Caesarean section (CS) is one of the most commonly performed surgical procedures in obstetrics, primarily employed to ensure the safety of both the mother and fetus in high-risk pregnancies [1]. While CS has significantly reduced maternal and fetal mortality, it remains a major surgical intervention with various perioperative and postoperative challenges. One critical stage in the CS procedure is placental delivery, which is traditionally accomplished through either spontaneous expulsion or manual removal [2]. The

method of placental delivery can have significant implications for maternal outcomes, particularly concerning blood loss, uterine tone, and the risk of postpartum complications [3].

Spontaneous placental delivery is often considered the preferred method, as it allows the uterus to contract naturally, thereby minimizing blood loss and promoting hemostasis. In contrast, manual removal involves the obstetrician actively separating the placenta from the uterine wall, which can result in increased blood loss and a higher likelihood of complications such as uterine injury and infection. Despite the widespread use of these two methods, there is limited consensus in the literature regarding their comparative outcomes during caesarean sections. Most studies have primarily focused on either blood loss or the incidence of infection but have not thoroughly examined the interaction of these factors in larger cohorts [4].

Studies have highlighted the significance of appropriate perioperative management to optimize outcomes in caesarean sections, including those related to placental delivery [5]. Furthermore, systematic reviews on surgical procedures for optimizing caesarean outcomes emphasize the importance of considering factors such as blood loss and postoperative complications [6]. The use of pharmacological agents, such as misoprostol, to reduce intraoperative hemorrhage during CS has also been extensively studied [7]. In addition, comparisons of surgical outcomes in complicated pregnancies, such as those with placenta previa or accreta, further underscore the importance of method selection in placental delivery.

Therefore, this study aims to compare the perioperative and postoperative outcomes of spontaneous placental delivery and manual removal, specifically examining blood loss, hemoglobin changes, and postoperative complications. By doing so, this study will provide valuable insights to guide clinical decisions in obstetric practice.

Study Design and Setting

This study was a hospital-based prospective observational study conducted in the Department of Obstetrics and Gynecology at Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, between November 2020 and November 2022. The study was approved by the institutional ethics committee, and informed written consent was obtained from all participants.

Study Population

The study included 200 pregnant women who met the inclusion and exclusion criteria and underwent caesarean section (LSCS) during the study period. The participants were randomly assigned to one of two groups based on the method of placental delivery:

Group S: Spontaneous delivery of the placenta

Group M: Manual removal of the placenta

Inclusion Criteria

• Pregnant women with gestational age between 30 to 42 weeks
• Primigravida and multigravida women with any age group
• Isolated oligohydramnios
• No antenatal complications other than decreased amniotic fluid index (AFI)

Exclusion Criteria

• Unwilling participants
• Gestational age less than 30 weeks
• Multiple pregnancies
• Polyhydramnios
• Placenta previa
• Placental abruption
• Pregnancy-induced hypertension, pre-eclampsia, and eclampsia
• Premature rupture of membranes
• Previous caesarean section
• Pregnancy with myoma
• Severe medical or surgical complications (e.g., heart, lung, kidney, or brain disorders)
• Severe anemia and bleeding disorders
• Procedure
• Pregnant women who met the inclusion criteria were randomly assigned to either Group S or Group M. The caesarean section was performed according to standard obstetric protocols.
• In Group S, the placenta was delivered spontaneously using controlled cord traction (the traditional method), with the uterus allowed to contract naturally.

In Group M, manual removal of the placenta was performed after the delivery of the baby. The placenta was manually separated from the uterine wall, and moderate cord traction was used.

Data Collection

Data on the following variables were collected:

Demographic and Clinical Information: Age, parity, and gestational age

Indications for LSCS:

Fetal distress, low Biophysical Profile (BPP), Cephalopelvic Disproportion (CPD), breech presentation, etc.

Blood Loss:

Blood loss was measured by weighing the blood-soaked sponges and suction fluid during placental separation. The net blood loss was calculated as the total blood volume from the suction apparatus and soaked sponges.

Hemoglobin Levels: Pre-operative and post-operative hemoglobin levels were measured to assess the hemoglobin drop.

Feto-Placental Delivery Interval: The time taken for placental delivery after the baby was delivered was recorded.

Postoperative Complications: Any complications such as fever, infection, or hemorrhage were noted.

Statistical Analysis

The collected data were entered into Microsoft Excel 2016 and analyzed using IBM SPSS Statistics version 20. Descriptive statistics, including mean, standard deviation, and percentages, were used to summarize the data. Categorical variables were analyzed using Pearson’s Chi-square test, while continuous variables were compared using the t-test or ANOVA as appropriate. A P-value of <0.05 was considered statistically significant.

Ethical Considerations

The study was conducted in compliance with ethical standards. Informed consent was obtained from all participants after explaining the risks, benefits, and voluntary nature of participation. Confidentiality and privacy of the participants were maintained throughout the study.

This study, conducted from November 2020 to November 2022, analyzed the perinatal outcomes of two methods of placental delivery during Cesarean section: manual removal (Group M) and spontaneous delivery (Group S). A total of 200 pregnant women were included in the study, with 100 women in each group.

Age Distribution

The age distribution of the women in both groups was similar, with the majority of participants in both Group S and Group M falling within the 21-25 years age group (57% and 54%, respectively). The mean age for Group S was 23.04 ± 3.34 years and for Group M it was 23.01 ± 3.26 years, showing no statistically significant difference (P = 0.949) (Table 1).

Table 1: Comparison of Age of Pregnant Women among the Study Groups (n=200)

Parity

Regarding parity, 79% of participants in Group S and 77% in Group M were primigravidae, while the remainder were multigravidae. The difference in parity between the two groups was not statistically significant (P = 0.733) (Table 2).

Table 2: Comparison of Parity in Pregnant Women Among the Study Groups (n=200)

Gestational Age

The majority of participants in both groups had a gestational age of 37-39 weeks (50% in Group S and 51% in Group M). The mean gestational age was 39.38 ± 1.21 weeks in Group S and 39.21 ± 1.42 weeks in Group M. There was no statistically significant difference in gestational age between the two groups (P = 0.364) (Table 3).

           Table 3: Comparison of Gestational Age in Pregnant Women Among the Study Groups (n=200)

Indications for LSCS

The most common indication for Cesarean section was fetal distress, occurring in 55% of Group S and 46% of Group M. Other indications included low Biophysical Profile (BPP), Cephalopelvic Disproportion (CPD), and breech presentation. No significant differences were observed in the indications for LSCS between the two groups (P = 0.685) (Table 4).

        Table 4: Comparison of Indications for LSCS in Pregnant Women among the Study Groups (n=200)

Blood Loss

A significant difference in blood loss between the groups was observed. In Group S, the majority of women (71%) experienced blood loss of 50 to 74.99 mL, whereas in Group M, 49% experienced blood loss between 100 to 124.99 mL, and 28% had blood loss exceeding 125 mL. The mean blood loss was significantly higher in Group M (114.47 ± 20.99 mL) compared to Group S (63.73 ± 11.56 mL), with a P-value of <0.0001 (Table 5).

Table 5: Comparison of Blood Loss in Pregnant Women Among the Study Groups (n=200)

Hemoglobin Levels

Pre-operative hemoglobin levels were similar in both groups, with means of 10.94 ± 0.91 g/dL for Group S and 10.96 ± 0.91 g/dL for Group M (P = 0.876). However, post-operative hemoglobin levels were significantly lower in Group M (9.58 ± 0.82 g/dL) compared to Group S (10.18 ± 0.83 g/dL), with a P-value of <0.0001 (Table 6).

Table 6: Comparison of Mean Hemoglobin before and After LSCS in Pregnant Women among the Study Groups (n=100)

Hemoglobin Drop

The mean drop in hemoglobin levels between the pre-operative and post-operative periods was significantly higher in Group M (1.36 ± 0.35 g/dL) than in Group S (0.82 ± 0.31 g/dL), with a P-value of <0.0001 (Table 7).

Table 7: Comparison of Mean Hemoglobin Drop in Pregnant Women Pre-Operative and Post-Operative Period among the Study Groups (n=200)

Additionally, a higher percentage of women in Group M (32%) experienced a hemoglobin drop of ≥1.5%, compared to only 5% in Group S (P <0.0001) (Table 8).

Table 8: Comparison of Hemoglobin Drop Percentage in Pregnant Women Pre-Operative and Post-Operative Period Among the Study Groups (n=200)

Feto-Placental Delivery Interval

The mean feto-placental delivery interval was significantly longer in Group S (62.06 ± 11.43 seconds) compared to Group M (43.95 ± 7.43 seconds), with a P-value of <0.0001 (Table 9).

Table 9: Comparison of Mean Feto-Placental Delivery Interval in Pregnant Women among the Study Groups (n=200)

Post-Operative Complications

Post-operative complications, particularly fever, were observed more frequently in Group M, with 12% of women experiencing fever, compared to 4% in Group S. This difference was statistically significant (P = 0.037) (Table 10).

Table 10: Comparison of Post-Operative Complications in Pregnant Women among the Study Groups (n=200)

The results of this study provide valuable insights into the comparative outcomes of spontaneous placental delivery versus manual removal during cesarean section (LSCS). Both methods are commonly used in obstetric practice, but the choice of technique can influence maternal outcomes, including blood loss, postoperative complications, and the time required for placental delivery. The findings of this study demonstrate that spontaneous delivery of the placenta is associated with lower blood loss, shorter feto-placental delivery intervals, and fewer postoperative complications when compared to manual removal.

Blood Loss and Hemoglobin Levels

One of the most notable findings of this study is the significant difference in blood loss between the two groups. Women in Group M (manual removal) experienced considerably higher blood loss (mean 114.47 ± 20.99 mL) compared to those in Group S (spontaneous delivery) (mean 63.73 ± 11.56 mL). This difference was statistically significant (P < 0.0001), aligning with previous studies that have highlighted the increased risk of hemorrhage associated with manual placental removal (Jacobs-Jokhan & Hofmeyr, 2004; Anorlu et al., 2008) [9, 11,12]. Manual removal involves separating the placenta from the uterine wall, which disrupts the vascular structure of the placenta and the decidual lining, resulting in more extensive bleeding. Additionally, the mean hemoglobin drop observed in Group M (1.36 ± 0.35 g/dL) was significantly higher than in Group S (0.82 ± 0.31 g/dL), suggesting a more substantial reduction in blood volume in the manual removal group. This drop in hemoglobin levels is consistent with the higher blood loss in Group M and may contribute to greater morbidity, including the need for blood transfusions in some cases (Yang et al., 2021; Eke et al., 2019) [13, 14].

Feto-Placental Delivery Interval

The feto-placental delivery interval, which measures the time taken for the placenta to be delivered after the baby, was significantly longer in Group S (mean 62.06 ± 11.43 seconds) compared to Group M (mean 43.95 ± 7.43 seconds). While this difference is statistically significant (P < 0.0001), it is important to note that the time taken for spontaneous placental delivery is influenced by factors such as uterine tone and placental adherence. Although Group M had a shorter delivery interval, it is likely due to the manual intervention required for placental removal, which is a more direct and forceful approach. Despite the shorter interval, Group M was associated with higher maternal morbidity due to the increased blood loss, as discussed earlier (Kukrer & Kukrer, 2021) [10].

Postoperative Complications

The incidence of postoperative complications was higher in Group M, with 12% of women experiencing fever, compared to 4% in Group S. This difference was statistically significant (P = 0.037). Fever is a common postoperative complication and can be indicative of infection or uterine atony. Manual removal of the placenta can increase the risk of infection, as it involves more aggressive handling of the uterine lining, which may cause microtears and facilitate bacterial entry (Dahlke et al., 2020) [8]. Moreover, the prolonged inflammatory response associated with higher blood loss could also contribute to the increased incidence of fever in Group M (Hofmeyr et al., 2008) [12].

Comparison with Previous Studies

The findings of this study are consistent with those from other studies comparing spontaneous and manual placental delivery. Previous research has indicated that spontaneous delivery of the placenta is associated with less blood loss and fewer postoperative complications compared to manual removal (Jacobs-Jokhan & Hofmeyr, 2004; Eke et al., 2019) [9, 13]. However, some studies have found that when performed in controlled settings, manual removal does not necessarily result in an increase in infection rates or blood loss (Hofmeyr et al., 2008) [12]. This discrepancy may be due to differences in patient populations, the surgical technique used, and the timing of uterotonic administration (Kukrer & Kukrer, 2021) [10].

Limitations of the Study

While this study provides important insights, it is not without limitations. The study design was observational, and randomization was not used, which could introduce selection bias. Additionally, the study was conducted at a single institution, which may limit the generalizability of the findings to other settings. Future studies with larger sample sizes and randomized controlled designs are needed to further investigate the long-term effects of different placental delivery methods on maternal health.

This study demonstrates that spontaneous placental delivery during cesarean section results in significantly less blood loss, a shorter feto-placental delivery interval, and fewer postoperative complications compared to manual removal of the placenta. Women in the spontaneous delivery group experienced lower hemoglobin drop and had a reduced risk of developing post-operative fever, a common complication associated with manual removal. These findings highlight the benefits of spontaneous placental delivery in minimizing maternal morbidity. Therefore, obstetricians should consider spontaneous delivery as the preferred method, especially in cases where reducing blood loss and minimizing the risk of complications are prioritized for better maternal health outcomes.

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