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

On average, approximately 1 L of blood is lost during cesarean section. An estimated 30% to 40% of patients develop postcesarean endometritis. The investigators wanted to learn whether blood loss and postoperative endometritis are associated with how the placenta is removed and with the site of uterine repair. In a prospective study, 840 women undergoing cesarean delivery were randomized to have manual placental delivery and exteriorized uterine repair (group 1 = 204); spontaneous placental delivery plus exteriorized uterine repair (group 2 = 220); manual placental delivery and in situ uterine repair (group 3 = 216); or spontaneous placental delivery with in situ uterine repair (group 4 = 200). Blood loss was estimated from the 48-hour levels of hematocrit and hemoglobin. Reductions in hemoglobin and hematocrit were similar in the 2 manual-removal groups and also the 2 spontaneous groups. There was no significant difference in these parameters between exteriorization and in situ repair. Differences were significantly greater in the manual-removal groups than when the placenta was spontaneously expelled. The 4 groups did not differ significantly in rates of endometritis, which ranged from 4% in group 4 to 20% in group 1. Endometritis was least frequent in group 4 and most frequent in group 1. The type of repair did not significantly influence rates of endometritis. The rate was, however, significantly higher with manual placental removal than in the spontaneous placental delivery groups. This study apparently is the largest prospective, randomized trial examining the effects of how the placenta is delivered and of uterine position at the time of repair on operative blood loss and postoperative endometritis associated with cesarean section. Manual removal of the placenta increases surgical blood loss, whereas spontaneous placental delivery lowers the risk of endometritis. The authors recommend that, in women undergoing cesarean delivery, the placenta be allowed to deliver spontaneously and the uterus be repaired in situ.