RETAINED PLACENTA

A Case Study presented by

ESTUDILLO, EDLYN H.
NOOL, JANINE V.
 A 36 year- old female G3P3 (3003) went back to our clinic two weeks after post-

Introduction vaginal delivery due to increased vaginal bleeding, also fever

and pain that doesn’t stop. Her Temp. was 38.6, BP 90/60 mmHg, HR:
Of the case: 105 bpm, RR: 22 cpm, O2 Sat. 97% and
(+) vaginal bleeding.
She reported that the bleeding began on the tenth day after delivery and
has increased in severity each subsequent day. She also experienced fever
and pain that didn’t stop. The delivery was uncomplicated with
minimal blood loss and the patient did not receive any epidural
anesthesia.
She has taken 400mg ibuprofen, 3 times daily and Ferrous
Sulfate 325mg 2 times daily since the delivery. The patient
reported a medical history of iron deficiency anemia due
to menorrhagia. Also, patient was adopted and did not
know her family history.
After gathering all the data and her assessment,
patient was immediately referred to the
nearest hospital for appropriate
evaluation and treatment to her case.
 Introduction of the case:
HEALTH CARE PLAN
Alias/Age: Patient X/ 36 years old G3P2 Date Handled: May 18,
2018

This case is from Dela Cruz – Pascual Birthing Clinic. As part of our
case study, we ask for help regarding the topic given to us.
This patient was giving birth via NSD last January 4, 2019.
 Introduction of the case
HEALTHCARE PLAN
Plan of Care
Assessment Diagnosis Interventions Rationale Evaluation
Subjective: Post-Partum Hemorrhage After series of Advised to take medication as To lessen vaginal bleeding,
Patient X Complaint Secondary to Retained interventions prescribed by the doctor pain, and possible infection
“Lower Abdominal Pain, Placenta Patient will improve     
Fever, and Heavy bleeding”   (-) fever   For volume loss replacement After series of intervention, the
Less pain  
    patient was able to maintain
  From 6 to no pain, The position increases
  Monitor IVF and increased venous return, making sure a adequate cardiac output as
  pads used will lessen fluids intake evidenced by strong pulses, BP of
Objective: from 3-4 pads/day to 1-2 greater availability of blood
Temp. 38.6     to the brain and other vital 110/80 mmHg, PR of 85 bpm, Temp
pads
BP: 90/60 mmHg As evidence by hypotension skin color will be back to Maintain a bed rest with an organs. Bleeding may be of 36.8 absence of pain and
90/60 mmHg normal elevation of the legs by 20-30° decreased with the bed rest. vaginal bleeding
HR: 105 bpm
RR: 22 cpm
and heavy bleeding
increased heart rate 105bpm
  and trunk horizontal.
 
 
This will help in determining  
O2 Sat. 97%
(+) Vaginal Bleeding
(slightly elevated)   the fluid loss. A urine output
of 30-50 ml/hr. or more  
RR 22 cpm and  
  Vaginal bleeding  
indicates an adequate
circulating volume. Voiding
 
      difficulty may happen with ----Goal Met----
  Measure a 24-hour intake and hematomas in the upper
    output. Observe for signs of portion of the vagina causing
(+) Skin Pallor voiding difficulty. pressure in the urethra.
(+) Vaginal Bleeding
Consumed 3-4 pads/day
soaked with blood
Pain Scale: 6
 Introduction of the case
DRUG STUDY
DRUG ACTION INDICATION CONTRAINDICATION INTERACTION ADVERSE EFFECT NURSING CONSIDERATION
NAME
Generic Ibuprofen contains the Contraindicated in Sometimes, one medication can CNS: Use drug only as suggested;
Name active ingredient patients hypersensitive interfere with the effects of another. Headache, dizziness, avoid overdose. Take the drug
Ibuprofen Unknown. Ibuprofen which belongs to to drug and in those Specialists refer to this as drug nervousness, aseptic with food or after meals if GI
May inhibit a group of medicines called with angioedema, interaction. and meningitis upset occurs. Do not exceed
prostaglandi non-steroidal anti- syndrome of nasal CV: the prescribed dosage.
n synthesis, inflammatory drugs polyps or Drugs that may interact with Peripheral edema, fluid
to produce (NSAIDs). It works by bronchospastic ibuprofen include: retention, edema
Brand anti- blocking the action of a reaction to aspirin or EENT: Avoid over-the-counter drugs.
Name inflammator substance in the body called other NSAIDs. lithium Tinnitus Many of these drugs contain
Advil y, analgesic, cyclo-oxygenase. Cyclo- warfarin G.I: similar medications, and
Medicol anti-pyretic oxygenase is involved in the oral hypoglycemics Epigastric distress, serious overdosage can occur.
Advance effects production of various Contraindicated to high dose methotrexate nausea, occult blood
chemicals in the body, some pregnant women. medication for lowering blood loss, peptic ulceration,
of which are known as Use cautiously in pressure diarrhea, constipation, You may experience these side
Dosage prostaglandins, patients with G.I angiotensin-converting enzyme abdominal pain, effects:
400mg Protaglandins are produced disorders, history of inhibitors bloating, G.I fullness, Nausea, GI upset, dyspepsia
in response to injury or peptic ulcer disease, beta-blockers dyspepsia, flatulence, (take drug with food); diarrhea
certain disease and would cardiac diuretics heartburn, decreased or constipation; drowsiness,
Route otherwise go on to cause decompensation, appetite. dizziness, vertigo, insomnia
P.O pain, swelling and hypertension, asthma This may not be an exhaustive list of G.U: (use caution when driving or
inflammation. All the or intrinsic coagulation drugs that interact with ibuprofen. Acute renal failure, operating dangerous
Frequency medicines in this group defects Anyone who is considering using azotemia, cystitis, machinery).
Three (NSAIDs) reduce ibuprofen should ask a pharmacist or hematuria
times a inflammation caused by doctor whether it is safe to do so with Hematologic:
day (TID) body’s own immune their existing medication. Plolonged Report sore throat, fever, rash,
system, and are effective itching, weight gain, swelling
pain killers. Ibuprofen can in ankles or fingers, changes in
be used to relieve. vision, black or tarry stools
 Introduction of the case
DRUG STUDY
DRUG ACTION INDICATION CONTRAINDICATION INTERACTION ADVERSE EFFECT NURSING
NAME CONSIDERATION
Generic Essential Prevention The following conditions are Severe Interactions of ferrous Large doses aggravate Store all forms at room
Name: component and treatment contraindicated with this sulfate include: pepticulcer, regional temperature
Ferrous in the of iron drug. Check with your •none enteritis, and ulcerative
Sulfate formation of deficiency physician if you have any of colitis. Give between meals
hemoglobin, anemia the following: Serious Interactions of with water but may give
Brand Name: myoglobin, ferrous sulfate include: Severe Iron Poisoning: with meals if
Feosol and Conditions: •demeclocycline, *Vomiting* gastrointestinal discomfort
enzymes. It •iron metabolism disorder dolutegravir, doxycycline, Severe abdominal occurs
Classification: is necessary causing increased iron storage eltrombopag, fleroxacin, pain*Dehydration*Diarr
Enzymatic for effective •an overload of iron in the gemifloxacin, levofloxacin, hea*Hyperventilation*Pa
mineral erythropoies blood lymecycline, minocycline, llor or Avoid simultaneous
andIron is and •a type of blood disorder moxifloxacin, cyanosis*Cardiovascular administration of antacids
preparation transport or where the red blood cells mycophenolate, norfloxacin, collapse or tetracycline
utilization of burst called hemolytic ofloxacin, oxytetracycline,
Dosage: oxygen anemia tetracycline Do not crush sustained-
325mg •an ulcer from too much released preparations
stomach acid This document does not
contain all possible
Route: •ulcerative colitis, an interactions. Therefore, Eggs and milk inhibit
P.O inflammatory condition of the before using this product, tell absorption
intestines your doctor or pharmacist of
Frequency: •problems with food passing all the products you use. Keep Monitor daily pattern of
two times a through the esophagus a list of all your medications bowel activity and stool
day (BID) •diverticular disease with you and share the list consistency
•excess iron due to repeated with your doctor and
blood transfusions pharmacist. Check with your
physician if you have health
questions or concerns.
 Introduction:
The third stage of labor is the interval from
delivery of the infant to expulsion of the
placenta. Delayed placental separation and
expulsion is a potentially life-threatening
event because it impedes normal postpartum
contraction of the uterus, which can lead to
hemorrhage.
This topic will discuss the diagnosis and
management of a retained placenta after
vaginal birth. Management of retained
products of conception after a miscarriage or
pregnancy termination is reviewed
separately.
Retained Placenta
 This can be defined as lack of expulsion of
the placenta, within 30 mins. of delivery of
the infant.
 This definition is suitable in the 3rd
trimester, when the 3rd stage if labor is
actively manage, because 98% of the
placentas are expelled by 30 mins. In this
setting.

left untreated, a retained

When it’s
placenta can cause life-threatening
complications for the mother, including
infection and excessive blood loss.
What are the types Uterine atony
This is most common type of retained placenta
of Retained Placenta that normally happens when the uterus stops
contracting or does not contract
enough in order to push out
Trapped Placenta the placenta.
A trapped placenta occurs when the placenta detaches from
the uterus but doesn’t leave the body. This often occurs
because the cervix starts to close before the placenta is
removed, causing the placenta to become trapped behind it.
Placenta Accreta
Placenta accreta causes the placenta to attach to the
muscular layer of the uterine wall rather than the uterine
lining. This often makes delivery more difficult and causes
severe bleeding. If the bleeding can’t be stopped, blood
transfusions or a hysterectomy may be required.
Placenta Adherens
Placenta adherens is the most common type
of retained placenta. It occurs when the uterus,
or womb, fails to contract enough to expel
the placenta. Instead, the placenta remains
loosely attached to the uterine wall.
What Are the Signs and Symptoms
of a Retained Placenta?
 The most obvious sign of a retained placenta is a failure
of all or part of the placenta to leave the body within an
hour after delivery.

 When the placenta remains in the body, women often

experience symptoms the day after delivery. Symptoms
of a retained placenta the day after delivery can include:

 a fever
 a foul-smelling discharge from the vagina
that contains large pieces of tissue
 heavy bleeding that persists
 severe pain that persists
Who Is at Risk for
a Retained Placenta?
Factors that can increase your risk of a retained placenta include:
 being over age 30
 giving birth before the 34thweek of pregnancy,
or having a premature delivery
 having a prolonged first or second
stage of labor
 having a stillborn baby
Risk factors related to poor uterine contraction
 High parity
 Prolonged use of oxytocin
Risk factors related to abnormal placentation
 History of uterine surgery
 IVF conception
Other risk factors
 Congenital uterine anomaly
 Prior history of retained placenta
 Who Is at Risk for
a Retained Placenta?
Some studies have suggested that prolonged
oxytocin use could be a potentially modifiable risk
factor for retained placenta, with one study reporting that
oxytocin use for over 195 mins increased the odds
ratio of the retained placenta by 2.0, and oxytocin use
over 415 mins increased the odds ratio by 6.5.5 It is less
clear whether oxytocin is directly involved in placental
retention, or if the association is mediated by uterine atony
or infection due to prolonged labor.

Reference:https://www.ncbi.nlm.nih.gov/pmc
How Is a Retained Placenta Diagnosed?

A doctor or a Midwife can diagnose a retained placenta by carefully

examining the expelled placenta to see if it’s still intact after delivery. The
placenta has a very distinct appearance, and even a small missing portion
can be cause for concern.

In some cases, however, it may not notice that a small part is missing
from the placenta. When this occurs, a woman will often experience
symptoms soon after delivery.
If your doctor suspects you have a retained placenta, they’ll
perform an ultrasound to look at the womb. If any part of the
placenta is missing, you’ll need treatment right away to avoid
complications.
How Is a Retained Placenta Treated?
Treatment for a retained placenta involves removing the entire placenta or any
missing parts of the placenta. It can include the following methods:
 Your doctor may be able to remove the placenta by hand,
but this carries an increased risk of an infection.
 They may also use medications either to relax the uterus
or to make it contract. This can help your body get rid of
the placenta.
 In some cases, breast-feeding can also be effective
because it causes your body to release hormones that
make your uterus contract.
 You doctor may also encourage you to urinate. A full
bladder can sometimes prevent the delivery of the
placenta.
If none of these treatments help the body
expel the placenta, your doctor may
need to perform emergency surgery to
remove the placenta or any remaining
pieces. Since surgery can lead to
complications, this procedure is
often done as a last resort.
This can also be the option on how
Retained Placenta Treated
 Manual placenta removal:
The doctor will have to remove the placenta by manually using her hand. You will not feel any
discomfort as you will be given local anesthesia either epidural or spinal. Once the anesthesia
starts working, your doctor will insert her hand very gently into your uterus and pull the
placenta and any part that is remaining in the body. You will be given antibiotics
intravenously to avert any kind of infection. After removing the placenta manually,
your doctor may give you more drugs intravenously to help the uterus
to contract.

 Curettage :
Here the doctor partially removes the placenta manually. He then makes use
of a curette to scrape the remnants of the placenta
embedded in the uterus Hysterectomy: This is a surgical
removal of placenta and mostly done in case the
placenta is deeply grown in the uterus as in case
of placenta percreta.
This can also be the option on how
Retained Placenta Treated

Controlled traction of cord:

This happens when the placenta is separated from the
uterus but fails to come out of the body. The doctor clamps
baby’s umbilical cord and then tries to gently pull it to help
get rid of the placenta from the body
What Are The Complications
Of A Retained Placenta?
In a normal delivery, the contraction of the uterus occurs in order to stop any
bleeding. However, if a part of the placenta is retained inside the uterus, it is
unable to contract properly causing blood vessels to bleed continuously. Your
uterus will not be able to properly close and thus prevent any blood loss.
If the expulsion of the placenta takes more than half an hour after
delivery, the chances of severe bleeding increases. Severe loss
of blood in the first twenty-four hours after birth is known
as Primary Postpartum Hemorrhage. If small fragments of
the placenta are left behind in the uterus, it can cause
severe bleeding and infection later. This case is known
as Secondary Postpartum Hemorrhage
which is quite rare.
How can a Retained Placenta be
prevented?
 You cannot do much to prevent retained placenta occurring
in next pregnancy

 If you have had a retained placenta in your previous

delivery, the risk of having the same in the next
delivery increases. Let your doctor know about
this so that she pays more attention to the third
stage of labor. Skin to skin contact with your
baby will help to decrease the risk of
retained placenta.
How can a Retained Placenta be
prevented?
 The prolonged use of oxytocin during
labor can cause retained placenta. Avoid
any use to these artificial labor inductions
to avoid the risk of retained placenta, C
section and uterine scar

 After you give birth to your baby, your

doctor will suggest that you massage your
uterus. This encourages uterine
contractions that help stop any bleeding
and prepare the uterus to return to a
smaller size
 Conclusion: Retained placenta after vaginal delivery can be a source
of significant hemorrhagic and surgical morbidity to the
mother. In considering ways to lesson morbidity, the
clinician should have a knowledge of risk factors for both
retained placenta and MAP, allowing them to triage those
patients most at risk of hemorrhage and prepare by
ensuring blood products are easily available.
When managing the patient with retained placenta, 30
minutes of elapsed third stage have been traditionally
used as a guideline for timing manual removal; however,
recent research has suggested that shorter duration of third
stage may in fact be less morbid.

Further research should be pursued to determine the best

timing and infection prophylaxis for this etiology.
Regardless, prompt diagnosis and management with
appropriate personnel, access to blood for massive
transfusion protocol, and surgical
equipment such as uterine suction and
tamponade can be required to treat
retained placenta and lessen its morbidity.
Reference:

https://www.dovepress.com/retained-placenta-after-vaginal-
delivery-risk-factors-and-management

https://www.sciencedirect.com/topics/medicine-and-dentistr
y/retained-placenta

https://www.whattoexpect.com/pregnancy/labor-and-deliver
y/retained-placenta/

https://www.ncbi.nlm.nih.gov/pmc
Special Thanks to our dearest
Prof. Kent Gabriel Austria
and to our
Classmates.