Spontaneous versus manual placental delivery during cesarean delivery: a systematic review and meta-analysis

J Matern Fetal Neonatal Med. 2022 Dec;35(26):10535-10544. doi: 10.1080/14767058.2022.2134769. Epub 2022 Oct 19.


Objective: Standardized techniques have been established for cesarean delivery to reduce cesarean delivery complication rates. Current recommendations suggest against manual removal of the placenta. The purpose of the present meta-analysis is to evaluate published data and provide a summary of the evidence.

Methods: For the purposes of this systematic review, we searched Medline, Scopus, the Cochrane Central Register of Controlled Trials CENTRAL, Google Scholar, and Clinicaltrials.gov databases from inception till June 2021 for relevant randomized controlled trials. Effect sizes were calculated in R.

Results: Overall, 19 studies were included that involved 5797 parturient. We did not detect significant differences in the mean intraoperative blood loss among the two techniques (MD = 149.18 ml, 95% CI = -32.55, 330.92). Similarly, intraoperative duration was comparable among the two groups (MD = -0.89 min, 95% CI = -2.34, 0.57). The risk of intraoperative hemorrhage was comparable among the two groups (OR = 1.75, 95% CI = 0.48, 6.36), although the provided result is based on underpowered sample size. Consequently, the need of transfusion was not increased (OR = 1.31, 95% CI = 0.71, 2.44). Neither postpartum endometritis (OR = 1.50, 95% CI = 0.94, 2.40) nor infectious morbidity (OR = 1.82, 95% CI = 0.94, 3.52) increased with manual placental extraction.

Conclusion: The findings of our study suggest that cephalad-caudad blunt expansion of the uterine incision may be safe; however, more data are needed to evaluate its impact on post-partum infectious morbidity as well as its safety in cases at increased risk of perioperative bleeding.

Keywords: Cesarean delivery; blood transfusion; complications; hemorrhage; manual placental removal; meta-analysis.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Blood Loss, Surgical
  • Cesarean Section / adverse effects
  • Cesarean Section / methods
  • Delivery, Obstetric / adverse effects
  • Endometritis* / etiology
  • Female
  • Humans
  • Placenta*
  • Pregnancy