Placental cord drainage and the effect on the duration of third stage labour, a randomized controlled trial. The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss. Cesarean section intraoperative blood loss and mode of placental separation. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial. 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. Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial. Intra-umbilical vein injection and retained placenta: evidence from a collaborative large randomised controlled trial. Grupo Argentino de Estudio de Placenta Retenida. Blood loss at time of cesarean section by method of placental removal and exteriorization versus in situ repair of the uterine incision.
To assess the effect of placental cord drainage on the duration of third stage labor, and to clarify the safety of this method regarding to postpartum hemorrhage, retained placenta, incidence of manual removal of placenta, and the need for blood transfusion.
                Randomized controlled trial.
                King Chulalongkorn Memorial Hospital.
                One hundred women in the third stage of labour after vaginal delivery were randomized. In the study group, placental cord drainage was performed. In both groups, the placenta was delivered by Brandt Andrew method. One case of placenta succenturiata was subsequently excluded. The duration of third stage was compared as the primary outcome. The incidence of postpartum hemorrhage, retained placenta, manual removal of placenta, and the need for blood transfusion were compared.
                In 99 cases with normal placentas, 49 cases were assigned to the study group, 50 cases were assigned to the control group. The third stage of labor was significantly shorter after placental cord drainage (5.1 +/- 2.4 minutes vs. 7.0 +/- 6.1 minutes). There was no postpartum hemorrhage, uterine atony, hypovolemic shock, or the need for blood transfusion in neither groups.
                Placental cord drainage shortens the duration of third stage labour. This method appears to be safe and does not increase postpartum complication. 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 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. Our purpose was to compare the controlled cord traction technique with the minimal intervention technique for delivery of the placenta. The primary outcome was the incidence of postpartum hemorrhage. Secondary outcomes included duration of third stage of labor, frequency of retained placenta, hemorrhagic shock, the need for blood transfusion, and the need for uterotonic agents to control postpartum hemorrhage.
                A total of 1648 women who were delivered vaginally were randomly allocated during labor to the controlled cord traction group (n = 827) or the minimal intervention group (n = 821). In the controlled cord traction group women received oxytocin, 10 units intramuscularly, with delivery of the baby's anterior shoulder, after which the placenta was delivered actively by controlled cord traction (Brandt-Andrews method). In the minimal intervention group the placenta was delivered by maternal pushing. Continuous intravenous oxytocin was given after delivery of the placenta. Odds ratios with 95% confidence intervals were calculated for each variable.
                The overall incidence of postpartum hemorrhage was significantly lower in the controlled cord traction group (5.8% vs 11%; odds ratio 0.50, 95% confidence interval 0.34 to 0.73). The incidence of retained placenta (> or = 30 minutes) was 1.6% in the controlled cord traction group and 4.5% in the minimal intervention group (odds ratio 0.31, 95% confidence interval 0.15 to 0.63). Significantly more patients in the minimal intervention group required additional uterotonic agents to control hemorrhage (5.1% vs 2.3%; odds ratio 0.44, 95% confidence interval 0.24 to 0.78).
                The controlled cord traction technique for delivery of the placenta results in a significantly lower incidence of postpartum hemorrhage and retained placenta, as well as less need for uterotonic agents, compared with the minimal intervention technique. 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. This study tested the hypotheses that active management of the third stage of labour lowers the rates of primary postpartum haemorrhage (PPH) and longer-term consequences compared with expectant management, in a setting where both managements are commonly practised, and that this effect is not mediated by maternal posture.
                1512 women judged to be at low risk of PPH (blood loss >500 mL) were randomly assigned active management of the third stage (prophylactic oxytocic within 2 min of baby's birth, immediate cutting and clamping of the cord, delivery of placenta by controlled cord traction or maternal effort) or expectant management (no prophylactic oxytocic, no cord clamping until pulsation ceased, delivery of placenta by maternal effort). Women were also randomly assigned upright or supine posture. Analyses were by intention to treat.
                The rate of PPH was significantly lower with active than with expectant management (51 [6.8%] of 748 vs 126 [16.5%] of 764; relative risk 2.42 [95% CI 1.78-3.30], p<0.0001). Posture had no effect on this risk (upright 92 [12%] of 755 vs supine 85 [11%] of 757). Objective measures of blood loss confirmed the results. There was more vomiting in the active group but no other important differences were detected.
                Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage. To determine whether intra-umbilical vein injection with saline solution, with or without oxytocin, reduces the need for manual removal of placenta compared with expectant management.
                Multicenter, randomised controlled trial.
                Eleven hospitals in four cities of Argentina: Buenos Aires, Corrientes, Rosario, and Salta.
                Two hundred and ninety-one women showing no evidence of placental separation thirty minutes after vaginal delivery.
                Three different management strategies: 1. intra-umbilical vein injection of saline solution plus oxytocin; 2. intra-umbilical vein injection of saline solution alone; and 3. expectant management.
                Primary: manual removal of the placenta. Secondary: blood loss after trial entry, haemoglobin level at 24 to 48 hours and at 40 to 45 days after delivery, blood transfusion, curettage, infection, and days of hospital stay.
                Rates of subsequent manual removal were similar: intra-umbilical vein injection of saline solution plus oxytocin (58%; RR 0.92; 95% CI 0.73-1.15), or saline alone (63%; RR 1.00; 95% CI 0.80-1.24), compared with expectant management (63%). There were also no detectable effects of the active managements on any of the secondary measures of outcome.
                Based on evidence available from randomised controlled trials, including this trial, it is unlikely that intra-umbilical injection with or without oxytocin, is clinically useful. We recommend that this intervention should not be used in third stage management of labour. 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.
There was a small reduction in the length of the third stage of labour and also in the amount of blood loss when cord drainage was applied compared with no cord drainage. The clinical importance of such observed statistically significant reductions, is open to debate. There is no clear difference in the need for manual removal of placenta, blood transfusion or the risk of postpartum haemorrhage. Due to small trials with medium risk of bias, the results should be interpreted with caution.