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Failure of placental delivery
within 30 minutes after
delivery of the fetus.
Longer the placenta remains
in uterus after delivery of
baby, the greater is the risk
Nirsuba Gurung MSON
Morbid Adherence of the placenta
Placenta Acreta (Placenta Accreta occurs
when the placenta attaches too deep in the
uterine wall but it does not penetrate the
uterine muscle. Placenta accreta is the most
common accounting for approximately 75% of
Placenta Increta (Placenta Increta occurs
when the placenta attaches even deeper into
the uterine wall and does penetrate into the
uterine muscle. Placenta increta accounts for
approximately 15% of all cases.) 3
Nirsuba Gurung MSON
(Placenta Increta occurs when the placenta
attaches even deeper into the uterine wall and
does penetrate into the uterine muscle. Placenta
increta accounts for approximately 15% of all
Uterine Abnormality ,uterine atony
Constriction Ring - reforming cervix
Nirsuba Gurung MSON 4
If the placenta is undelivered after 30 minutes
Breastfeeding or nipple stimulation
Change of position - encourage an upright
The management is done according to condition of
If the placenta is separated and retained
:express placenta by controlled cord traction
Unseparated retained placenta :manual removal
of placenta under general anesthasia 5Nirsuba Gurung MSON
Insertion of large bore IV (18g) cannula
Insert urinary catheter
Commence/continue oxytocin infusion 20
units in 1 litre / rate – 60drops per
Measure and accurately record blood
Prepare and transfer patient to theatre
for manual removal of placenta (MROP)
Nirsuba Gurung MSON 6
Manual placenta removal is a procedure to
remove a retained placenta from the uterus
Take blood for grouping and cross match and
send for hemoglobin if it has not been done
• Tell the woman (and her support person)
what is going to be done, listen to her and
respond attentively to her questions and
• Provide continual emotional support and
reassurance, as feasible.
Nirsuba Gurung MSON 9
• Prepare the necessary equipment
• Antiseptic solution
• Sterile gloves
Blood and subtitutes
Anasthesia and analgesics
Ergometrine and oxytocin
Give anesthesia (IV pethidine (25-50mg) and
diazepam (10 mg), or ketamine
Give a single dose of prophylactic antibiotics:
Ampicillin 2 g IV PLUS metronidazole 500 mg IV,
Cefazolin 1 g IV PLUS metronidazole 500 mg IV
Put on personal protective equipment.
Use antiseptic handrub or wash hands and
forearms thoroughly with soap and water and
dry with a sterile cloth or air dry.
Put high-level disinfected or sterile surgical
gloves on both hands. (Note: elbow-length
gloves should be used, if available.)
Hold the umbilical cord with a clamp
Pull the cord gently until it is parallel to the floor
Place the fingers of one
hand into the vagina ih
the shape of cone by
drawing the fingers and
the thumb together and
into the uterine cavity,
following the direction
of the cord until the
placenta is located.
Do not go in and out of
the uterus as these
increase the risk of
When the placenta has
been located, let go of the
cord and move that hand
onto the abdomen to
support the fundus
abdominally and to provide
prevent uterine inversion
Move the fingers of the
hand in the uterus
laterally until the edge of
the placenta is located.
Supporting the fundus while
detaching the placenta
Keeping the fingers
tightly together, ease
the edge of the hand
gently between the
placenta and the uterine
wall, with the palm
facing the placenta.
Gradually move the hand
back and forth in a
smooth lateral motion
until the whole placenta
is separated from the
Withdrawing the hand
from the uterus
If the placenta does not separate from
the uterine wall by gentle lateral
movement of the fingers at the line of
cleavage, suspect placenta accreta and
arrange for surgical intervention
16Nirsuba Gurung MSON
When the placenta is completely
Palpate the inside of the uterine cavity
to ensure that all placental tissue has
Slowly withdraw the hand from the
uterus bringing the placenta with it.
Continue to provide counter-traction
to the fundus by pushing it in the
opposite direction of the hand that is
Give oxytocin 20 units in 1 L IV fluid (normal
saline or Ringer’s lactate) at 60 drops/minute.
Have an assistant massage the fundus to
encourage atonic uterine contraction.
If there is continued heavy bleeding, give
ergometrine 0.2 mg IM or give prostaglandins.
Examine the uterine surface of the placenta to
ensure that it is complete.
Examine the woman carefully and repair any tears
to the cervix or vagina, or repair episiotomy.
Immerse both gloved hands in 0.5%
chlorine solution. Remove gloves by
turning them inside out.
If disposing of gloves, place them in a
leak proof container or plastic bag.
If reusing surgical gloves, submerge
them in 0.5% chlorine solution for 10
minutes for decontamination
Use antiseptic hand rub or wash hands thoroughly
with soap and water and dry with a clean, dry
cloth or air dry.
Monitor vaginal bleeding and take the woman’s
Every 15 minutes for 1 hour
Then every 30 minutes for 2 hours
Make sure that the uterus is firmly contracted.
Record procedure and findings on woman’s record.
Observe the woman closely until the
effect of IV sedation has worn off.
Monitor the vital signs (pulse, blood
pressure, respiration) every 30 minutes
for the next 6 hours or until stable.
Palpate the uterine fundus to ensure
that the uterus remains contracted.
Check for excessive lochia.
Continue infusion of IV fluids.
Transfuse as necessary.
21Nirsuba Gurung MSON
Umbilical vein injection of saline solution
plus oxytocin appears to be effective in
the management of retained placenta.
Saline solution alone does not appear be
more effective than expectant
management. The difficulties in
implementing this intervention are related
to the training of personnel in the
technique of giving injections into the
23Nirsuba Gurung MSON
The incidence of placenta accreta
has increased 10-fold10-fold in thein the
past 50 yearspast 50 years, to a current
frequency of 1 per 2,5001 per 2,500
largely as a result of the
increase in the number ofincrease in the number of
cesarean sectionscesarean sections
24Nirsuba Gurung MSON
Risk factors for placenta accreta include :
1. placenta previa with or without previous
2. previous myomectomy.
3. previous cesarean delivery.
4. submucous leiomyomata.
5. maternal age of 36 years and older.
25Nirsuba Gurung MSON
Active Mx of third stage can
prevent & reduce the incidence of
In case of risk factors,always
consider placenta accreta & L/f
usg/doppler features in antenatal
period & plan accordingly.
26Nirsuba Gurung MSON