Impact of cesarean section on placental transfusion and iron-related hematological indices in term neonates: a systematic review and meta-analysis

Placenta. 2014 Jan;35(1):1-8. doi: 10.1016/j.placenta.2013.10.011. Epub 2013 Nov 20.


Evidence suggests that cesarean section is likely associated with a reduced placental transfusion and poor hematological status in neonates. However, clinical studies have reported somewhat inconsistent results. We conducted a systematic review and meta-analysis to examine whether cesarean section affects placental transfusion and iron-related hematological indices. Pubmed, Web of Science, ScienceDirect, and Ovid Databases were searched for relevant studies published before April 9, 2013. Mean differences between cesarean section and vaginal delivery in outcomes of interests (placental residual blood volume; hematocrit level, hemoglobin concentration, and erythrocyte count in cord/peripheral blood) were extracted and pooled using a random effects model. We identified 15 studies (n = 8477) eligible for the meta-analysis. Compared with neonates born vaginally, those born by cesarean section had a higher placental residual blood volume [weighted mean difference (WMD), 8.87 ml; 95% confidence interval (CI), 2.32 ml-15.43 ml]; a lower level of hematocrit (WMD, -2.91%; 95% CI, -4.16% to -1.65%), hemoglobin (WMD, -0.51 g/dL; 95% CI, -0.74 g/dL to -0.27 g/dL) and erythrocyte (WMD, -0.16 × 10(12)/L; 95% CI, -0.30 × 10(12)/L to -0.01 × 10(12)/L). Subgroup analysis showed that the WMD for hematocrit in neonate's peripheral blood (-6.94%; 95% CI, -9.15% to -4.73%) was substantially lower than that in cord blood (-1.75%; 95% CI, -2.82%, -0.68%) (P value for testing subgroup differences <0.001). In conclusion, cesarean section compared with vaginal delivery is associated with a reduced placental transfusion and poor iron-related hematologic indices in both cord and peripheral blood, indicating that neonates delivered by cesarean section might be more likely affected by iron-deficiency anemia in infancy.

Keywords: CI; Caesarean section; Iron deficiency; MD; MOOSE; Meta-analysis; NOS; Newcastle-Ottawa scale; Placental transfusion; SD; Systematic review; WMD; confidence interval; mean difference; meta-analyses of observational studies in epidemiology; standard deviation; weighted mean difference.

Publication types

  • Meta-Analysis
  • Observational Study
  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Anemia, Iron-Deficiency / etiology
  • Cesarean Section*
  • Delivery, Obstetric / methods
  • Erythrocyte Count
  • Female
  • Fetal Blood / chemistry
  • Hematocrit
  • Hemoglobins
  • Humans
  • Infant, Newborn / blood*
  • Infant, Newborn, Diseases / etiology
  • Placenta / blood supply*
  • Pregnancy


  • Hemoglobins