RETAINED PLACENTA

Stages of labour :
• First stage is when the cervix
dilates to 10 cm.
• Second stage is delivery of the
baby through the vagina
• Third stage is when the placenta
is delivered
Management of the third stage
ACTIVE MANAGEMENT
• Routine use of Oxytocin
(uterotonic)
• Early clamping and cutting
of the cord
• Controlled cord traction
RECOMENDED
PHYSIOLOGICAL
MANAGEMENT
• No routine use of uterotonic
drugs
• Clamping of the cord only
after pulsation stops
• Placenta delivered by
maternal effort
Definition of Retained Placenta
A placenta is retained when it has not been expelled after:
• 30 minutes following active management
• 60 minutes following physiological management of the third stage
PATIENTS MAY PRESENT WITH POST-PARTUM HAEMMORHAGE
CAUSES:
• Placenta adherens: Myometrium fails to contract behind the placenta.
• Trapped placenta: detached placenta is trapped behind a closed
cervix.
• Placenta accreta: Placenta penetrates the myometrium to a varying
degree preventing detachment.
First establish has the placenta separated
• Indicated by:
1. A sudden rush of blood.
2. Fundus moves higher and becomes rounded.
3. Increase in length of part of the umbilical cord visible at the vulva.
4. Raising of fundus does not cause the cord to decrease in length.
The placenta has separated
• Try to deliver the placenta by 'rubbing up' the uterus.
• Then push it towards the vagina to help with expulsion of the
placenta and membranes.
• These are held and twisted whilst pulling constantly so that
membranes are kept intact.
How to Manage: the placenta has not separated
• ABCDE – Is the patient stable? (Pulse, Blood pressure & Respiratory rate)
• Ensure IV access
• Carry out the procedure under anaesthetic (epidural/general anaesthesia)
• Continue oxytocin infusion
• Attempts to remove the placenta .
How to remove the placenta
• Place a gloved hand into the uterus, with the other hand on the fundus to control
it.
• Follow the umbilical cord until you find the lower edge of the placenta.
• Push the hand between the placenta and the body of the uterus and ease the
placenta away with a sawing action
• When fully detached, explore the uterine cavity for damage and for other pieces of
placenta.
• Massage the fundus with one hand whilst extracting the placenta and membranes
with the hand in the uterine cavity.
• Look carefully at the placenta to be sure that it is complete.
• Inject ergometrine IV and IM.
Complications
• Infection
• Secondary Post partum haemorrhage
POST PARTUM HAEMMORHAGE
• Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls
and may be primary or secondary
• Primary PPH: occurs within 24 hours
Cause: Uterine atony (90% of cases), genital trauma, clotting
factors
• Secondary PPH occurs between 24 hours - 12 week
 Cause: Retained placental tissue or Endometritis
Risk factors for primary PPH include
• Previous PPH
• Prolonged labour
• Pre-eclampsia
• Increased maternal age
• Polyhydramnios
• Emergency caesarean section
• Placenta Praevia, placenta Accreta
• Macrosomia
• Ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
MANAGEMENT
• CALL FOR HELP & GIVE IMMEDIATE CLINICAL TREATMENT
1. ABCDE: Assess BR, HR, RR, gain IV access, Give oxygen if required
2. Give intravenous fluids
3. Identify source of bleeding
4. Insert catheter: Empty the bladder
5. Uterine massage
6. Uterotonic drugs - Administer bolus of:
• Oxytocin (10 UNITS intravenous) or
• Ergometrine (0.5 mg intramuscular) or
7. Controlled cord traction if the placenta has not yet been delivered
https://www.youtube.com/watch?v=MEt2IQz
ia6E
=UTERINE MASSAGE