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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 labor. 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 or in your intravenous line, 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 percent of cases within 30 minutes of your baby's birth, if you have a managed third stage - this happens in less than 5 percent 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 doctor or 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 this happens you can usually help to deliver the placenta by pushing with a contraction when the midwife tells you to, but occasionally the cervix will have closed too much to let the placenta out. Retained placenta may be due to a small piece of placenta, connected to the main part of the placenta by a blood vessel, being left behind in the uterus. This is called a succenturiate lobe. The obstetrician or midwife will examine the placenta and membranes carefully after delivery to ensure that they are complete. If she notices a vessel leading to nowhere, this should alert her to the possibility of part of the placenta being retained. Sometimes a part of the placenta may adhere to a fibroid, or a scar from a previouscesarean section. Sometimes a full bladder will prevent the placenta from being delivered, so your doctor or midwife may insert a catheter to drain your bladder. What are the problems associated with retained placenta? Normally after the placenta is delivered, your uterus contracts down to close off all the blood vessels inside the uterus. If the placenta only partially separates, the uterus cannot contract properly, so the blood vessels inside will continue to bleed. If the third stage is managed and delivery of the placenta takes longer than 30 minutes after the birth of your baby, your risk of heavy bleeding increases substantially. Heavy bleeding in the first 24 hours after birth is known as primary postpartum hemorrhage (PPH). If small fragments of placenta or membrane are retained and are not detected immediately, this may cause heavy bleeding and infection later on. This is known as secondary PPH and happens in just under one per cent of births. How is it treated? If the third stage is taking a while, you could try breastfeeding your baby or rubbing your nipples, as this can cause the uterus to contract and may help to expel the placenta. If you're sitting or lying down, try changing to a more upright position so that gravity can help. If you choose a managed third stage, you'll be given an injection of an oxytoxic drug to make your uterus contract and your doctor or midwife will use controlled cord traction to gently pull the placenta out. If the placenta still can't be removed, it may need to be removed manually. You'll be given a regional anesthetic such as a spinal or epidural, or you can ask for a general anesthetic if you prefer. Before the placenta is removed manually your doctor or midwife will insert a catheter in to empty your bladder and you'll be given intravenous (IV) antibiotics to prevent infection. After manual extraction, you may need more drugs which are given intravenously to help the uterus contract down. If you have prolonged heavy bleeding in the days or weeks following the birth, you may be referred for an ultrasound scan to see if there are any fragments of placenta or membrane in your uterus. If so, you will be admitted to hospital for removal under anesthetic - a procedure known as evacuation of retained products of conception (ERPC), and treated with antibiotics. The uterus not contracting. If the uterus does not contract the placenta cannot separate. In some cases weaker, uncoordinated contractions can lead to partial separation, not being strong enough to fully detach and deliver the placenta. A strong contraction can be stimulated with either natural interventions or with oxytocic injections. A full bladder. If the woman's bladder is full the uterus may not be able to contract adequately. The placenta can stay attached or only partially separate, until the bladder is emptied. 'Fiddling' with the uterus. Actions by the caregiver prodding, poking, massaging or 'rubbing up' the uterus before the placenta has separated (often referred to as 'fiddling' with the uterus) can interfere with the complete detachment of the placenta. These procedures were commonly performed in the past, aimed at stimulating a contraction. We now know that they can often cause weaker, irregular contractions leading to partial separation of the placenta and in some cases retention of the placenta within the uterus. Partial separation can increase the woman's blood loss possibly leading to a postpartum haemorrhage. Prematurely pulling on the cord before the placenta separates can also cause partial separation. A bicornuate uterus. This is where the woman has an unusually shaped uterus. A piece of tissue or 'septum' inside the uterus (that was present before the pregnancy) extends from the top of the uterus or fundus, inside the uterus. This is also known as a 'heart-shaped uterus'.