Cell savage, the collection and return of lost autologous blood during surgery, is frequently used in cardiothoracic and vascular surgeries. The use of cell savage in obstetrics, however, has been limited due to the concern of amniotic fluid embolism and RhD hemolytic disease. In order to evaluate the safety and effectiveness of cell savage, 3,028 pregnant women at risk for hemorrhaging were randomized in a 1:1 ratio to undergo either standard care or routine cell salvage during emergency and scheduled cesarean sections. Rates of blood transfusions were similar in both groups—3.5% in the standard care group compared to 2.5% in the cell salvage group (adjusted odds ratio 0.65; 95% CI, 0.42 to 1.01, p=0.056). In addition, fetomaternal hemorrhage was higher among women in the cell salvage group compared to the standard care group (25.6% vs. 10.5%; adjusted odds ratio 5.63; 95% CI 1.43 to 22.14, p=0.013). Furthermore, cost effectiveness analyses comparing use of cell salvage versus standard care for women undergoing cesarean sections were inconclusive. The effectiveness of cell salvage may be greater in resource limited locations or situations where red blood cells are scarce.