This study evaluated risk factors and outcomes of manual removal of the placenta (MROP) at a tertiary hospital in Nigeria. The study compared 92 cases that underwent MROP to 91 matched controls. Risk factors for MROP included previous uterine scarring from procedures like dilation and curettage or cesarean section. Doctors performed MROP more often than midwives. On average, the third stage of labor was longer for those needing MROP. Establishing guidelines around diagnosing retained placenta could help reduce unnecessary MROP procedures.

1. SEMINAR ON
MANUALREMOVAL
OF PLACENTA
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SUBMITTED
TO-
MS. SAPNA
KUMARI
TUTOR
AIN,GUWAHATI

2. Contents
• Introduction
• Definition
• Anatomy and physiology
• Placental separation
• Retained placenta
• Causes
• Management
• Manual removal of placenta
• Complication
• Summary
• Recent advancement.
• Conclusion

3. INTRODUCTION
• Only eutherian mammals possess the
placenta. The human placenta is discoid,
because of its shape; hemochorial, because
of direct contact of the chorion with the
maternal blood and deciduate, because
some maternal tissue is shed at parturition.
The placenta is attached to the uterine
wall and establishes connection between
the mother and fetus through the umbilical
cord. The fact that maternal and fetal
tissues come in direct contact without
rejection suggests immunological
acceptance of the fetal graft by the
mother.

4. Definition
• Manual removal of placenta is a procedure to remove a retained
placenta from the uterus after childbirth.

5. Anatomy and Physiology

6. PLACENTAL
SEPARATION
AND
EXPULSION
Normally the placenta is expelled in three
stage
1.It first separates from the uterine muscle,
2. Then it descends into lower uterine segment
of uterus & vagina
3. Then it is expelled outside.
Problems can occur at any of these stages

7. SIGNS OF
PLACENTAL
SEPARATION
1. Lengthening
of the visible
portion of the
umbilical cord.
2. Increased
bleeding from
the vagina.
3. Change in
shape of the
uterus from
flat (discoid) to
round (globular)
4. The placenta
being expelled
from the
vagina.

8. Methods of placenta expulsion

9. RETAINED
PLACENTA
• Retained placenta is a condition in which all or part of
the placenta or membranes remain in the uterus during
the third stage of labour. Retained placenta can be
broadly divided into:
1. failed separation of the placenta from the uterine
lining
2. placenta separated from the uterine lining but
retained within the uterus
• A retained placenta is commonly a cause of postpartum
haemorrhage, both primary and secondary.
• Retained placenta is generally defined as a placenta
that has not undergone placental expulsion within 30
minutes of the baby's birth where the third stage of
labor has been managed actively.
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10. CAUSES
Placenta separated but not expelled out.
Simple adherent placenta.
Morbidly adherent placenta
Defect of trophoblast function.
Defect of decidua basalis .
Abnormal vascularization

11. RISK FACTORS
• Previous retained placenta
• Previous injury or surgery to the uterus
• Preterm delivery
• Induced labor
• Multiparity

12. RISK OF RETAINED PLACENTA
• 1. Hemorrhage and
• 2. Infection.
• After the placenta is delivered, the uterus should contract
down to close off all the blood vessels inside the uterus.
• If the placenta only partially separates, the uterus cannot
contract properly, so the blood vessels inside will continue
to bleed. A retained placenta thereby leads to hemorrhage

13. MANAGEMENT
Management Details:
• If the placenta is undelivered after 30 minutes
consider:
• Emptying bladder
• Breastfeeding or nipple stimulation
• Change of position - encourage an upright position
• The management is done according to condition
of placenta as
Seperated
Unseparated
Complicated
 If the placenta is separated and retained
:express placenta by controlled cord traction
 Unseparated retained placenta manual removal

14. MANUAL
REMOVAL OF
PLACENTA
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15. STEP -1
• The operation is done under general anesthesia. In extreme urgency
where anesthetist is not available, the operation may have to be
done under deep sedation with 10 mg diazepam given intravenously.
The patient is placed in lithotomy position. With all aseptic
measures, the bladder is catheterized.

16. STEP-2

17. STEP-3 • Counter pressure on the uterine
fundus is applied by the other hand
placed over the abdomen. The
abdominal hand should steady the
fundus and guide the movements of
the fingers inside the uterine cavity
until the placenta is completely
separated.

18. STEP-4
• As soon as the placental margin is
reached, the fingers are
insinuated between the placenta
and the uterine wall with the back
of the hand in contact with the
uterine wall. The placenta is
gradually separated with a
sideways slicing movement of the
fingers, until whole of the
placenta is separated .

19. STEP-5
• When the placenta is
completely separated, it is
extracted by traction of the
cord by the other hand. The
uterine hand is still inside the
uterus for exploration of the
cavity to be sure that nothing
is left behind

20. STEP-6 • Intravenous methergine 0.2 mg is given
and the uterine hand is gradually
removed while massaging the uterus by
the external hand to make it hard.
After the completion of manual
removal, inspection of the
cervicovaginal canal is to be made to
exclude any injury.

21. STEP-7
• The placenta and membranes
are inspected for
completeness and be sure that
the uterus remains hard and
contracted.

22. NURSING RESPONSIBILITY

23. COMPLICATIONS

24. SUMMARY

25. RECENT ADVANCEMENT
• TOPIC - Manual removal of the placenta: Evaluation of some risk
factors and management outcome in a tertiary maternity unit. A
case controlled study
• AUTHOR NAME – O.I Akinola
• PLACE- Nigeria
• DATE-march 2013
• SORCE- pubmed

26. • Objective: Lack of consensus on when to diagnose and manage retained placenta in the absence of
hemorrhage in the 3rd stage of labor, has often subjected Manual removal of placenta (MROP) to the
discretion of the accoucher. This study aimed to appraise the practice of manual removal of placenta in a
tertiary institution in Nigeria with a view to evaluating risk factors for the procedure and advance probable
guidelines to enhance standardization of diagnosis of retained placenta. Design: Case controlled study.
Setting: Tertiary maternity center in South west Nigeria. Participants: Data from the hospital records of 92
parturients who had MROP from January to December 2009 were compared with 91 immediate next
parturients without MROP matched for age and parity. Variables such as the past obstetric and
gynecological history, status of accoucher, gestational age at delivery, duration of 3rd stage, estimated
blood loss, quantum of blood transfused and length of hospitalization were extracted and subjected to
statistical analysis using the SPSS package. Results: There were 4613 deliveries of which 92 parturients had
MROP, an incidence of 1.99%. The mean duration of 3rd stage in the study group was 35.6 ± 18.8 minutes
compared to 21.6 ± 6.28 minutes in the control. Doctors were the accoucher in 96.8% of cases while
midwives took the deliveries in 84.4% in the control group. Previous scarring of the pregnant uterus such
as dilatation and curettage and caesarean section predisposed to MROP compared to the control group (P
< 0.032) and (P < 0.024) respectively but there was no significant difference between the two groups with
respect to previous myomectomy. Conclusion: There is a need to establish standard guidelines in the
management of the 3rd stage of labor with definite criteria for diagnosis of retained placenta to reduce
the probable risk of unnecessary MROP.
• Keywords: Accoucher; “Haemorrhage”; Pa