الفهرس 
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Abstract
A cesarean section is done when vaginal delivery is considered dangerous to the baby or the mother, so it is a life-saving operation. The rate of cesarean section has increased from 5% to more than 20% over the last 3 decades as a belief that cesarean section will reduce perinatal mortality.
This rate has been increasing and continues in future to the extent that cesarean section can be done as an elective as well as emergency procedure. Cesarean section may be associated with complications like hemorrhage, fever and endometritis, venous thromboembolism, and abnormal placentation in the following pregnancies. Women undergoing cesarean delivery have higher risk of hemorrhage compared to those undergoing normal delivery.
The mode of placental delivery may contribute to an increase or decrease in the morbidity associated with Cesarean delivery, and many studies have shown it to be a key role in determining the blood loss during Cesarean delivery.
In this study, we aimed to compare manual removal versus spontaneous delivery of the placenta at Cesarean section; and whether manual removal is associated with higher risk of blood loss compared with spontaneous placental delivery.
This randomized prospective comparative study was conducted at tertiary care hospital at Ain Shams Maternity University hospitals from June 2022 till December 2022 and performed on a total of 200 women who prepared for elective cesarean section.
The current study revealed that there was no significant difference between the studied groups regarding baseline demographic (age, BMI and gestational age) (p values = 0.638, 0.841, 0.139) respectively.
As regards hemoglobin and hematocrit level, our study results revealed that there is no statistically significant difference between the study groups regarding preoperative hemoglobin and hematocrit level while postoperatively, Spontaneous placental delivery group showed significantly higher postoperative hemoglobin and hematocrit level (p value = 0.005) and lower hemoglobin and hematocrit reduction (p value>0.001).
Consequently, spontaneous group significantly had lower blood loss after placental separation during cesarean section and blood loss during cesarean section and in the first 24 hours (p value>0.001) with no need for blood transfusion for both groups.
Our study results reported that the need for extra uterotonics was statistically significant less frequent in spontaneous group compared to the manual removal group.
As regards the postoperative hemodynamics, our study results revealed that the manual removal group had significant increased postoperative temperature and the postoperative heart rate was statistically significantly lower in spontaneous group and postoperative systolic and diastolic blood pressure were statistically significantly higher in spontaneous group compared to the manual removal group. All the postoperative hemodynamics showed statistically significantly differences among the studied groups expect after 24 hours.
As regards the postoperative complications, our study results revealed that there is no statistically significant difference between the study groups regarding postoperative complications of atony, PPH, endometritis, uterine inversion and ICU admission with no statistically significant difference as regards the hospital stay.
We concluded that this randomized study showed a statistically significantly increased amount of blood loss with manual removal of the placenta compared to the spontaneous placental separation group with no effect on the duration of surgery. Postoperative hematocrit and postoperative hematocrit drop, Postoperative Hemoglobin and Postoperative Hemoglobin DROP were significantly lower in women who had their placenta spontaneous separation when compared to women who had manual separation. Consequently, Spontaneous separation of the placenta during cesarean section is more beneficial than manual separation.
We recommend applying Spontaneous separation of the placenta during cesarean section.