What is retained placenta?

Retained placenta means that all or part of the placenta or membranes are left behind in the uterus (womb) during the third stage of labour. The third stage is when you deliver the placenta and membranes. You'll be treated for a retained placenta if the third stage takes longer than usual or if there are signs that any of the placenta or membrane is still attached to the uterus. A natural third stage, which involves you actively delivering the placenta by pushing it out, normally takes about 10 to 20 minutes but it can take up to an hour. The third stage can be speeded up with an injection in your thigh, given just as your baby is being born. This is known as a managed third stage and usually takes about five to 10 minutes. Managing the third stage reduces the risk of you experiencing heavy bleeding. You'll be treated for retained placenta if you have not completely delivered the placenta: • within one hour of your baby's birth, if you have a natural third stage - this happens in about 13 per cent of cases • within 30 minutes of your baby's birth, if you have a managed third stage - this happens in less than five per cent of cases Why and how does a retained placenta happen? There are three main causes of retained placenta: • uterine atony - this means that the uterus stops contracting or doesn't contract enough for the placenta to separate from the wall of the uterus • trapped placenta - the placenta comes away from the uterus successfully but becomes trapped behind a closed cervix • placenta accreta - an area of the placenta remains attached because it is deeply embedded into the uterus wall

A trapped placenta can happen during a managed third stage if the cord snaps during "controlled cord traction". Your midwife gives you an injection and then waits for signs that the placenta has separated. Controlled cord traction is when she puts one hand on your tummy to keep your uterus steady whilst pulling gently on the cord with her other hand. If the placenta has separated and is ready to come out, it will slide easily through the vagina. If it has not completely separated, if the cord is very thin or if your midwife pulls too hard, the cord may snap, leaving the placenta inside the uterus. If

being left behind in the uterus. The midwife will examine the placenta and membranes carefully after delivery to ensure that they are complete. so the blood vessels inside will continue to bleed. If you're sitting or lying down. If you choose a managed third stage. If the placenta only partially separates. this should alert her to the possibility of part of the placenta being retained. the uterus cannot contract properly.this happens you can usually help to deliver the placenta by pushing with a contraction when the midwife tells you to. connected to the main part of the placenta by a blood vessel. Sometimes a part of the placenta may adhere to a fibroid. Heavy bleeding in the first 24 hours after birth is known as primary postpartum haemorrhage (PPH). but occasionally the cervix will have closed too much to let the placenta out. If small fragments of placenta or membrane are retained and are not detected immediately. Retained placenta may be due to a small piece of placenta. your uterus contracts down to close off all the blood vessels inside the uterus. This is called a succenturiate lobe. try changing to a more upright position so that gravity can help. so your midwife may insert a catheter to drain your bladder. This is known as secondary PPH and happens in just under one per cent of births. you could try breastfeeding your baby or rubbing your nipples. this may cause heavy bleeding and infection later on. you'll be given an injection of an oxytoxic drug to make your uterus contract and your midwife will use controlled cord traction to gently pull the placenta out. How is it treated? If the third stage is taking a while. your risk of heavy bleeding increases substantially. What are the problems associated with retained placenta? Normally after the placenta is delivered. as this can cause the uterus to contract and may help to expel the placenta. or a scar from a previous caesarean section. Sometimes a full bladder will prevent the placenta from being delivered. . If the third stage is managed and delivery of the placenta takes longer than 30 minutes after the birth of your baby. If she notices a vessel leading to nowhere.

and treated with antibiotics. you may wish to discuss with your midwife whether or not to have a natural third stage with your next baby. You'll be given a regional anaesthetic such as a spinal or epidural. you have a higher risk of it happening again. The four signs of placental separation are: Apparent lengthening of the visible portion of the umbilical cord. if the retained placenta happened because the cord snapped or the cervix closed too quickly after having the oxytocic injection. If so. Before the placenta is removed manually your midwife will insert a catheter in to empty your bladder and you'll be given intravenous (IV) antibiotics to prevent infection. it may happen again. or placenta accreta. often with additional pushing efforts by the mother. you avoid the possibility of the cervix closing too quickly and trapping the placenta. so if you have another premature labour. or you can ask for a general anaesthetic if you prefer. Increased bleeding from the vagina. By allowing the placenta to deliver naturally.If the placenta still can't be removed. but may take as long as an hour. probably because the placenta was designed to stay put for 40 weeks. . you may need more drugs which are given intravenously to help the uterus contract down. you may be referred for an ultrasound scan to see if there are any fragments of placenta or membrane in your uterus. I had a retained placenta with my first labour. the placenta normally detaches from the inside of the uterus and is expelled.a procedure known as evacuation of retained products of conception (ERPC). you will be admitted to hospital for removal under anaesthetic . Retained Placenta After delivery of the baby. Normally this occurs within a few minutes of delivery of the baby. Retained placenta is more common in premature births than those born full term. However. After manual extraction. If you have prolonged heavy bleeding in the days or weeks following the birth. Can I do anything to stop it happening again? If you have already had a retained placenta in a previous birth. it may need to be removed manually. There is not much you can do to prevent it happening again if it was due to the placenta adhering to an old caesarean scar.

These abnormal attachments may be partial or complete. You may need to release the placenta and then re-grab it. The placenta being expelled from the vagina. Insert the side of your hand in between the placenta and the uterus. curl your fingers around the bulk of the placenta and exert gentle downward and outward traction. sweep the placenta off the uterus. It may be necessary to curette the placental bed to reduce bleeding. You may need to push through the placental membranes to accomplish this. be prepared to deal with an abnormally adherent placenta (placenta accreta or placenta percreta). Most placentas can be easily and uneventfully removed in this way. Sometimes. Placenta Accreta and Percreta When you manually remove the placenta. A few prove to be problems. a manual removal of the placenta is undertaken. . Using the side of your hand. If partial and focal. the attachments can be manually broken and the placenta removed. Commonly. IV narcotic analgesia will prove helpful in relieving this discomfort Manual Removal of the Placenta One hand is inserted through the vagina and into the uterine cavity. After most of the placenta has been swept off the uterus. after about 30 minutes of waiting or if there is increased bleeding without evidence of placental separation.Change in shape of the uterus from flat (discoid) to round (globular). Then pull the placenta through the cervix. Anesthesia (regional or general) is typically used for this as manual removal can cause considerable abdominal cramping.

Bleeding from this problem will be considerable. Hypertonic Uterine Dysfunction An elevated tone of the uterus that generally occurs in the latent phase of labor. which will lead to prolonged labor. Synonym(s): Uterine hyperstimulation or hypertonic uterine dysfunction is a potential complication of labor induction. Uterine hyperstimulation may result in fetal heart rate abnormalities. The condition causes frequent and intense contractions. uterine rupture. Contractions are usually irregular and are not forceful enough to dilate cervix at a satisfactory rate. post partum uterine artery ligation or hysterectomy. It is defined as either a series of single contractions lasting 2 minutes or more or a contraction frequency of five or more in 10 minutes. or placental abruption. This may be caused by the mid segment of the uterus contracting with such a force that is greater than the fundus or a lack of nerve impulse synchronization. after the cervix has dilated to more than 4 cm.Recovery is usually satisfactory. consider tight uterine and/or vaginal packing to slow the bleeding until surgery is available. It is usually treated by administering terbutaline. Hypotonic Uterine Dysfunction Uterine dysfunction that typically occurs during the active phase of labor. although more than the usual amount of post partum bleeding will be noted. . and the patient will likely end up with multiple blood transfusions while you prepare her for a life-saving. you probably won't be able to remove the placenta in other than handfuls of fragments. If extensive or complete. If surgery is not immediately available. but they are not effective.

Secondary inertia: inertia developed after a period of good uterine contractions when it failed to overcome an obstruction so the uterus is exhausted. * More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia. weak and of short duration Etiology Unknown but the following factors may be incriminated: General factors: > Primigravida particularly elderly. Management : . * Slow cervical dilatation. Clinical picture * Labour is prolonged. oxytocin as in induced labour. * Tocography: shows infrequent waves of contractionswith low amplitude. * Uterine contractions are infrequent. weak and of short duration. > Hormonal due to deficient prostaglandins or > Improper use of analgesics. >Anaemia and asthenia. > Nervous and emotional as anxiety and fear. * The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour.Definition The uterine contractions are infrequent. * Membranes are usually intact. Types Primary inertia: weak uterine contractions from the start.

General measures > Examination to detect disproportion. Amniotomy: a. > Prophylactic antibiotics in prolonged labourparticularly if the membranes are ruptured. > vaginal delivery is amenable. > Proper management of the first stage (see normal labour).1. >the cervix is more than 3 cm dilatation and > the presenting part occupying well the lower uterine segment .malpresentation or malposition and manage according to the case.Providing that.

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