Placenta delivery at caesarean section

Anorlu RI, Maholwana B, Hofmeyr GJ

Published Online:

July 16, 2008

There are various methods of delivery of placenta at caesarean section. These include placental drainage with spontaneous delivery, cord traction and manual removal. The last two methods: cord traction (usually combined with massage or expression of the uterus) and manual removal are frequently used. The review identified 15 studies involving 4694 women. Delivery of the placenta by cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay.

Abstract (click to read)

Background:

Worldwide, caesarean section is the most common major operation performed on women. Some of the reported short-term morbidities include haemorrhage, postoperative fever and endometritis. The method of delivering the placenta is one procedure that may contribute to an increase or decrease in the morbidity of caesarean section. Two common methods used to deliver the placenta at caesarean section are cord traction and manual removal.

Objectives:

To compare the effects of manual removal of the placenta with cord traction at caesarean section.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2007).

Selection criteria:

All randomised controlled trials comparing manual removal and cord traction or spontaneous of delivery of the placenta.

Data collection and analysis:

Two authors independently assessed studies and extracted data.

Main results:

We included 15 studies (4694 women). There was significant heterogeneity for the duration of surgery, blood loss and haematological outcomes. The only possible contributing factor found was greater protection from blood loss in two trials in which cord traction was combined with uterine massage. A random-effects model meta-analysis was used for these outcomes.

Manual removal of the placenta was associated with more endometritis (relative risk (RR) 1.64, 95% confidence interval (CI) 1.42 to 1.90; 4134 women, 13 trials); more blood loss (ml) (weighted mean difference (WMD) 94.42 ml, 95% CI 17.19 to 171.64; 2001 women, eight trials); more blood loss > 1000 ml (RR 1.81, 95% CI 1.44 to 2.28; 872 women, two trials); lower haematocrit after delivery (%) (WMD -1.55, 95% CI -3.09 to -0.01; 384 women, two trials); greater haematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00 to 0.78; 1777 women, five trials); longer duration of hospital stay (days) (WMD 0.39 days, 95% CI 0.17 to 0.61; 546 women, three trials).

The duration of surgery was shorter in one trial but not overall.

There were no significant differences in feto-maternal haemorrhage, blood transfusion, puerperal fever (numbers studied for these outcomes were small).

Authors' conclusions:

Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay. Future trials should provide information on interval between the delivery of the infant and of the placenta, change in lochia, blood splashing during placental removal and uterine pain after operation, as well as the effects of delayed cord clamping.

This record should be cited as:

Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at caesarean section. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: CD004737. DOI: 10.1002/14651858.CD004737.pub2

Assessed as up to date:

March 14, 2008

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Primary Review Group:

Pregnancy and Childbirth Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

Which is the most effective method of delivering the placenta at caesarean section?

Bottom line:

Delivery of the placenta with cord traction has advantages compared to manual removal.These include less endometritis, blood loss, and decrease in haematocrit levels postoperatively, and a shorter duration of hospital stay.There were no significant differences between the two methods in rates of foeto-maternal haemorrhage, blood transfusion or puerperal fever (although the numbers studied for these outcomes were small).

Caveat:

A possible longer interval between birth of the baby and delivery of the placenta with cord traction was the only relative disadvantage noted, but this did not significantly increase the overall duration of surgery.The sample size of the studies was variable.The blood loss at operation was estimated by different methods in the various trials. Most of the studies did not mention blinding at the time of measurement of blood loss in theatre and reading of charts on the wards.

Context:

Worldwide, caesarean section is the most common major operation performed on women. Some of the reported short term morbidities include haemorrhage, postoperative fever and endometritis.The method of removing the placenta may contribute to an increase or decrease in the morbidity of caesarean section.Two methods used to deliver the placenta are cord traction and manual removal.

Cochrane Systematic Review:

Anorlu RI et al. Methods of delivering the placenta at caesarean section. Cochrane Reviews 2008, Issue 3. Article No. CD004737. DOI: 10.1002/14651858. CD004737.pub2. This review contains 15 studies involving 4694 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Pregnancy & childbirth > Caesarian section > Surgical techniques

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Placenta delivery at caesarean section

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