What is the only evidence-based indication for manual removal of the placenta?

Manual removal of the placenta is a procedure generally performed when there is a significant clinical indication for doing so. The only evidence-based indication for this intervention is persistent bleeding following delivery. This bleeding can be a sign of retained placental tissue or an inability of the uterus to contract effectively, which may necessitate manual removal to prevent further complications such as severe hemorrhage.

Persistent bleeding suggests that there could be an underlying issue with the placenta's separation from the uterine wall or that pieces of the placenta have not been expelled, leading to continued bleeding. Addressing this situation promptly is crucial in order to manage blood loss and protect the health of the mother.

While uterine atony can also lead to significant bleeding, it is typically managed first with uterotonics and other interventions to encourage uterine contraction before considering manual removal. Persistent pain and signs of infection are important clinical signals but are not directly evidence-based indicators for manual removal of the placenta.