title: 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).
  
  
  CONCLUSIONS
  The time interval of 15 min may be a more appropriate time interval to recommend placental removal to prevent PPH.
authors.affiliation: a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA .
authors.forename: Kelly
authors.initials: K
authors.lastname: Cummings
authors.affiliation: b School of Women's and Infants' Health, University of Western Australia , Perth , Australia , and.
authors.forename: Dorota A
authors.initials: DA
authors.lastname: Doherty
authors.affiliation: a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA .|b School of Women's and Infants' Health, University of Western Australia , Perth , Australia , and.
authors.forename: Everett F
authors.initials: EF
authors.lastname: Magann
authors.affiliation: a Department of Obstetrics and Gynecology , University of Arkansas for Medical Sciences , Little Rock , AR , USA .
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Wendel
authors.affiliation: c Department of Obstetrics and Gynecology , University of Mississippi Medical Center , Jackson , MS , USA.
authors.forename: John C
authors.initials: JC
authors.lastname: Morrison
mesh_terms: D016001:Confidence Intervals; D036861:Delivery, Obstetric / Q000592:standards*; D005260:Female; D006801:Humans; D007749:Labor Stage, Third / Q000502:physiology*; D016017:Odds Ratio; D018457:Placenta, Retained / Q000628:therapy*; D006473:Postpartum Hemorrhage / Q000517:prevention & control*; D011247:Pregnancy; D012372:ROC Curve; D012307:Risk Factors; D013997:Time Factors
keywords: Maternal morbidity; maternal mortality; placental removal time interval; postpartum hemorrhage; third stage of labor