RETAINED

PLACENTAL
FRAGMENTS

BY: CELIA R. RECEL, RN,

MAN
DEFINITION:
◦is a condition in which you fail to expel placenta and
membranes within 30 minutes of the birth of your baby. This
condition is also known as retained fetal membrane or
retained cleansing.
◦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
 Retained Placental Fragments
RISK FACTORS CAUSES
◦ Previous retained placenta
◦ Placenta separated but not expelled
◦ Previous injury or surgery to the uterus
◦ Preterm delivery ◦ Simple Adherent Placenta
◦ Induced labor ◦ Morbid adherence of the placenta:
◦ Multiparity
1. Placenta Accreta
◦ Premature labor or giving birth before the 34th week of
pregnancy. 2. Placenta Increta
◦ Induction or augmentation of labor.
3. Placenta Percreta
◦ Lobulated placenta.
◦ Constriction ring-reforming cervix
◦ Previous cases of retained placenta.
◦ Having more than five births previously. ◦ Full bladder
◦ Conceiving after the age of 35. ◦ Uterine abnormality
◦ Giving birth to a stillborn baby.
◦ Prolonged first or second stage of labor.
 Causes of Retained Placenta
1. 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
2. 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.
3. 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 up to 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
4.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
Morbid adherence
of the placenta:

1. Placenta Accreta
2. Placenta Increta
3. Placenta Percreta
Signs And Symptoms Of Retained Placenta a day after the
delivery:

◦Fever
◦Foul smelling discharge containing large tissue
residue
◦Persistent bleeding
◦Severe cramps and contractions
◦Delay in milk production
Risks of Retained Placenta
◦There may be severe bleeding which may be life-
threatening.
◦ 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.
1. 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.
 Management / Treatment of
Retained Placenta
2. 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
Management / Treatment of
Retained Placenta
3. Curettage
o In the case of placenta accreta, manual
removal is done partially, and curettage
removes the rest.
oUnder this method, a curette is used to
remove the placental debris from the uterus
through scrapping
 Management / Treatment of Retained
Placenta
4. 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
1. Uterine inversion
2. Shock (hypovolemic)
3. Postpartum hemorrhage
4. Puerperal Sepsis
5. Subinvolution
6. Hysterectomy