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J Matern Fetal Neonatal Med. 2018 Dec;31(24):3308-3313. doi: 10.1080/14767058.2017.1369522. Epub 2017 Aug 30.

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

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a Department of Obstetrics and Gynecology, Faculty of Medicine , Cairo University , Cairo , Egypt.



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.


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.


Blood loss was 875.2 ± 524.2 ml in group A versus 731.8 ± 426.7 ml 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 (>1000 ml), 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.


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.


Cesarean section; health care in developing countries; manual placental removal; postpartum hemorrhage

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