This is a situation where the placenta is not expelled 30 minutes after the birth of the baby.

The incidence of retained placenta is about 2% of deliveries. The risk of having a retained placenta is markedly increased (20-fold) if the gestation is< or = 26 weeks gestation. From 26 to 37 weeks it is increased three times than at term. There is a 10-fold increase risk of haemorrhage in a patient with a retained placenta. The haemorrhage peaks at 40 minutes after delivery.

Causes of retained placenta:

a) Uterine Atony; This could be due to grand multiparity, prolonged labour , uterine malformation or large placental area (Diabetes mellitus and multiple pregnancy).

b) Morbid adherent placenta ( Placenta Increta, placenta acreta and placenta percreta).

c) Seperated but retained due to poor voluntary effort. This could be due to maternal exhaustion or prolonged labour.

d) Incarcerated placenta due to constrictive ring. This could be due to ergometrine given too early or attempts to deliver the placenta before it has separated.

Complications of retained placenta.

i) Post partum haemorrhage.

ii) Post partum shock

iii)Puerperal sepsis.

iv) Risk of recurrence in subsequent pregnancies.

Management of retained placenta.

The first step is to find out if the placenta is separated or not. One should look out for features of placental separation such as lengthening of the cord, gush of blood coming out of the vagina and the uterus becomes round and firm with the level of the fundus rising. If the placenta is separated it has to be delivered by controlled cord traction.

After delivery of the placenta ,it should be inspected for completeness. This is important because certain segments of the placenta could be retained. In such cases manual exploration of the uterine cavity is required . This should be done under anaesthesia.

Manual removal of the placenta

If there is retained placenta with post-partum haemorrhage, one should manually remove the placenta without delay. For manual removal of the placenta general anaesthesia is preferable. However if the facilities are not available the following steps can be undertaken:

a) Sedate the mother with 50mg of pethidine(25mg iv and 25mg im) and diazepam 10mg iv slowly.

b) The patient should be placed in the dorsal position.

c) Insert an iv canula (14G)  and send blood for grouping and DT (direct test).

d) Manual removal of the placenta must be undertaken under full aseptic conditions.

e) The bladder should be emptied.

f) Steady the uterus with the left hand placed on the abdomen.

g) Make your hand as narrow as possible and trace the course of the umbilical cord into the uterus, feel the edge of the placenta.

h) Having reached the lower edge of the placenta gently detach it with a sweeping action using the edge of the hand while keeping the fingers together to avoid perforating the uterus.

When the placenta has been completely separated from the uterus, it should be grasped and pulled out from the uterus.

i) After delivery of the placenta both the maternal and fetal sides should be inspected to ensure that it is removed completely.

j)After removal of the placenta the fundus and abdomen must be examined carefully for evidence of perforation.

k) If there is any evidence of incomplete separation the uterus should be re-explored.

l) Syntocinon drip is necessary to cause a firm contraction and cease bleeding.

m) Continuous monitoring of pulse rate, blood pressure, respiratory rate and vaginal bleeding is important for the first 24 hours (Mainly to detect perforation of the uterus  and infection).

n) Antibiotics must be given (Cefuroxime, Amoxycillin, Metronidazole) should be given orally for 3-5 days. This is to prevent infection (puerperal sepsis).

References:

Chapter 26 p 319, Dewhurst’s Textbook of Obstetrics and Gynaecology for Postgraduates -sixth edition -blackwell science publication.

Clinical Obstetrics for Undergraduates, compiled by Dr WDN De Alwis, Dr R Gnanasekeram, Dr N. Gunawansa. Edited by Professor Randeniya MB;BS. MS, FRCOG, National Hospital of Sri Lanka.

Textbook of Obstetrics and Gynaecology for Medical Students by Akin Agbola et al Volume 2 second edition.

Labour Ward Manual- A guide for the trainee by Deepal  S Weerasekera MS(O$G), MRCOG, FRCS (Ed), Kapila K Gunawardene MS (O$G), MRCOG, Jayatissa Nalin Rodrigo FRCOG, FCS (SL), Dobst (Cey).

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