EXAMINATION OF PLACENTA

INTRODUCTION

Placenta is formed by foetal and maternal components •Maternal component –decidua

placental is the inner portion of the placenta, which is formed by trophoblastic invasion of
endometrium •Fetal component –chorion frondosum is formed by an arterial plexus (branches
of umbilical artery), protruding into inter villous spaces as chorionic villi placenta normally
lies along the anterior or posterior wall of uterus and may extend to lateral wall with
increasing gestational age .

•The term placenta weighs ~470g to 500g and measures ~22cm in diameter with a thickness
of 2.0-2.5cm •Placental thickness is usually directly proportional to gestation age, to the
extent that it can often predict the gestation weeks (e.g. 21 mm thickness at 21 weeks
gestation).

Examination of the Placenta

•A 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, hemorrhage, tumors and nodules
should be noted

DEFINITION

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.
PURPOSE 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.
 To ensure that the entire placenta and membranes have been expelled and no part has
been retained.
 To make sure that placenta is of normal size, shape, consistency and weight.
 To detect abnormalities such as infarctions, calcification and additional lobes.
 . To detect the length of the cord, number of blood vessels and site of insertion of the
cord.
 To check weight of placenta and measure length of cord
Clinical Characteristics of the Normal Placenta

 A fresh, term, healthy placenta is approximately 15 – 20 cm in diameter

 2.0 to 2.5 cm thick and height ranges between 40 -60cm. It generally weighs
approximately 5-600gms (1/6 of the baby’s birth weight)
 The maternal surface of the placenta should be dark maroon in colourand should
consist of around 20 cotyledons. The structure should appear complete, with no
missing cotyledons.
 The fetal surface of the placenta should be shiny, gray and translucent enough that the
color of the underlying maroon villous tissue may be seen.
 The normal cord contains two arteries and one vein. During the placental
examination, the delivering physician should count the vessels in either the middle
third of the cord or the fetal third of the cord, because the arteries are sometimes fused
near the placenta and are therefore difficult to differentiate.
 Fetal membranes are usually gray, wrinkled, shiny and trans lucent. It consist of two
layers; the amnion and the chorion.
PROCEDURE: EXAMINATION OF THE
PLACENTA

 Explain the procedure to the parents and ask if they wish to observe.
 Ensure that there is adequate lighting to check the placenta.
 If the lighting in the delivery room is dim, it is advised that the placenta is
examined in an alternative location where there is adequate lighting
 Prepare a flat surface with protection to avoid blood spillage.
 Prepare syringe and needle if cord samples are required
 Wearing an apron and gloves lay the placenta fetal side uppermost, noting the
size, shape, smell and colour.
 Examine the cord, noting the length, insertion point and presence of true knots or
thrombi.

Inspect the umbilical cord vessels

 at the cut end at the furthest point from the placenta as the arteries can be fused
around the insertion site making it difficult to differentiate them.
 Observe the fetal side for irregularities such as succenturate lobes, missing
cotyledons, fatty deposits or infarctions
 Lift the placenta up by the cord, by doing this the membranes can be observed for
completeness. There is usually a single hole where the baby passes through the
membranes
 Return the placenta to the surface and spread out the membranes to look for extra
vessels, lobes or holes in the surface.
 Separate the amnion from the chorionby pulling the amnion back over the base of the
umbilical cord to ensure both are present.
 over to inspect the maternal surface.
 Examine the cotyledons, ensuring all are present, noting the size and any areas of
infarction, blood clots or calcification. Retain the clots to make an accurate
assessment of blood loss.
 The lobes of a complete placenta fit neatly together without any gaps with the edges
forming a uniform circle.
 Broken fragments of cotyledon should be carefully replaced before making an
accurate assessment. E.g. succenturate lobes, missing cotyledons, fatty deposits or
infarctions.
ARTICLES REQUIRED FOR EXAMINATION OF PLACENTA,
MEMBRANES AND CORD
Equipment’s Rationale

1. Placenta with cord 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 examiner from spilled blood

5. Plastic apron- 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 balls- 2 or 3 To separate the membranes

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’s.

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

6, This aids in inspection of membranes. If the membranes are complete, strip the amnion

from the chorion and see if both membranes are present.

7. Spread the mackintosh on the table surface and lay the placenta on a flat surface.

8. 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 bysulci
(furrows) in to which decidua dips down to form septa.

III. Normally maternal surface is dark red in colour but whitepatches/ infarctions may be seen
on maternal surface thatmay be due to the disposition of lime salts. The edges of thematernal
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.

IV. Separate amnion and chorion using the probe. Peel off amnion from the fatal surface till
the insertion of cord to
see the chorionic plate from which the placenta develops.

V. Note the insertion of the umbilical cord. It is normally central but it may be laterally
inserted.

VI. Measure the length of the umbilical cord. It is normally 50cm and ranges from 30-100
cm. 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.

VII. Clean the stump of the cord and look for vessels. It has two arteries and one vein. Note
for the knots in the cord.

VIII .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
The baby weight at term.

IX. Record the findings of examination of placenta and membranes and an estimate of blood
loss in mother’s note

X. Discard placenta in yellow bag after the procedure is over. Discarded placenta is sent for
incineration.

XI. Perform the aftercare of articles and replace all the articles to utility

EXAMINATION 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

 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 3distinct 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.

EXAMINATION OF 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 adiabatic mother, congenital malformations (especially genital
and renal) of foetus.

 Missing a blood vessel

: May indicate congenital anomaly of gastrointestinal and genitourinary system