoperative HB (p=.015) and HCT (p=.031). In group A, odds ratios for blood loss (>1000ml), HB drop (>4g/dl), postpartum hemorrhage and blood transfusion were 2.581, 2.850, 2.614 and 1.665, respectively. However, the total operative time (p=.326), duration of hospital stay (p=.916) and intensive care unit (ICU) admission (p=.453) were not statistically different between the two groups.Conclusions: Manual removal of the placenta at CS is associated with a higher risk of blood loss, postpartum hemorrhage and blood transfusion, with no decrease in operative time.