Methods of delivering the placenta at caesarean section

  • Review
  • Intervention

Authors

  • Rose I Anorlu,

    Corresponding author
    1. University of Lagos, Department of Obstetrics and Gynaecology, Lagos, Nigeria
    • Rose I Anorlu, Department of Obstetrics and Gynaecology, University of Lagos, College of Medicine, Surulere, Lagos, PMB 12003, Nigeria. rianorlu2004@gmail.com.

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  • Babalwa Maholwana,

    1. Effective Care Research Unit, East London, South Africa
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  • G Justus Hofmeyr

    1. University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Department of Obstetrics and Gynaecology, East London Hospital Complex, East London, Eastern Cape, South Africa
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Abstract

Background

Worldwide, caesarean section is the most common major operation performed on women. Some of the reported short-term morbidities include haemorrhage, postoperative fever and endometritis. The method of delivering the placenta is one procedure that may contribute to an increase or decrease in the morbidity of caesarean section. Two common methods used to deliver the placenta at caesarean section are cord traction and manual removal.

Objectives

To compare the effects of manual removal of the placenta with cord traction at caesarean section.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2007).

Selection criteria

All randomised controlled trials comparing manual removal and cord traction or spontaneous of delivery of the placenta.

Data collection and analysis

Two authors independently assessed studies and extracted data.

Main results

We included 15 studies (4694 women). There was significant heterogeneity for the duration of surgery, blood loss and haematological outcomes. The only possible contributing factor found was greater protection from blood loss in two trials in which cord traction was combined with uterine massage. A random-effects model meta-analysis was used for these outcomes.

Manual removal of the placenta was associated with more endometritis (relative risk (RR) 1.64, 95% confidence interval (CI) 1.42 to 1.90; 4134 women, 13 trials); more blood loss (ml) (weighted mean difference (WMD) 94.42 ml, 95% CI 17.19 to 171.64; 2001 women, eight trials); more blood loss > 1000 ml (RR 1.81, 95% CI 1.44 to 2.28; 872 women, two trials); lower haematocrit after delivery (%) (WMD -1.55, 95% CI -3.09 to -0.01; 384 women, two trials); greater haematocrit fall after delivery (%) (WMD 0.39, 95% CI 0.00 to 0.78; 1777 women, five trials); longer duration of hospital stay (days) (WMD 0.39 days, 95% CI 0.17 to 0.61; 546 women, three trials).
The duration of surgery was shorter in one trial but not overall.

There were no significant differences in feto-maternal haemorrhage, blood transfusion, puerperal fever (numbers studied for these outcomes were small).

Authors' conclusions

Delivery of the placenta with cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay. Future trials should provide information on interval between the delivery of the infant and of the placenta, change in lochia, blood splashing during placental removal and uterine pain after operation, as well as the effects of delayed cord clamping.

摘要

背景

剖腹產中的胎盤娩出方法

剖腹產手術(帝王切開術)可說是世界上的女性最常接受的手術之一,而常見的短期合併症包括出血、術後發燒及子宮內膜炎等。其中胎盤產出方式是影響剖腹產併發症的關鍵之一,兩種常見的胎盤產出方式包括臍帶牽引及人工取出。

目標

比較剖腹產中兩種胎盤取出方法包括臍帶牽引及人工取出胎盤。 。

搜尋策略

搜尋策略 搜尋的資料庫:Cochrane Pregnacy and Childbrith Group's Trials Register (2007.9.30)。

選擇標準

所有討論人工胎盤取出、臍帶牽引及自動胎盤產出的Randomised controlled trials。

資料收集與分析

兩位作者獨立分析這些資料。

主要結論

共有15個研究共計4694位女性被計入本研究。在手術時間、失血量及血液檢驗上的結果有顯著差異。其中兩個研究中顯示以臍帶牽引加上子宮按摩的方法對減少出血有所幫助,這些結果是用randomeffects model metaanalysis來比較的。人工取出胎盤相對來說有較高的機率導致子宮內膜異位,更多的出血量、甚至更多造成出血大於1000cc的可能、分娩後較低的血比容及較大的術前術後血比容落差、較長的住院天數。其中只有在一個研究中顯示人工取出胎盤有較短的手術時間。而在胎兒母體間出血、書寫、產褥熱的機率是無差異的。(但在這些結果研究的樣本數較少)

作者結論

作者結論 在剖腹產時,以臍帶牽引取出胎盤的方法,相較於人工取出有較多的優點,包括較少發生子宮內膜異位,較少出血,較少的術後血比容降低,較短的住院天數。 未來更多的研究應致力於胎兒娩出後到胎盤取出的時間、惡露量的變化、胎盤取出時的瞬間出血量及術後的子宮疼痛、延遲夾住臍帶的影響等。

翻譯人

本摘要由中國醫藥大學附設醫院張維君翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在剖腹生產時有數種取出胎盤的方法,包括自然娩出、臍帶牽引及人工取出。其中後兩者是最常使用的方法。這個review包含了15個研究,共計4694位女性,而臍帶牽引相較於人工取出更多的優點,包括較少的子宮內膜異位發生、較少出血、術後較少的血比容減少及較短的住院天數。

Plain language summary

Placenta delivery at caesarean section

There are various methods of delivery of placenta at caesarean section. These include placental drainage with spontaneous delivery, cord traction and manual removal. The last two methods: cord traction (usually combined with massage or expression of the uterus) and manual removal are frequently used. The review identified 15 studies involving 4694 women. Delivery of the placenta by cord traction at caesarean section has more advantages compared to manual removal. These are less endometritis; less blood loss; less decrease in haematocrit levels postoperatively; and shorter duration of hospital stay.

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