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Retained Placenta

The third stage of labour commences with the completed delivery of the fetus and ends with the completed delivery of the placenta and its attached membranes. The length of the third stage itself is usually 5-15 minutes. The absolute time limit for delivery of the placenta, without evidence of significant bleeding, remains unclear. Periods ranging from 30-60 minutes have been suggested. An extended third stage is associated with postpartum haemorrhage.

Aetiology

Retained placenta may be caused by:

  • Placenta that has either completely or partially separated from the uterus and is entrapped by cervix as it closes (following administration of an oxytocic agent)
  • Atonic uterus
  • Abnormally adherent placenta as in placenta accreta. This may be partial or total with, in rare cases, placenta invading the myometrium deeply (placenta increta) even to the external serosa (placenta percreta).
Epidemiology

Placenta accreta - 1/2,500 deliveries. After 2 caesarean sections for placenta praevia, there is approximately 40% risk of placenta accreta.1

Management

With significant haemorrhage, try to discover if placenta has separated as indicated by:

  • A sudden rush of blood
  • Fundus moves higher and becomes round
  • Increase in length of part of umbilical cord visible at vulva
  • Raising of fundus does not cause cord to decrease in length.

If placenta has separated, try to deliver the placenta by 'rubbing up' uterus or giving IM synthetic oxytocin to produce a contraction. Then push it towards the vagina to help with expulsion of placenta and membranes. These are held and twisted whilst pulling constantly so that membranes are kept intact.
If placenta has not detached, it needs to be removed manually under anaesthetic:

  • Place gloved hand into uterus with other hand on fundus to control it
  • Follow umbilical cord until find lower edge of placenta
  • Push the hand between the placenta and the body of the uterus and ease placenta away with a sawing action (N.B. in cases of placenta accreta the placenta will not detach easily and use of excess force can result in life-threatening haemorrhage which may require hysterectomy)
  • When fully detached, explore the uterine cavity for damage and other pieces of placenta
  • Massage fundus with one hand whilst extracting placenta and membranes with hand in uterine cavity
  • Look carefully at placenta to be sure that it all there
  • Inject ergometrine IV and IM.
  • Alternative management technique involves injecting saline plus oxytocin into the umbilical vein.2

The Release Trial, which commenced in 2005, is a randomised controlled trial of umbilical vein oxytocin versus placebo for the treatment of retained placenta. 3

Complications

Retained placenta is in itself life threatening because of its association with postpartum haemorrhage. 4
Manual removal carries the risk of damage to genital tract and puerperal infection. Manual removal of placenta increases the likelihood of bacterial contamination in the uterine cavity. There are no randomized controlled trials to evaluate the effectiveness of antibiotic prophylaxis to prevent endometritis after manual removal of placenta in vaginal birth.5

Prevention

Sulprostone is a potent stimulator of uterine smooth muscle contractions with high abortifacient activity. It reduces the need for the manual removal of the placenta by 49%.6

Document References
  1. RCOG Greentop Guidelines; No.27: Placenta praevia and placenta praevia accreta: diagnosis and management. Last revised Oct 2005
  2. Carroli G, Bergel E.; Umbilical vein injection for management of retained placenta (Cochrane Review).; In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.
  3. Weeks A, Mirembe F, Alfirevic Z; The Release Trial: a randomised controlled trial of umbilical vein oxytocin versus placebo for the treatment of retained placenta. BJOG. 2005 Oct;112(10):1458. [abstract]
  4. Chhabra S, Dhorey M; Retained placenta continues to be fatal but frequency can be reduced. J Obstet Gynaecol. 2002 Nov;22(6):630-3. [abstract]
  5. Chongsomchai C, Lumbiganon P, Laopaiboon M; Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004904. [abstract]
  6. van Beekhuizen HJ, de Groot AN, De Boo T, et al; Sulprostone reduces the need for the manual removal of the placenta in patients with retained placenta: a randomized controlled trial. Am J Obstet Gynecol. 2006 Feb;194(2):446-50. [abstract]
Internet and Further Reading Acknowledgements EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 1724
Document Version: 20
DocRef: bgp263
Last Updated: 26 Nov 2006
Review Date: 25 Nov 2008


















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See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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