HOLY FAMILY COLLEGE OF NURSING

MATERIAL
ON
PLACENTAL
EXAMINATION

SUBMITTED TO SUMBITTED BY
MADAM MRS. SHIKHA Ms. ANURADHA
TUTOR MSc. NURSING 1ST YEAR
HFCON HFCON
 PLACENTAL
EXAMINATION
INTRODUCTION
Retained products of conception are one of the main causes of postpartum haemorrhage
and infection. The placenta and membranes should be examined carefully for
irregularities and completeness as soon as possible after birth. It is also useful to detect
any abnormalities.
A thorough inspection must be undertaken to ensure that no part of the placenta or
membranes have been retained as this may result in a postpartum haemorrhage and/or
infection. Inspection of the placenta should be performed as soon as possible after birth.

DEFINITION OF PLACENTA:
Placenta is a choriodecidual structure (forms from chorion, maternal decidua and
maternal blood), which helps in maintenance of pregnancy and development of fetus.
The placenta is partly fetal and partly maternal in origin. It connects closely with
mother’s circulation to carry out functions, which the fetus is unable to perform for itself
during intrauterine life. The survival of the fetus depends on the integrity and efficiency
of the placenta.
A fresh, term, healthy placenta is approximately 15 – 20 cm in diameter (Johnson and
Taylor 2010) and 2.0 to 2.5 cm thick. It generally weighs approximately 5-600gms (1/6
of the baby’s birth weight). However, the measurements can vary considerably
depending on a number of variables including ethnicity, pathophysiology and baby
weight. The maternal surface of the placenta should be dark maroon in colour and
should consist of around 20 cotyledons. The fetal surface of the placenta should be
shiny, grey and translucent so that the colour of the underlying maroon villous tissue
may be seen.

The Umbilical cord

At term, the typical umbilical cord is 55 to 60 cm in length, with a diameter of 2.0 to
2.5 cm. The cord vessels are suspended in Wharton's jelly. The normal cord contains
two arteries and one vein.

CORD KNOTS
A true cord knot occurs when the fetus passes through a loop of umbilical cord, usually
early in pregnancy. In most cases, a knot does not cause fetal compromise. However, if
sufficient tension is placed on the cord before or during labor and delivery, blood flow
may be cut off, and signs of fetal asphyxia may occur.

CORD VESSELS
The umbilical cord typically contains two arteries and a single vein. If only one artery
and one vein are grossly visible, the fetal anomaly rate is nearly 50 percent. These
anomalies may affect the cardiovascular, genitourinary or gastrointestinal system, and
other systems as well.

THROMBOSES
Thrombosis of cord vessels is often overlooked by both delivering physicians and
pathologists. This is an important cause of fetal injury.

FETAL MEMBRANES
Fetal membranes should be thin, grey and glistening. Thick, dull, discolored or foul-
smelling membranes indicate the possibility of infection. The nature of the odor may
provide a clue to the infecting organism: a fecal odor may indicate Fusobacterium or
Bacteroides, while a sweet odor may indicate Clostridium or Listeria.
Green-colored fetal membranes are frequently the result of meconium staining.
However, a green color may be imparted by changing blood pigments from an earlier
bleeding event or by the myeloperoxidase in leukocytes in the case of infection.

The Membrane
The membranes consist of two layers; the amnion and the chorion.

Multiple pregnancy
The placenta and membranes for multiple births are more complex as there are a variety
of possible combinations of placenta and membranes
Visually, the surfaces and cord are as described above for singletons. When checking
membranes it is helpful to look at the early ultrasound report to see what type of
twinning was diagnosed: Monochorionic, monoamniotic (MC, MA) twins are very rare
but have just one placenta, one pair of amnion and chorion and two cords

Monochorionic, diamniotic twins (MC, DA) have one placenta and one chorion (the
outer slightly thicker membrane), but, on the shiny fetal surface should have two cords,
each inside its own amnion Dichorionic, diamniotic (DC, DA) twins always have two
separate placental units, each with two layers of membranes, just like a singleton. They
may however, be side by side, and appear to be joined at first glance. The diagrams
below show the arrangement of placenta/ membranes and cord in utero for each type of
twin.
DEFINITION OF PLACENTAL EXAMINATION:

Placental examination is an important procedure of Labour room which is done to

identify any abnormalities, lesions and prepare material for histological examination.
or
It is thorough inspection of placenta after delivery to check for its completeness and
abnormalities.

AIMS OF PLACENTAL EXAMINATION:

• Identification of risk of retained products of conception

• To check for any variations in placenta or cord which may indicate either
congenital anomalies in baby or may complicate labour/ postpartum period

ARTICLES REQUIRED FOR EXAMINATION OF PLACENTA,

MEMBRANES AND CORD:

S.NO. ARTICLES RATIONALE

1. Placenta with cord-1 • For examination
2. Sink with tap water • For cleaning placenta of fresh blood and
blood clots
3. Gloves- 1 pair • To protect hands of the examiner
4. Mask • To protect face of the examiner from
spilled blood
5. Plastic apron- 1 • To protect clothing of the examiner
6. Basin • To keep placenta with cord for
examination
7. Mackintosh • To spread on table so as to prevent soiling
on table
8. Bowl with cotton • To separate the membranes
balls- 2 or 3
9. Weighing scale • To measure the weight of placenta
 10. Inch tape/ Scale • To measure the length and diameter
11. Yellow poly bag • To discard the placenta

STEPS OF PROCEDURE FOR EXAMINATION OF PLACENTA:

1. Wear the Personal Protective equipment.

2. Keep placenta with cord in the basin and take it to the sink and wash thoroughly
under running water.
3. Fill basin with clean water and wash until all the blood clots are removed.
4. Hold placenta by the cord thus allowing the membranes to hang.
5. Spread out the hand inside the membranes through the hole from which the baby
was delivered. This aids in inspection of membranes. If the membranes are
complete, strip the amnion from the chorion and see if both membranes are
present.
6. Spread the mackintosh on the table surface and lay the placenta on a flat surface.
7. Measure the diameter and depth of the placenta. Measure the length of the
remaining cord with placenta.
8. Weigh the placenta if abnormally large or small and record weight in maternal
health record.
9. Examine for both the maternal and fetal surfaces one after the other in a good
light.

MATERNAL SURFACE:
I. Take the placenta in both cupped hands and check for the completeness of
placenta. Broken pieces of cotyledons must be replaced before assessing the
maternal surface.
II. Place the placenta on the mackintosh and count the lobes also called cotyledons
of placenta which normally numbered to be 16-20. These cotyledons are
separated by sulci (furrows) in to which decidua dips down to form septa.
III. Normally maternal surface is dark red in colour but white patches/ infarctions
may be seen on maternal surface that may be due to the disposition of lime salts.
The edges of the maternal surface form a uniform circle.

FETAL SURFACE:
It is white and shiny surface. Branches of umbilical veins and arteries are visible
spreading out from the insertion of the umbilical cord.
I. Separate amnion and chorion using the probe. Peel off amnion from the fetal
surface till the insertion of cord to see the chorionic plate from which the placenta
develops.
II. Note the insertion of the umbilical cord. It is normally central but it may be
laterally inserted.
III. Measure the length of the umbilical cord. It is normally 50 cm and ranges from
30-100 cms. A cord measuring less than 40 cm is considered as short. A very long
cord may lead to true knots in the cord and it may become wrapped around the
neck or body of the fetus resulting in occlusion of the blood vessels during labour.
IV. Clean the stump of the cord and look for vessels. It has two arteries and one vein.
Note for the knots in the cord.

IV. Note for the false knots in the cord, it is comprised of Whartson’s jelly, a
gelatinous substance formed from mesoderm.
10.Weigh the empty basin and then again weigh the basin with placenta in it and
calculate the actual weight of placenta. Weight of the placenta is about 1/6 th of
the baby weight at term. Weight of placenta may also be affected by the time of
clamping. Early clamping of cord results in more placental weight while late
clamping leads to less placental weight, owing to amount of blood retained in
placenta.
11.Record the findings of examination of placenta and membranes and an estimate
of blood loss in mother’s note
 12.Discard placenta in yellow bag after the procedure is over. Discarded placenta is
sent for incineration.
13.Perform the aftercare of articles and replace all the articles to utility.

ANATOMICAL VARIATIONS OF THE PLACENTA AND CORD:

• Placenta succenturiate: A small extra lobe is present, separate from main

placenta and joined to it by blood vessels, which run through the membrane to
reach it.
Risks associated with placenta succenturiate :
✓ Increased risk of PPH due to retained placental tissues.
✓ Increased incidence of vasa previa
✓ Subinvolution
✓ Uterine sepsis
✓ Polyp formation

• Circumvallate placenta: An opaque ring is seen on fetal surface. The ring is

situated at varying distance from the margin of placenta. The ring is composed of
a double fold of amnion and chorion with degenerated decidua vera and fibrin in
between, vessels radiate from the cord insertion as far as the ring and then
disappear from view, the peripheral zone outside the ring is thicker and the edge
is elevated and rounded.
• Bipartite placenta: 2 complete and separate lobes are present, each with a cord
leaving it. The cord joins a short distance from the 2 parts of the placenta.

• Tripartite placenta: Similar as bipartite placenta but with 3 distinct lobes.

 • Battledore insertion of cord: Cord attached at the very edge of the placenta. If
associated with low implantation of the placenta, there is chance of cord
compression in vaginal delivery leading to fetal anoxia or even death; otherwise
it has got little clinical significance.

• Velamentous insertion of cord: the cord is attached to the membranes. The

branching vessels traverse between the membranes for a varying distance before
they reach and supply the placenta. If the leash of blood vessels happens to
traverse through the membranes overlying the internal os, in front of the
presenting part, the condition is vasa previa.

ABNORMALITIES OF CORD:

• Short cord: Length less than 40 cm. May lead to dystocia, premature separation
of placenta and foetal distress.

• Long cord: Excessive long cord may lead to cord prolapsed, cord loops around
the neck, looped or knotted cord.
 • Single umbilical artery: It may indicate child born of a diabetic mother,
congenital malformations (especially genital and renal) of foetus.

• Missing a blood vessel: May indicate congenital anomaly of gastrointestinal and

genitourinary system.

SUMMARY AND CONCLUSION

One-minute examination of the placenta performed in the delivery room provides
information that may be important to the care of both mother and infant. The findings
of this assessment should be documented in the delivery records. During the
examination, the size, shape, consistency and completeness of the placenta should be
determined, and the presence of accessory lobes, placental infarcts, hemorrhage, tumors
and nodules should be noted. The umbilical cord should be assessed for length,
insertion, number of vessels, thromboses, knots and the presence of Wharton's jelly. The
color, luster and odor of the fetal membranes should be evaluated, and the membranes
should be examined for the presence of large (velamentous) vessels. Tissue may be
retained because of abnormal location of the placenta or because of placenta accreta,
placenta increta or placenta percreta. Numerous common and uncommon findings of
the placenta, umbilical cord and membranes are associated with abnormal fetal
development and perinatal morbidity. The placenta should be submitted for pathologic
evaluation if an abnormality is detected or certain indications are present.

BIBLIOGRAPHY
• Manocha Sneh Lata, Procedure and practices in Midwife, Kumar publishing
house, page no. 78-83
• Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition,
page no. 47-52
• Dutta D.C., Textbook of obstetrics, New Central Book agency publication 6th
edition page no: 54-48
• Daftary N. S., Chakaravarti Sudip, Holland and Brews Manual of Obstetrics,
Elsevier publication, 3rd edition, page no. 52-54