RETAINED

PLACENTA
• DEFINITION:
• The placenta is said to be retained when
it is not expelled from the uterus even 30 minutes
after the delivery of the baby
• Normally the placenta is expelled in three stage - it
first separates from the uterine muscle, then it
descends into the lower segment of the uterus and
vagina and then it is expelled outside. Problems can
occur at any of these stages
 Risk Factors
• Previous retained placenta
• Previous injury or surgery to the uterus
• Preterm delivery
• Induced labor
• Multiparity
 Causes
• Placenta separated but not expelled
• Simple Adherent Placenta
• Morbid adherence of the placenta:
Placenta Accreta
Placenta Increta
Placenta Percreta
• Constriction ring-reforming cervix
• Full bladder
• Uterine abnormality
 Causes of Retained Placenta
• Placenta separated but not expelled: The placenta
may separate completely from the uterine muscle
but may still be retained within the uterus. There
are three causes for this retention:
• Failure of the woman to push out the placenta due
to exhaustion or prolonged labour.
• Closure of the cervix preventing the placenta from
being expelled.
• A constriction ring in the uterus can hold up the
placenta
• Simple Adherent Placenta:The placenta may fail to
separate completely from the uterine muscle due to
lack of contraction of the uterine muscles. This
condition, called 'uterine atonicity' occurs in
cases where the uterine muscles have become lax,
either due to repeated pregnancy, prolonged labor
or overdistension of the uterus during pregnancy, as
in twin pregnancy. Simple Adherent Placenta is the
commonest cause for retention of placenta.
• Morbid adhesion of the placenta: Morbid adhesion
of the placenta can occur when the placenta is
implanted deeply into the uterine muscles and thus
fails to separate. The placenta can burrow upto
different depths in the uterine muscle. In simple
cases, it is only attached firmly to muscle and can
be stripped off by hand. In severe morbid adhesion,
the placenta can burrow through the full thickness
of the muscle. In this case, the uterus may be
needed to be removed ('hysterectomy') to control
the bleeding. There are three types of morbid
adhesion of the placenta
• Placent Accreta: In this condition, the placenta
penetrates deep into the uterine endometrium and
reaches the muscles but does not penetrate into the
muscles.
• Placent Increta: Here, the placenta attaches even
deeper into the uterine wall and penetrates into the
uterine muscle.
• Placent Percreta: In this condition, the placenta not
only penetrates through the full thickness of the
uterine muscles but also attaches to another organ
such as the bladder or the rectum. Placenta percreta is
very rare
 Risks of Retained Placenta

• There may be severe bleeding which may be

lifethreatening.
• Attempts at manual removal of the placenta can
cause multiple injuries to the mother such as like
vulvar hematoma, perineal tears, cervical tears and
vaginal wall tears.
 Management Details
• If the placenta is undelivered after 30 minutes
consider:
• Emptying bladder
• Breastfeeding or nipple stimulation
• Change of position – encourage an upright position
• If bleeding: immediately
• Inform Anaesthetist
• Insertion of large bore IV (18g) cannula
• Insert urinary catheter
• Commence/continue oxytocin infusion 20 units in 1
litre / rate – 60drops per min
• Measure and accurately record blood loss
• Prepare and transfer patient to theatre for manual
removal of placenta (MROP)
 Management / Treatment of Retained
Placenta
• Treatment will depend on the cause of the retention of the
placenta. If bleeding is present, active treatment is done to
control the blood loss and support the general condition of
the patient.
• Controlled Cord Traction

• If the placenta is separated but not expelled, then controlled

cord traction should be carried out. In this method, the uterus
is held in place or pushed up gently through the abdominal
wall by the left hand. The cut umbilical cord hanging from the
vagina is held in the right hand and pulled steadily and slowly
to pull out the placenta.
• Manual removal of the placenta

• The placenta may need to be removed manually if

controlled cord traction fails.
• The patient is put under general anesthesia in the
operation theatre. Under all aseptic conditions, the
sterile gloved hand of the doctor is inserted into the
uterus. The placenta is stripped from the uterine
muscle gently and brought out.
Introducing one
hand into the
vagina along cord
Supporting the fundus
while detaching the
placenta
• Hysterectomy: If the placenta is too deeply
embedded into the uterine musculature (called
placenta accrete), a hysterectomy to remove the
uterus may be indicated.
 Post procedure care

• Observe the woman closely until the effect of IV

sedation has worn off.
• Monitor the vital signs (pulse, blood pressure,
respiration) every 30 minutes for the next 6 hours
or until stable.
• Palpate the uterine fundus to ensure that the
uterus remains contracted.
• Check for excessive lochia.
• Continue infusion of IV fluids.
• Transfuse as necessary.
 Complications of a Retained Placenta
• Uterine inversion
• Shock (hypovolemic)
• Postpartum hemorrhage
• Puerperal Sepsis
• Subinvolution
• Hysterectomy
Thank you