THE EFFECT OF PLACENTAL REMOVAL METHOD ON THE INCIDENCE OF POSTCESAREAN INFECTIONS

OBJECTIVE: Our purpose was to determine whether the incidence of posto perative endometritis and wound infection is associated with the metho d of placental removal at the time of cesarean section. STUDY DESIGN: Parturients undergoing cesarean delivery were prospectively randomized to have the placenta removed manually or spontaneously. Patients were excluded from participation if they had received intrapartum prophyla ctic antibiotics or had been determined to have chorioamnionitis. Afte r delivery of the infant women in the manual group had the placenta ex tracted by the primary surgeon, whereas women in the spontaneous group had the placenta delivered by gentle traction on the umbilical cord. All study subjects received perioperative prophylactic antibiotics. Th e primary outcome variable was a postcesarean infection, defined as po stcesarean endometritis or wound cellulitis requiring drainage and ant ibiotic therapy. RESULTS: A total of 333 women were enrolled in the in vestigation, with 165 assigned to the manual removal group and 168 all ocated to have spontaneous removal. There were no statistically signif icant differences in mean gestational age, frequency or duration of ru ptured membranes, frequency or duration of labor, or mean number of va ginal examinations between the two study groups. Postoperative infecti ons occurred in 25 of 168 (15%) women in the spontaneous delivery grou p compared with 44 of 165 (27%) women in which the placenta was manual ly extracted (relative risk 0.6, 95% confidence interval 0.4 to 0.9, p = 0.01). Subset analysis of patients delivered with ruptured membrane s similarly demonstrated a statistically significant reduction in the incidence of postoperative infections with spontaneous placental remov al compared with manual extraction (20% vs. 38%, relative risk 0.5, 95 % confidence interval 0.3 to 0.9, p = 0.02). There was a similar trend toward a reduction in postdelivery infections associated with spontan eous placental removal in women with intact membranes; however, this d ifference did not attain statistical significance. CONCLUSION: Spontan eous delivery of the placenta after cesarean delivery is associated wi th a decrease in the incidence of postcesarean infections.