Manual removal of placenta (MRP) is a procedure to remove a retained placenta from the uterus after childbirth. It is performed under general anesthesia or deep sedation with the patient in lithotomy position after catheterizing the bladder. One hand is inserted into the uterus to locate the placenta and separate it from the uterine wall with a sawing motion while applying counter pressure on the abdomen. The placenta is then extracted while massaging the uterus, and ergometrine is injected to ensure uterine contraction. Complications can include hemorrhage, injury, infection or inversion if not performed correctly.

1. MANUAL
REMOVAL OF
PLACENTA
Here is where your
presentation begins

2. • INTRODUCTION
 Manual removal of placenta is a procedure.
 A procedure to remove a retained placenta from the uterus.
 The MRP is done under general anaesthesia or deep sedation.
 Patient placed in lithotomy position.
 And the bladder is catheterized.

3. • DEFINITION
According to Nima Bhaskar
“Retained placenta means that all or parts of the
placenta or membranes are left behind in the uterus
(womb) during the third stage of labour.”

4. According to Anamma Jacob
“Manual placenta removal is a procedure to
remove a retained placenta from the uterus after
child birth.”

5. According to Neelam Kumari
“A procedure in which the retained placenta is
removed manually from the uterus called as
manual removal of placenta.”

6. • INDICATION
 Review general care.
 Provide emotional support.
 Give pethidine and diazepam I.V. slowly or use ketamine.
 Give single dose of prophylactic antibiotics:
1. ampicillin 2gms IV + metro 500mg IV
or 2. cefazolin 1gm IV + metro 500mg IV
 Operation done under general aneasthesia and if not available may have to be done
under sedation with 10mg diazepam IV.
 Bladder is catheterized.

7.  One hand is introduced into the uterus.
 Smearing with antispetic solution in cone shaped
manner following the cord.
 Counter pressure on the uterine fundus is applied by
the other placed over the abdomen.
 Fingers are insituated between the placenta and the
uterine wall with the back of the hand in contact with
the uterine wall.
 The uterine wall hand is still inside of the uterus for
exploration of the cavity to be sure that nothing left.

8.  Intravenous Ergometrine 0.25mg is given and
uterine hand is gradually removed.
 After the completion of manual removal
,inspection of the cervico vaginal canal is to
made to exclude any injury.
 The placenta and membranes are to be
inspected for completeness.

9. • POST PROCEDURE CARE
 Observe the woman closely until the effects of IV sedation has worn off.
 Monitor the vital signs every 30 minutes for the next 6 hours or until stable.
 Palpate the uterine fundus to ensure the uterus remains contracted.
 Continue infusion of IV fluids.

10. • COMPLICATION
 Hemorrhage due to incomplete removal.
 Shock.
 Injury to the uterus.
 Infection.
 Inversion.
 Embolism.
 Thromboembolism.

11. • CAUSES
 UTERINE ATONY – uterus stops contraction or does not contract enough for the
placenta to separate from the wall of the uterus.
 TRAPPED PLACENTA – placenta comes away from the uterus succesfully but
comes trapped behind a closed cervix.
 PLACENTA ACCRETE – area of the placenta remains attached because it is
deeply embedded into the uterus wall.

12. • PATHOPHYSIOLOGY
I. During child birth the hormone oxytocin is released into the blood.
II. Oxytocin is responsible for uterine muscle contraction.
III. If for some reason adrenaline is released into the blood , oxytocin release
can be inhibited and therefore prevent the uterus from contracting.

13. • MANAGEMENT
 Place a gloved hand into the uterus.
 Follow the umbilical cord until find the lower edge of the placenta.
 Push the hand between the placenta and the body of the uterus and ease the
placenta away with a sawing action.
 When fully detached , explore the uterine cavity for damage.
 Massage the fundus with one hand whilst extracting the placenta.
 Look carefully.
 Inject Ergometrine IV.

14. • CONCLUSION
• Retained placenta can be defined as lack of placental expulsion within 30 minutes of
delivery.
• This time period can be expanded to 90 to 120 minutes for births in second trimester
and third stages of labour managed without oxytocin.
• The strongest risk factor for retained placenta is gestational age less than 26 weeks.
• Postpartum hemorrhage is the major complication of retained placenta.