Manual removal of placenta at caesarean section

Although manual removal of the placenta is commonly carried out, opinions differ about the best technique for delivery of the placenta at caesarean section. The objective of this review was to assess the effects of manual removal of the placenta at caesarean section. We searched the Cochrane Pregnancy and Childbirth Group trials register. Randomised and quasi-randomised trials comparing manual removal of placenta to spontaneous separation and controlled cord traction for delivery in pregnant women undergoing elective or emergency caesarean section. Trial quality assessment and data extraction were done by one reviewer. Three trials involving 224 women were included. The trials were of reasonable quality. Manual removal of the placenta was associated with a clinically important and statistically significant increase in maternal blood loss (weighted mean difference 436.35, 95% confidence interval 347.82 to 524.90). Manual removal was also associated with increased post-partum endometritis (odds ratio 5.44, 95% confidence interval 1.25 to 23.75) and a statistically non-significant trend towards an increase in feto maternal haemorrhage (odds ratio 2.19, 95% confidence interval 0.69 to 6.93). The evidence suggests that manual removal of the placenta at caesarean section may do more harm than good, by increasing maternal blood loss and increasing the risk of infection.