The effect of placental removal method and site of uterine repair on postcesarean endometritis and operative blood loss

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.