This document discusses three obstetric emergencies: retained placenta, adherent placenta, and inversion of the uterus. For retained placenta, it defines it as occurring when the placenta remains in the uterus 30 minutes after delivery. Manual removal of the placenta is described as the management. Adherent placenta occurs when the placenta does not separate from the uterine wall, and types include placenta accreta, increta, and percreta. Inversion of the uterus is defined as the uterus turning inside out, and can be caused by fundal pressure or cord traction after delivery. Replacement by working from the cervix to fundus is the first step

1. Obstetric emergency cont…
 Retained placenta
Adherent placenta
inversion of the uterus
BY MUKEREM.A 2007

2. Session Objectives
By end of session, students will be able to:
• Define retained placenta
• Discuss the causes, Management retained
placenta
• Discuss the causes, Management Adherent
placenta
• Describe the cause, management ,prevention
and Complication of inversion of uterus
2

3. Obstetric emergency cont…
7. Managing retained placenta
Retained placenta
Defn: - When placenta remain 30 minutes after
delivery having left the upper uterine segment
BY MUKEREM.A 2007

4. Obstetric emergency cont…
Causes:
Poor uterine action
Hourglass contraction – this is a constriction ring in
the third stage caused by giving ergometrine and not
expelling the placenta in time.
A full bladder
Mismanagement of the third stage.
i.e. – trying to expel the placenta before it has
separated completely this may induce spasm of the
lower uterine segment.
BY MUKEREM.A 2007

5. Obstetric emergency cont…
Management
Manual removal of the placenta.
Steps for manual removal of the placenta
1. An intravenous infusion must first be sited
with 20 Iu of ocytocin
2. An effective anesthesia by in progress
3. Manual removed is performed with full
aseptic precautions.
4. With the left hand the umbilical cord is held
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6. Obstetric emergency cont…
5. While the right hand is inserted in to the vaginal
and the uterus following the direction of the cord.
6. Once, the placenta is located the cord is released
then left hand support the fundus abdominally.
7. Right hand will feel for a separated edge of the
placenta. Then the fingers of the right hand are
extended and the border of the hand is gently
eased between the placenta and the uterine wall
with the palm facing the placenta.
BY MUKEREM.A 2007

7. Obstetric emergency cont…
8. Then with a sideways slicing movement the
placenta is carefully detached.
9. When the placenta is completely separated the
left hand rubs up a contraction and expels the
right hand with the placenta in it’s grasp
10. The placenta should be checked immediately
for completeness so that any further exploration of
the uterus may be carried out without delay.
11. An oxytocic drug is given up on completion
usually intravenous ergometrine 0.5mg.
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8. Manual Removal
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9. Obstetric emergency cont…
Adherent placenta
Defn - When the placenta 30 minutes after delivery still
has not separeted left the upper uterine segment or
placenta implantation in which there is abnormally firm
adherence in the uttering wall. As the consequence of
partial or total absence of deciduas basalis
Causes of adherent placenta
When deciduas formation is defective. Associated
condition includes implantation in the lower uterine
segment, over a previous c/s scar, or other uterine
incisions, or after uterine curettage and grand
multiparty.
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10. Obstetric emergency cont…
Types of adherent placenta
Three types
1. Placenta accreta:- when placenta villi are
attached to the myometrium
2. Placenta increta:- when placenta villi invade
the myometrium.
3. Placenta percreta:-when placenta villi
penetrate through the myometrium.
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11. Obstetric emergency cont…
Management
If uterus is ‘not needed’ (further fertility not
needed) – hysterectomy
If uterus is needed – doctor can remove it
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12. Obstetric emergency cont…
8. Managing inversion of the uterus
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13. GROUP DISCUSSION
• What is different between
Prolaps of the Uterus and
Inversion of the Uterus???
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14. Obstetric emergency cont…
Acute inversion of the uterus
Defn; Inversion means that the uterus has
turned inside out
A rare but potentially life threatening
complication of third stage of labour
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15. Obstetric emergency cont…
Causes
Causes are all connected to applying force to
the uterine fundus when it is relaxed and the
cervix is dilated.
Exerting controlled cord traction when the
uterus is relaxed especially if the placenta is
centrally sited in the fundus.
Forcibly attempting to expel the placenta by
using fundal pressure when the uterus is atonic
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16. Obstetric emergency cont…
Combining fundal pressure and cord traction
to delivery the placenta.
Multiparous mother followed delivery and
who pushed vigorously or possibly has coughed
or sneezed.
Short umbilical cord
Sudden emptying of the distended uterus
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17. Obstetric emergency cont…
Classification
A. According to severity
1. First degree: The fundus reaches the internal os
2. Second degree: The body or corpus of the uterus is
inverted to the internal os
3. Third degree: The uterus, cervix and vagina are
inverted and are visible
B. According to time of the inversion
1. Acute: Immediately after delivery, with placenta still
attached.
2. Chronic: Inversion occur after the first 24 hours
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18. Obstetric emergency cont…
Sign and Symptoms
In serious cases the inner surface of the fundus
appears at the vaginal outlet.
In less severe instances the fundus is dimpled
The fundus is not palpable abdominally
Sudden onset of shock is the out standing sing
accompanied by severe pain which is caused by
the ovaries being dragged in to the inverted
uterus.
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19. Obstetric emergency cont…
Management
1. Help is summoned
2. The best chance of replacing the uterus occurs
immediately following the inversion. Pressure
is applied first to the part nearest the cervix
working upwards to the fundus on the
principle of “Last out first in”.
3. No attempt is made to remove the placenta
until the uterus is the right way out otherwise
hemorrhage can not be controlled. An
inverted uterus cannot contract and retract
BY MUKEREM.A 2007

20. Obstetric emergency cont…
4. If replacement of a totally inverted uterus is
not possible it should be gently placed inside
the vagina to relieve traction on the ovaries
and fallopian tubes.
Raising the foot of the bed will also help to
relieve the tension and alleviate shock. And
refer her to the nearest hospital.
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21. QUESTION ???
• What measures can we take to
prevent of inversion of the
uterus ?
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22. Obstetric emergency cont…
Prevention of inversion of the uterus
Proper management of the third stage
Avoid combining fundal expression and cord
traction to delivery the placenta.
Do not pull on the cord unless the placenta
has separated.
Do not leave the patient until the uterus is
contracted and rounded.
BY MUKEREM.A 2007

23. Obstetric emergency cont…
Complication of inversion of uterus
Shock – due to tension on the ovaries
Hemorrhage – the condition is worse
attempt is made to remove the placenta
while the uterus is not in the right way.
Infection
Paralytic ileus
Intestinal obstruction
Anemia and in some cases sterility
BY MUKEREM.A 2007