The document defines and discusses retained placenta, which occurs when the placenta is not expelled from the uterus within 30 minutes of delivery. There are several potential causes of retained placenta, including failure of the placenta to separate fully from the uterine wall due to issues like uterine atonicity. Management involves controlling bleeding if present and attempting controlled cord traction or manual removal of the placenta in the operating room if needed. Leaving the placenta retained poses risks like severe bleeding.

1. RETAINED
PLACENTA
KAWITA
BAPAT

2. • DEFINITION:
• The
placenta
is
said
to
be
retained
when
it
is
not
expelled
from
the
uterus
even
30
minutes
aEer
the
delivery
of
the
baby

3. • Normally
the
placenta
is
expelled
in
three
stage
-­‐
it
first
separates
from
the
uterine
muscle,
then
it
descends
into
the
lower
segment
of
the
uterus
and
vagina
and
then
it
is
expelled
outside.
Problems
can
occur
at
any
of
these
stages

4. Risk
Factors
• • Previous
retained
placenta
• • Previous
injury
or
surgery
to
the
uterus
• • Preterm
delivery
• • Induced
labor
• • MulPparity

5. Causes
• Placenta
separated
but
not
expelled
• Simple
Adherent
Placenta
• Morbid
adherence
of
the
placenta:
Placenta
Accreta
Placenta
Increta
Placenta
Percreta

6. • ConstricPon
ring-­‐reforming
cervix
• Full
bladder
• Uterine
abnormality

7. Causes
of
Retained
Placenta
• Placenta
separated
but
not
expelled:
The
placenta
may
separate
completely
from
the
uterine
muscle
but
may
sPll
be
retained
within
the
uterus.
There
are
three
causes
for
this
retenPon:
• Failure
of
the
woman
to
push
out
the
placenta
due
to
exhausPon
or
prolonged
labour.
• Closure
of
the
cervix
prevenPng
the
placenta
from
being
expelled.
• A
constricPon
ring
in
the
uterus
can
hold
up
the
placenta

8. • Simple
Adherent
Placenta:The
placenta
may
fail
to
separate
completely
from
the
uterine
muscle
due
to
lack
of
contracPon
of
the
uterine
muscles.
This
condiPon,
called
'uterine
atonicity'
occurs
in
cases
where
the
uterine
muscles
have
become
lax,
either
due
to
repeated
pregnancy,
prolonged
labor
or
overdistension
of
the
uterus
during
pregnancy,
as
in
twin
pregnancy.
Simple
Adherent
Placenta
is
the
commonest
cause
for
retenPon
of
placenta.

9. • Morbid
adhesion
of
the
placenta:
Morbid
adhesion
of
the
placenta
can
occur
when
the
placenta
is
implanted
deeply
into
the
uterine
muscles
and
thus
fails
to
separate.
The
placenta
can
burrow
upto
different
depths
in
the
uterine
muscle.
In
simple
cases,
it
is
only
aVached
firmly
to
muscle
and
can
be
stripped
off
by
hand.
In
severe
morbid
adhesion,
the
placenta
can
burrow
through
the
full
thickness
of
the
muscle.
In
this
case,
the
uterus
may
be
needed
to
be
removed
('hysterectomy')
to
control
the
bleeding.
There
are
three
types
of
morbid
adhesion
of
the
placenta

10. • Placent
Accreta:
In
this
condiPon,
the
placenta
penetrates
deep
into
the
uterine
endometrium
and
reaches
the
muscles
but
does
not
penetrate
into
the
muscles.
• Placent
Increta:
Here,
the
placenta
aVaches
even
deeper
into
the
uterine
wall
and
penetrates
into
the
uterine
muscle.
• Placent
Percreta:
In
this
condiPon,
the
placenta
not
only
penetrates
through
the
full
thickness
of
the
uterine
muscles
but
also
aVaches
to
another
organ
such
as
the
bladder
or
the
rectum.
Placenta
percreta
is
very
rare

11. Risks
of
Retained
Placenta
• There
may
be
severe
bleeding
which
may
be
lifethreatening.
• AVempts
at
manual
removal
of
the
placenta
can
cause
mulPple
injuries
to
the
mother
such
as
like
vulvar
hematoma,
perineal
tears,
cervical
tears
and
vaginal
wall
tears.

12. Management
Details
• If
the
placenta
is
undelivered
aEer
30
minutes
consider:
• Emptying
bladder
• BreasZeeding
or
nipple
sPmulaPon
• Change
of
posiPon
–
encourage
an
upright
posiPon

13. • If
bleeding:
immediately
• Inform
AnaesthePst
• InserPon
of
large
bore
IV
(18g)
cannula
• Insert
urinary
catheter
• Commence/conPnue
oxytocin
infusion
20
units
in
1
litre
/
rate
–
60drops
per
min
• Measure
and
accurately
record
blood
loss
• Prepare
and
transfer
paPent
to
theatre
for
manual
removal
of
placenta
(MROP)

14. Management
/
Treatment
of
Retained
Placenta
• Treatment
will
depend
on
the
cause
of
the
retenPon
of
the
placenta.
If
bleeding
is
present,
acPve
treatment
is
done
to
control
the
blood
loss
and
support
the
general
condiPon
of
the
paPent.
• Controlled
Cord
TracPon
• If
the
placenta
is
separated
but
not
expelled,
then
controlled
cord
tracPon
should
be
carried
out.
In
this
method,
the
uterus
is
held
in
place
or
pushed
up
gently
through
the
abdominal
wall
by
the
leE
hand.
The
cut
umbilical
cord
hanging
from
the
vagina
is
held
in
the
right
hand
and
pulled
steadily
and
slowly
to
pull
out
the
placenta.

16. • Manual
removal
of
the
placenta
• The
placenta
may
need
to
be
removed
manually
if
controlled
cord
tracPon
fails.
• The
paPent
is
put
under
general
anesthesia
in
the
operaPon
theatre.
Under
all
asepPc
condiPons,
the
sterile
gloved
hand
of
the
doctor
is
inserted
into
the
uterus.
The
placenta
is
stripped
from
the
uterine
muscle
gently
and
brought
out.

17. Introducing one
hand into the
vagina along cord

18. Supporting the fundus
while detaching the
placenta

20. • Hysterectomy:
If
the
placenta
is
too
deeply
embedded
into
the
uterine
musculature
(called
placenta
accrete),
a
hysterectomy
to
remove
the
uterus
may
be
indicated.

21. Post
procedure
care
• Observe
the
woman
closely
un3l
the
effect
of
IV
seda3on
has
worn
off.
• Monitor
the
vital
signs
(pulse,
blood
pressure,
respira3on)
every
30
minutes
for
the
next
6
hours
or
un3l
stable.
• Palpate
the
uterine
fundus
to
ensure
that
the
uterus
remains
contracted.
• Check
for
excessive
lochia.
• Con3nue
infusion
of
IV
fluids.
• Transfuse
as
necessary.

22. ComplicaPons
of
a
Retained
Placenta
• Uterine
inversion
• Shock
(hypovolemic)
• Postpartum
hemorrhage
• Puerperal
Sepsis
• SubinvoluPon
• Hysterectomy