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RETAINED PLACENTA - CLINICAL GUIDELINE FOR

DIAGNOSIS AND MANAGEMENT


1.

Aim/Purpose of this Guideline


This guideline gives guidance to all hospital and community based midwives,
Obstetricians and obstetric anaesthetists in the diagnosis and management of a
retained placenta.

2.

The Guidance
The placenta is considered retained if it remains undelivered after 30 minutes of an
actively managed third stage and 60 minutes of a physiological third stage.
2.1. Retention may be caused by
Full bladder
Poor management of an active or physiological third stage
Snapped cord
Abnormal /invasive placental insertion (i.e. placental accreta)
Uterine abnormality
A retained placenta will not necessarily be accompanied by haemorrhage but a
haemorrhage can occur at any point. This may be concealed, therefore it is
essential to monitor the women closely, using a Modified Obstetric Early Warning
chard (MEOWS), to identify early deterioration in her condition.
This must be commenced at the point of diagnosing retained placenta.
2.2. Management
As soon as retained placenta is confirmed:
In the community setting, dial 999 and arrange transfer to the obstetric unit
immediately. Keep a clear record of the running total estimated blood loss (EBL)
during transfer up until handover in the acute unit. It is IMPERATIVE that the
amount of blood loss is communicated to the acute unit staff on handover.
In the hospital setting and the third stage has been managed physiologically
revert to active management giving 10 IU of oxytocin IM and follow the Active
Management of Third Stage Clinical Guideline.
Inform the Delivery Suite Coordinator and Middle Grade/Consultant obstetrician
on diagnosis of retained placenta
DO NOT leave the woman unattended whilst the placenta remains insitu
Empty the bladder, catheterise if the woman cannot pass urine herself
Assist the woman to breast feed or show her how to stimulate her nipples if
breastfeeding is not an option

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Undertake maternal observations every 10 minutes or more frequently as the


observations dictate using MEOWS. Including observations of the womans
colour, her own report on how she feels, and observe the vaginal loss
Ensure there is IV access, and blood has been taken for full blood count (FBC)
and group and screen
Do NOT use IV oxytocin infusion but commence intravenous fluids
Administer an intra-umbilical vein injection of 20ml saline + 20IU oxytocin, as
close to the vulva as is practical. Do not use at a Twin birth. Do not perform in
the community setting wait until the patient is on delivery suite
2.3. If placenta is still retained 20 minutes after the umbilical oxytocin has been
given:
The obstetrician should perform a vaginal examination
Obtain consent for manual removal
Inform anaesthetist/ODA/theatre team
Transfer patient to theatre and ensure adequate anaesthesia
Perform manual removal
IV Antibiotics at time of procedure, and orally thereafter.
NB: If there is excessive bleeding or signs of maternal shock at any time
that the placenta is retained, inform the obstetrician immediately and
arrange immediate transfer into theatre. Do not wait and manage any of the
above. Inform the anaesthetist of current MEOWS score and EBL in order
that appropriate anaesthesia is chosen.
2.4. Previous Caesarean Section
A retained placenta in a patient with a previous caesarean section must be treated
with great care; the likelihood of a placenta accreta is increased. During manual
removal if there is any suggestion that the placenta is not separating call a
consultant for further advice.

3.

Monitoring compliance and effectiveness

Element to be
monitored

The number of retained placenta will be recorded on the maternity


services monitoring dashboard on a monthly basis

Lead

Maternity Risk Manager

Tool

The following points should be audited


In the absence of active bleeding, the placenta was retained
greater than 60 minutes following physiological
management.
Regular maternal observations were undertaken on and
recorded on a MEOWS chart

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IV access was ensured


IV oxytocin infusion was not used
Trends should also be excluded, such as:
Person conducting the delivery
Type of management of third stage.
Frequency

If the red flag alert is breached on the maternity dashboard, an audit of


retained placenta for the month in question will be allocated to a junior
doctor/midwife by the Risk Management Midwife

Reporting
arrangements

The results will be reviewed at the Maternity Risk Management


Forum.

Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared

Any deficiencies are identified and action plan will be developed


and monitored by the Maternity Risk Management Forum
Results and lessons learnt will be distributed through the Maternity
Risk Management Newsletter and presented at the Perinatal Audit
Meeting

4. Equality and Diversity


4.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Diversity & Human Rights Policy' or the Equality and Diversity website.
4.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 1.

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Appendix 1. Governance Information


Document Title

Retained placenta, Clinical guideline for the


diagnosis and management of

Type of document

Clinical

Date valid from:

5th June 2014

Date valid to:

5th June 2017

Directorate / Department responsible


(author/owner)

Maternity risk manager, Maternity services,


Obs and Gynae directorate

Contact details:

01872 252270
This guideline gives guidance to all hospital
and community based midwives, Obstetricians
and obstetric anesthetists in the diagnosis and
management of a retained placenta

Brief summary of contents

Placenta, 3rd stage of labour, PPH, retained,


active, physiological, management

Suggested keywords

RCHT

Target audience:

PCH

CFT

KCCG

Executive Director responsible for


Clinical Guideline:
Date revised:
This document replaces (exact title of
previous version):

Management of retained placenta

Approval route (names of


committees)/consultation:

Maternity Guideline Group


Obs and Gynae Directorate
Divisional Board

Divisional Manager confirming approval


processes

Head of Midwifery

Name and Post Title of additional


signatories

Not Required

Signature of Executive Director giving


approval
Publication Location (refer to Policy on
Policies Approvals and Ratification):
Document Library Folder/Sub Folder

Internet & Intranet

Midwifery and obstetrics

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Intranet Only

Links to key external standards

CNST 3.7,

Related Documents:

Major/Massive Obstetric Haemorrhage (MOH) Clinical Guideline For Management

Training Need Identified?

No.

Version Control Table


Date

Versio
n No

October
2007

V1.0

October
2009

Summary of Changes
Initial Issue

V1.1

Minor changes

December
V1.2
2011

Minor changes

5th June
2014

Minor change in section 2.2. Management


Do NOT use IV oxytocin infusion but
commence intravenous fluids

V1.3

Changes Made by
(Name and Job Title)
Jan Clarkson
Maternity Risk
Manager
Jan Clarkson
Maternity Risk
Manager
Jan Clarkson
Maternity Risk
Manager
Jo Crocker
Delivery Suite Coordinator

This document is only valid on the day of printing


Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.
This version supersedes any previous versions of this document.

All or part of this document can be released under the Freedom of Information Act
2000

This document is to be retained for 10 years from the date of expiry.

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Appendix 2.Initial Equality Impact Assessment Screening Form


Name of service, strategy, guideline, policy or project (hereafter referred to as policy)
to be assessed:
Clinical guideline for the diagnosis and management of retained placenta
Is this a new or existing Procedure?
Directorate and service area:
Maternity services, Obs and Gynae
Existing
directorate
Name of individual completing
Telephone:
assessment:
Jan Clarkson
01872 252270
Maternity risk manager
1. Procedure Aim*
This guideline gives guidance to all hospital and
community based midwives, Obstetricians and obstetric
anaesthetists in the diagnosis and management of a
retained placenta
2. Procedure Objectives*
3. Procedure intended
Outcomes*

To ensure safe, effective and evidence based diagnosis


and management of a retained placenta
To ensure safe, effective and evidence based diagnosis
and management of a retained placenta

4. How will you measure


the outcome?

By compliance monitoring

5. Who is intended to
benefit from the
Procedure?

Pregnant woman

6a. Is consultation
required with the
workforce, equality
groups etc. around this
procedure?

No

b. If yes, have these


groups been consulted?

N/A

c. Please list any groups N/A


who have been consulted
about this procedure.

*Please see Glossary

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7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands:
Age

No
X

Rationale for Assessment / Existing Evidence


All pregnant women.

All pregnant women.

Race / Ethnic
communities /groups

All pregnant women.

Disability -

All pregnant women.

Religion /
other beliefs

All pregnant women.

Marriage and civil


partnership

All pregnant women.

Pregnancy and maternity

All pregnant women.

Sexual Orientation,

All pregnant women.

Sex (male, female, trans-

Yes

gender / gender
reassignment)

learning
disability, physical
disability, sensory
impairment and
mental health
problems

Bisexual, Gay, heterosexual,


Lesbian

You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
You have ticked Yes in any column above and
No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
Major service redesign or development
No
8. Please indicate if a full equality analysis is recommended.
Yes
X

9. If you are not recommending a Full Impact assessment please explain why.
N/A
Signature of policy developer / lead manager / director
Jo Crocker
Delivery Suite Co-ordinator
Names and signatures of
1. Elizabeth Anderson
members carrying out the
2.
Screening Assessment

Date of completion and submission


5th June 2014

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD
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A summary of the results will be published on the Trusts web site.


Signed: Elizabeth Anderson
Date: 5th June 2014

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