Timing of manual placenta removal to prevent postpartum hemorrhage: is it time to act?

Abstract

Objective: The length of the third stage of labor is an important risk factor for postpartum hemorrhage (PPH). Current practice recommends manual placenta removal, if not delivered spontaneously, within 30 min. The review reexamines the evidence to determine the optimal length of the third stage of labor.

Methods: A MEDLINE search that associated the length of the third stage of labor with the risk of PPH was undertaken.

Results: A retrospective cohort study revealed the risk of a PPH became significant at 10 min (odds ratio = 2.1, 95% confidence interval: 1.6–2.6), and had doubled by 20 min (odds ratio = 4.3, 95% confidence interval: 3.3–5.5). A receiver operator curve determined the optimal length of the third stage of labor to prevent PPH was 18 min. A follow up randomized controlled trial showed that hemodynamic compromise secondary to a PPH can be reduced with manual placenta removal at 10 compared to 15 min (6.4 versus 19.2%, p = 0.001).

Conclusion: The time interval of 15 min may be a more appropriate time interval to recommend placental removal to prevent PPH.

Keywords:

• Maternal morbidity
• maternal mortality
• placental removal time interval
• postpartum hemorrhage
• third stage of labor

Acknowledgements

The authors thank Donna Eastham for her editorial work on this article and Shelia Thomas for her assistance with the literature review.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.