Retained Placenta

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 Retained Placenta

• Definition:Failure of placental delivery within

30 minutes after delivery of the foetus.

• Incidence: 1%.

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 Causes
1. Retained separated placenta due to:
> Atony of the uterus: due to causes mentioned
before.
> Constriction ring.
> Rupture uterus: where the placenta passes to
the peritoneal cavity.

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 Causes
2.Retained non-separated placenta due to:
> Atony of the uterus.
>Abnormal adherence of the placenta which
may be:
a. Simple adhesion: Manual separation can be
done easily.
b. Morbid adhesion:Placenta accreta/Placenta
accreta/Placenta percreta
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 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.
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 Management
Uterine atony
* Ergometrine and massage with gentle cord
traction if failed do,
* Brandt-Andrews manoeuvre if failed do,
* Crédé’s method if failed do,
* Manual separation of the placenta.

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 Constriction ring
• Deep anaesthesia and amyl nitrite inhalation
are given before manual separation of the
placenta.

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Morbid adherence of the placenta
* Simple adhesion and partial placenta accreta:
Manual separation is usually successful.
* Complete accreta: 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. The patient is given antibiotics to
guard against infection and methotrexate to
enhance the autolysis.

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 In case of rupture uterus
• Manage as in rupture uterus.
• Crédé’s method:
* The bladder is evacuated.
* The uterus is massaged to induce contraction.
* The fundus is grasped by 4 fingers behind and
the thumb in front to squeeze the placenta.
* The fundus is then pushed downwards and
backwards to expel the placenta.
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 Complications
* Shock.
* Inversion of the uterus.
* Partial separation of the placenta causing postpartum
haemorrhage.
* Retained parts of the placenta or membranes.
* Failure due to:
> obesity,
> non-co-operative patient,
>placenta accreta
> rigidity of the abdominal wall, or
> constriction ring.
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 Manual Removal of The Placenta

* The procedure is done under general

anaesthesia.
* The right hand is introduced along the
umbilical cord into the uterus.
* The lower edge of the placenta is identified
and by a sawing movement from side to side
the placenta is separated from its bed.

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 Manual Removal of The Placenta
* Grasp the placenta and deliver it out.
* Examine the placenta and membranes for
completeness.
* The left hand is supporting the uterus
abdominally throughout the procedure.

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 Complications
* Perforation of the uterus.
* Retained parts.
* Infection.

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 Complications of Retained Placenta

* Shock.
* Postpartum haemorrhage.
* Puerperal sepsis.
* Subinvolution.
* Retained parts with subsequent haemorrhage,
infection, placental polyp formation or
choriocarcinoma.
* Complications of the methods used for its
separation.

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