RETAINED PLACENTA

Worku A.
 Objectives
At the end of this session, the students will
able to:
• Define retained placenta
• Discuss cause of retained placenta
• Explore management of retained placenta
• Demonstrate manual removal of retained placenta.
 Retained Placenta

Definition: The placenta is said to be retained when

it is not expelled out even 30 minutes after the
birth of the baby.
 Causes Retained Placenta
There are three phases involved in the normal
expulsion of placenta:
Separation through the spongy layer of the
decidua
Descent into the lower segment and vagina
Finally its expulsion to outside.
 Causes retained placenta cont …..
Interference in any of these physiological processes,
results in its retention.
A. Placenta completely separated but retained -is due to
poor voluntary expulsive efforts.
B. Simple adherent placenta

- is due to uterine atonicity in cases of grand multipara,

over distension of uterus, prolonged labor, uterine
malformation or due to bigger placental surface area.
 The commonest cause of retention of non-separated
placenta is atonic uterus
 Causes Retained Placenta cont …..

C. Morbid adherent placenta—partial or complete.

 Placenta accreta: There is deficient or absent
decidua basalis so that chorionic villi penetrate the
superficial layer of the myometrium either
partially (partial placenta accreta) or completely
(complete placenta accreta).
 Morbid adherent placenta cont…..
 Placenta increta : The chorionic villi penetrate
deeply in the myometrium.
 Placenta percreta: Penetration up to the peritoneal
coat.
 The condition is more associated with placenta
praevia due to defective decidual reaction in the
lower segment.
 Causes Retained Placenta cont …..

D. Placenta incarcerated following partial

or complete separation
-due to constriction ring (hour-glass
contraction), premature attempts to deliver
the placenta before it is separated.
 Clinical Picture
 Bleeding : occurs only if the placenta is separated
partially or completely.
 Uterus: is lax in case of atony.
 Vaginal examination may reveal:

- Constriction ring.
- Rupture uterus.
-Morbid placental adherence where there is no
plane of cleavage.
 Diagnosis Retained Placenta

 The diagnosis of retained placenta is made by an

arbitrary time (30 minutes) spent following delivery
of the baby.
 Features of placental separation are assessed
 The hour-glass contraction or the nature of
adherent placenta (simple or morbid) can only be
diagnosed during manual removal.
 Management of retained placenta

 During the period of arbitrary time limit of half an

hour, the patient is to be watched carefully for
evidence of any bleeding, revealed or concealed
and to note the signs of separation of placenta.
 The bladder should be emptied using a rubber
catheter.
 Any bleeding during the period should be managed
as outlined in third stage bleeding.
 Management cont…..
 Placenta is separated and retained

-To express the placenta out by controlled cord

traction.
 Unseparated retained placenta (apparently
uncomplicated): -Manual removal of placenta
 Management cont…..
Management of Unforeseen Complications during
Manual Removal
1. Hour-glass contraction—The placenta, either
unseparated or separated—partially or completely,
may be trapped by a localized contraction of circular
muscles of the uterus
• Administration of any oxytocic, especially ergometrine in
the active management of third stage or undue irritability of
the uterus by premature attempts to express the placenta is
the important cause.
 Management cont…..
• Management: The ring should be made to relax
by deepening the plane of anesthesia (halothane
is useful in these cases),
• Then the cone shaped hand is introduced and
the separation of the placenta is preferably done
from above downwards to minimize bleeding.
 Management cont…..

2. Morbid adherent placenta—In majority, the

diagnosis is made only during attempted manual
removal.
 Hysterectomy is the treatment.
 If the patient is young and in need of more
children, the umbilical cord is cut short and
placenta is left in situ to undergo autolysis.
 Management cont…..
Complicated retained placenta
 Retained placenta with shock but no hemorrhage:

-To treat the shock and when the condition improves, manual
removal of the placenta is to be done.
 Retained placenta with hemorrhage:
 Retained placenta with sepsis:

- Provide broad spectrum antibiotic, then as soon as the

general condition permits, arrangement is made for manual
removal.
 Complicated retained placenta …cont

 Retained placenta with an episiotomy wound:

-The bleeding points of the episiotomy wound
are to be secured by artery forceps.
-An early decision for manual removal should be
taken followed by repair of the episiotomy
wound.
 Retained Placental Fragments
 When a portion of the placenta—one or more lobes—
is retained, it prevents the uterus from contracting
effectively.
 Feel inside the uterus for placental fragments.
 Manual exploration of the uterus is similar to the
technique described for removal of the retained
placenta.
 Remove placental fragments by hand, ovum forceps or
large curette.
 MANUAL REMOVAL OF PLACENTA

• Review for indications.

• Review general care principles and start an IV
infusion.
• Provide emotional support and encouragement.
• Give Pethidine and diazepam IV slowly (do not
mix in the same syringe) or use Ketamine
 Manual Removal cont……
• Give a single dose of prophylactic antibiotics:

- Ampicillin 2 g IV PLUS Metronidazole 500 mg IV;

- OR cefazolin 1 g IV PLUS Metronidazole 500 mg
IV.
• Hold the umbilical cord with a clamp.
• Pull the cord gently until it is parallel to the floor.
 Manual Removal cont……

• Wearing high-level disinfected

long sleeve gloves or similar
modification, insert a hand into
the vagina and up into the
uterus
 Manual Removal cont……
• Let go of the cord and move the hand up over the
abdomen in order to support the fundus of the uterus and
to provide counter-traction during removal to prevent
inversion of the uterus.
• Move the fingers of the hand laterally until the edge of the
placenta is located.
 Manual Removal cont……

• If the cord has been detached previously,

insert a hand into the uterine cavity.
• Explore the entire cavity until a line of
cleavage is identified between the placenta
and the uterine wall.
 Manual Removal cont……

 Detach the placenta from

the implantation site by
keeping the fingers tightly
together and using the
edge of the hand to
gradually make a space
between the placenta and
the uterine wall.
 Manual Removal cont……
 Proceed slowly all around the placental bed until
the whole placenta is detached from the uterine
wall.
 If the placenta does not separate from the
uterine surface by gentle lateral movement of
the fingertips at the line of cleavage, suspect
adherent placenta
 Manual Removal cont……

 Hold the placenta and slowly withdraw the

hand from the uterus, bringing the
placenta with it.
 With the other hand, continue to provide
counter-traction to the fundus by
pushing it in the opposite direction of the
hand that is being withdrawn
 Manual Removal cont……
• Palpate the inside of the uterine cavity to ensure
that all placental tissue has been removed.
• Give oxytocin 20 units in 1 L IV fluids (normal
saline or Ringer’s lactate) at 60 drops per minute.
• If there is continued heavy bleeding, give
ergometrine 0.2 mg IM or prostaglandins.
• Examine the uterine surface of the placenta to
ensure that it is complete
 Manual Removal cont……

Post-procedure Care

• Observe the woman closely in labor ward or

where she can be monitored closely for at least 6
hours or until stable.
• Check and rub the uterus every 15 minute for
the next two hours.
 Post-procedure Care cont…..

• Monitor the vital signs (pulse, blood pressure,

respiration) every 30 minutes for the next 6
hours
• Continue with IV fluid and oxytocin drip for next 4-6
hours.
• Continue infusion of IV fluids.

• If patient is stabilized, assist her to initiate breast

feeding if appropriate
Thank You!!!