Retained placenta

Nirsuba Gurung Assistant Lecturer

MSON

RETAINED PLACENTA

1Nirsuba Gurung

MSON

Failure of placental delivery within 30 minutes after delivery of the fetus.

Longer the placenta remains in uterus after delivery of baby, the greater is the risk of PPH

2Nirsuba Gurung MSON

Morbid Adherence of the placenta Placenta Acreta (Placenta Accreta occurs

when the placenta attaches too deep in the uterine wall but it does not penetrate the uterine muscle. Placenta accreta is the most common accounting for approximately 75% of all cases.)

Placenta Increta (Placenta Increta occurs when the placenta attaches even deeper into the uterine wall and does penetrate into the uterine muscle. Placenta increta accounts for approximately 15% of all cases.)


Placenta Percreta (Placenta Increta occurs when the placenta attaches even deeper into the uterine wall and does penetrate into the uterine muscle. Placenta increta accounts for approximately 15% of all cases.)

Uterine Abnormality ,uterine atony Constriction Ring - reforming cervix Full bladder

Nirsuba Gurung MSON 4

If the placenta is undelivered after 30 minutes consider: Emptying bladder Breastfeeding or nipple stimulation Change of position - encourage an upright

position

The management is done according to condition of placenta as SeperatedUnseparated complicated

If the placenta is separated and retained :express placenta by controlled cord traction

Unseparated retained placenta :manual removal of placenta under general anesthasia


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)



Manual placenta removal is a procedure to remove a retained placenta from the uterus after childbirth

Take blood for grouping and cross match and send for hemoglobin if it has not been done

• Tell the woman (and her support person) what is going to be done, listen to her and respond attentively to her questions and concerns.

• Provide continual emotional support and reassurance, as feasible.


• Prepare the necessary equipment• Antiseptic solution • Sterile gloves Blood and subtitutes Anasthesia and analgesics Ergometrine and oxytocin Antibiotics

Give anesthesia (IV pethidine (25-50mg) and diazepam (10 mg), or ketamine

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 Put on personal protective equipment.

Use antiseptic handrub or wash hands and forearms thoroughly with soap and water and dry with a sterile cloth or air dry.

Put high-level disinfected or sterile surgical gloves on both hands. (Note: elbow-length gloves should be used, if available.)

Hold the umbilical cord with a clamp Pull the cord gently until it is parallel to the

floor

Place the fingers of one hand into the vagina ih the shape of cone by drawing the fingers and the thumb together and into the uterine cavity, following the direction of the cord until the placenta is located.

Do not go in and out of the uterus as these increase the risk of infection

When the placenta has been located, let go of the cord and move that hand onto the abdomen to support the fundus abdominally and to provide counter-traction to prevent uterine inversion

Move the fingers of the hand in the uterus laterally until the edge of the placenta is located.


Supporting the fundus while detaching the placenta

Keeping the fingers tightly together, ease the edge of the hand gently between the placenta and the uterine wall, with the palm facing the placenta.

Gradually move the hand back and forth in a smooth lateral motion until the whole placenta is separated from the uterine wall:

Withdrawing the hand from the uterus

If the placenta does not separate from the uterine wall by gentle lateral movement of the fingers at the line of cleavage, suspect placenta accreta and arrange for surgical intervention


When the placenta is completely separated: Palpate the inside of the uterine

cavity to ensure that all placental tissue has been removed.

Slowly withdraw the hand from the uterus bringing the placenta with it.

Continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn.

Give oxytocin 20 units in 1 L IV fluid (normal saline or Ringer’s lactate) at 60 drops/minute.

Have an assistant massage the fundus to encourage atonic uterine contraction.

If there is continued heavy bleeding, give ergometrine 0.2 mg IM or give prostaglandins.

Examine the uterine surface of the placenta to ensure that it is complete.

Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy.

Immerse both gloved hands in 0.5% chlorine solution. Remove gloves by turning them inside out. If disposing of gloves, place them in

a leak proof container or plastic bag.

If reusing surgical gloves, submerge them in 0.5% chlorine solution for 10 minutes for decontamination

Use antiseptic hand rub or wash hands thoroughly with soap and water and dry with a clean, dry cloth or air dry.

Monitor vaginal bleeding and take the woman’s vital signs: Every 15 minutes for 1 hour Then every 30 minutes for 2 hours

Make sure that the uterus is firmly contracted.

Record procedure and findings on woman’s record.

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.


Shock Postpartum haemorrhage Puerperal Sepsis Subinvolution Hysterectomy Embolism Thrombophlebitis Risk of reoccurence


Umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta. Saline solution alone does not appear be more effective than expectant management. The difficulties in implementing this intervention are related to the training of personnel in the technique of giving injections into the umbilical vein.


The incidence of placenta accreta has increased 10-fold10-fold in in the past 50 yearsthe past 50 years, to a current

frequency of 1 per 2,500 1 per 2,500 deliveriesdeliveries.

largely as a result of the increase in the number increase in the number of cesarean sectionsof cesarean sections


Risk factors for placenta accreta include :1. placenta previa with or without previous

uterine surgery.2. previous myomectomy.3. previous cesarean delivery. 4. submucous leiomyomata. 5. maternal age of 36 years and older.


Active Mx of third stage can prevent & reduce the incidence of retained placenta.

In case of risk factors,always consider placenta accreta & L/f usg/doppler features in antenatal period & plan accordingly.


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Health & Medicine

Retained placenta