A.

1 Active Management of the Third Stage of Labour Prevention and Treatment of Postpartum
Hemorrhage
--> An IV bolus of oxytocin, 5 to 10 IU (given over 1 to 2 minutes), can be used for PPH
prevention after vaginal birth but is not recommended at this time with elective Caesarean
section.
--> Carbetocin, 100 ug given as an IV bolus over 1 minute, should be used instead of continuous
oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the
need for therapeutic uterotonics.

A.2 WHO FOR AMTSL

--> CCT is the recommended method for removal of the placenta in caesarean section. New
WHO Recommendations Help to Focus Implementation.
--> Comprehensive Emergency Obstetric Care (Government of India Initiative) has shown
33%reduction in maternal deaths and AMTSL is an important component. AMTSL reduces the
occurrence of severe PPH by approximately 60-70%.Since 2007 WHO recommendations have
supported AMTSL as a critical intervention for PPH prevention and AMTSL has become a
central component of the PPH reduction strategies.

A.3 Prevention of Post Partum Hemorrhage (PPH )

PPH prevention in Cesarean section FOGSI recommends active management to prevent
PPH in cesarean sections.
Oxytocin (IM/IV diluted) is the recommended uterotonic drug for the prevention of PPH
in cesarean section. Oxytocin 10 units IM is recommended. If administered
intravenously it should be given in a dose of 5 units diluted to 5ml over 1 minute.
Intravenous infusion of oxytocin 10-20 U in 500ml (150ml/hour) is an acceptable
alternative.
Cord traction is the recommended method for removal of the placenta in cesarean section.
The principles for cord clamping are same as mentioned above.

A.4 THE COMPARISON OF PLACENTAL REMOVAL METHODS ON OPERATIVE

BLOOD LOSS

 CONCLUSION : Spontaneous delivery of placenta has significant reduction of blood

loss as compared to manual removal. This is a
practical intervention which can be
implemented in our operative practice without
increasing operating time.
Many study trials have shown the spontaneous delivery of placenta method to be superior
over manual method because of reduced intra operative blood loss and reduced incidence
of post operative endometritis.
Spontaneous

Manual

Significant blood loss >1000 cc

(n=78)
10

(n=67)
18

Value
0.033

Difference in HB 2.0 gm/dl

(12.82 %)
6

(26.8 %)
13

0.037

Blood transfusion

(7.692 %)
3

(19.40 %)
6

0.204

Additional use of Oxytocics

(3.846 %)
17

(8.955 %)
23

0.092

Time interval between delivery

(21.79 %)
2.79

(34.32 %)
1.25

0.050

of baby and placenta

Total Operating Time (Min)

1.43
38.88

0.45
40.06

0.349

7.9

6.9

A.5 Spontaneous delivery or manual removal of the placenta during caesarean section: a
randomised controlled trial.
Allowing spontaneous delivery of the placenta during caesarean section reduces
significant blood loss. This intervention is highly feasible, as the increase in oper- ating
time should be minimal, especially if the waiting time is restricted to 5 minutes after the
delivery of the infant.
Spontaneous (n 235)
All participants
Significant blood loss
Difference in Hb _ 2.5 g/dL
Blood transfusion
Stratified analysis
Previous CS
Primary CS
Adjusted for previous CS
Primiparous women
Multiparous women
Adjusted for parity
Emergency CS
Elective CS
Adjusted for emergency CS

Manual (n 237)

RR (95% CI)

30 (13)

49 (21)

0.62 (0.41 0.94)

30 (13)
4 (2)

48 (20)
3 (1)

0.63 (0.41 0.96)

1.34 (0.30 5.9)

11/102 (11)
19/133 (14)

11/92 (12)
38/145 (26)

17/99 (17)
13/136 (10)

31/113 (27)
18/124 (15)

14/81 (17)
16/154 (10)

29/81 (36)
20/156 (13)

0.90 (0.41 2.0)

0.55 (0.33 0.90)
0.63 (0.42 0.96)
0.63 (0.37 1.1)
0.66 (0.34 1.3)
0.64 (0.42 0.97)
0.48 (0.28 0.84)
0.81 (0.44 1.5)
0.62 (0.41 0.93)

A.6 Methods of delivering the placenta at caesarean section (CCT INCLUDED)

Delivery of the placenta by cord traction at caesarean section has more advantages than
manual removal. There is less endometritis; less blood loss; less decrease in haematocrit
levels postoperatively and shorter duration of hospital stay. A possible longer interval
between birth of the baby and delivery of the placenta is the only disadvantage, but this did
not signicantly increase the overall duration of surgery.

A.7 BLOOD LOSS IN MANUAL EXTRACTION OF PLACENTA VERSUS SPONTANEOUS

DELIVERY DURING ELECTIVE CESAREAN SECTION (CCT INCLUDED)
--> Delivery of placenta with cord traction at cae- sarean section has more advantages compared
to manual removal. Manual removal of placenta is associated with more blood loss as compared
to spontaneous removal of placenta by umbilical cord traction.

Number of patients with significant drop in Hb%

Group A
n (%)

Group B
n (%)

p-value

5
(11.9%)

12
(28.57%)

0.02

A.8 Spontaneous delivery or manual removal of the placenta during cesarean section: A
randomized controlled trial

In this study a significant decrease in blood loss was seen in patients undergoing
cesarean delivery in whom the placenta was spontaneously removed rather than
manually. Additional support for greater blood loss in the manual placental
delivery group was found with a significantly greater decrease in hemoglobin
concentration at 48 hours after operation (1.31 vs 0.67 g/dL). The duration of
surgery was not altered by the mode of placental delivery.
Spontaneous separation of placenta is advocated at the time of caesarean section
because reduced blood loss helps in decreasing the post operative morbidity and
improves post operative recovery.

Shows primary outcome

Spontaneous
Mean hemoglobin (gm/dL)

Manual

P value

Significance

Before surgery
After 48 hours of surgery
Difference
P value
Mean Blood Loss (mL)
Mean time taken for placental
delivery (sec.)

10.10 0.829
9.430.917
0.67
P<0.001
55.1121.07

10.070.829
8.760.917
1.31
P<0.001
100.922.52

60.0221.68

50.520.5

>0.05
Not significant
<0.001 Highly significant
Highly significant
<0.001 Highly significant

Time taken for placental delivery

Manual

Spontaneous
Time taken for placental
delivery (in seconds)
0-20
20-40
40-50
40-60
50-60
60-80
80-100
100-120
120-140
Total

No

No. %

1
5
10

2
10
20

2
16
16

4
32
32

16
12
3
2
1

32
24
6
4
2

4
6
6
0
0

8
12
12
0
0

50

100

50

100

Blood loss in placental delivery

Spontaneous
Blood loss (mL)

No.

Manual
%

No.

20-40
40-60
60-80
80-100
100-120
120-140
Total

12
26
5
5
2
0
50

24
52
10
10
4
0
100

1
3
7
10
24
5
50

2
6
14
20
48
10
100

Difference in hemoglobin before and after surgery (in spontaneous and manual group).
Difference in
hemoglobin

(g/dL)
0-0.4
0.4-0.8
0.8-1.2
1.2-1.6
1.6-2
Total

Spontaneous
(Group I)
No.
26
12
5
4
3
50

%
52
24
10
8
6
100

Manual
(Group II)
No.
2
7
11
22
8
50

%
4
14
22
44
16
100

A9. A Comparative Study of Effects of Spontaneous Delivery of Placenta versus Manual

Removal of Placenta During Caesarean Section

For women allocated to Group A, the obstetrician was instructed to wait until
spontaneous delivery of placenta. Controlled cord traction was performed to facilitate
placental delivery. To avoid excessive bleeding in the interval, clamps were placed on the
uterine incision for hemostasis. If spontaneous delivery had not occurred after 5 minutes,
or in case of excessive bleeding, manual removal of placenta was performed and the
cases were excluded from the study. After delivery, the placenta and membranes were
examined and, if found complete, manual exploration of the cavity was not performed. In
Group B, the surgeon introduced her hand into the uterine cavity to detach and remove
the placenta as soon as possible after the delivery of infant. In both the groups, 10 IU
oxytocin in i.v.drip was infused immediately after delivery of the infant. All uterine
incisions were low transverse and all were closed after exteriorisation of the uterus.

Thus we conclude that manual removal of placenta only seems to be superior in saving
the time taken to extract out placenta, but it is actually not so. The overall duration of
surgery remains comparable. Manual removal of placenta adds to the post-operative
complications in form of greater blood loss and infections. Thus we recommend to wait
for spontaneous separation of placenta during caesarean section so as to decrease the
morbidity associated with caesarean section. Manual removal of placenta should be
reserved for those cases in whom placenta does not separate spontaneously till 5 minutes.