Retained placenta is defined as failure to deliver the placenta within 30 minutes of childbirth. Risk factors include preterm delivery, induced labor, and uterine abnormalities. If the placenta is not expelled, manual removal may be needed to control bleeding and prevent complications like hemorrhage. Diagnosis involves assessing for signs of separation and feeling the placenta through the cervix. Treatment depends on the cause but may include controlled cord traction, manual removal in the operating room, or hysterectomy for deeply embedded placentas.

1. RETAINED PLACENTA
By Arnold Ephraim
MD student.
From KCOHAS
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2. Learning Objectives
At the end of this session students are supposed to be able to do the following
a) Define retained placenta
b) Identify risk factors/causes of retained placenta
c) Describe pathogenesis of retained placenta
d) Describe clinical features and complications of retained placenta
e) Explain differential diagnoses of retained placenta
f) Establish provisional and differential diagnoses
g) Treat the patient according to guidelines
h) Describe preventive measures for retained placenta
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3. Introduction and Definition
• The placenta is said to be retained when it is not expelled from the
uterus even 30 minutes after the delivery of the baby
• This definition is suitable in the third trimester when the third stage
of labour is actively managed because 98 percent of placentas are
expelled by 30 minutes in this setting.
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4. Introduction and Definition…
• 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
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5. Types
• Trapped or incarcerated placenta: separated placenta but not
delivered spontaneously or with light cord traction because the cervix
has begun to close.
• Placenta adherens: The placenta is adherent to the uterine wall, but
easily separated manually.
• Placenta accreta: The placenta is pathologically invading the
myometrium due to a defect in the decidua.
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6. Pathogenesis;
• Phases of 3rd stage of labor
• Latent phase – Immediately after birth, all of the myometrium
contracts except for the portion beneath the placenta.
• Contraction phase – The retroplacental myometrium contracts.
• Detachment phase – Contraction of the retroplacental myometrium
produces horizontal (shear) stress on the maternal surface of the
placenta, causing it to detach.
• Expulsion phase – Myometrial contractions expel the detached
placenta from the uterus.
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7. Pathogenesis cont…
• A trapped placenta may be seen as a failure of the expulsion phase.
• Placenta adherens appears to result from contractile failure in the
retroplacental area (i.e., a prolonged latent phase of the third stage of
labour).
• The pathogenesis of placenta accreta is completely different, as it is a
structural rather than a functional abnormality.
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8. Prevalence
• In a systematic review of observational studies, the median
prevalence of retained placenta at 30 minutes is between 2.7 - 1.5%.
• The overall prevalence of retained placenta varies across settings and
over time.
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9. Risk Factors
• Previous retained placenta
• Previous injury or surgery to the uterus
• Preterm delivery
• Induced labor
• Multiparity
• Maternal age ≥30 years
• Uterine abnormalities
• Defective placental implantation
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10. Risk Factors…
• There may be severe bleeding which may be life threatening.
• Attempts at manual removal of the placenta can cause multiple
injuries to the mother such as like vulvar hematoma, perineal tears,
cervical tears and vaginal wall tears.
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11. 11
Causes
• Placenta separated but not expelled
• Simple Adherent Placenta
• Morbid adherence of the placenta:
• Placenta Accreta
• Placenta Increta
• Placenta Percreta
• Constriction ring-reforming cervix
• Full bladder
• Uterine abnormality

12. Causes…
• Placenta separated but not expelled: The placenta may separate
completely from the uterine muscle but may still be retained within the
uterus.
There are three causes for this retention:
• Failure of the woman to push out the placenta due to exhaustion or
prolonged labor.
• Closure of the cervix preventing the placenta from being expelled.
• A constriction ring in the uterus can hold up the placenta
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13. Causes…
• Simple Adherent Placenta: The placenta may fail to separate
completely from the uterine muscle due to lack of contraction of the
uterine muscles.
This condition, 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 retention of
placenta.
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14. Causes…
• 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 attached 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
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15. Causes…
• Placent Accreta: In this condition, the placenta penetrates deep into
the uterine endometrium and reaches the muscles but does not
penetrate into the muscles.
• Placent Increta: Here, the placenta attaches even deeper into the
uterine wall and penetrates into the uterine muscle.
• Placent Percreta: In this condition, the placenta not only penetrates
through the full thickness of the uterine muscles but also attaches to
another organ such as the bladder or the rectum. Placenta percreta is
very rare
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16. Diagnosis
• A diagnosis of trapped placenta is made when the classic clinical signs of
placental separation are present and the edge of the placenta is palpable
through a narrow cervical OS.
• A diagnosis of placenta adherens or placenta accreta is made in the
absence of signs and symptoms of placental separation.(lengthening of the
umbilical cord, gush of blood from the vagina, uterus becomes globular,
firm and bullotable, elevation of the fundal height, and contraction of the
fundus)
• Ultrasound can differentiate between a detached trapped placenta and an
adherent placenta.
• On USG, the myometrium will be thickened in all areas except where the
placenta is attached, where it will be very thin or even invisible
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17. Treatment and Management
• If the placenta is undelivered after 30 minutes consider:
• Emptying bladder
• Breastfeeding or nipple stimulation
• Change of position – encourage an upright position
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18. Treatment and Management…
If bleeding: immediately
• Inform Anaesthetist
• Insertion of large bore IV (18g) cannula
• Insert urinary catheter
• Commence/continue ocytocine infusion 20 unit in 1 litre / rate –
60drops per min
• Measure and accurately record blood loss
• Prepare and transfer patient to theatre for manual removal of
placenta (MROP)
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19. Treatment and Management…
• Treatment will depend on the cause of the retention of the placenta.
If bleeding is present, active treatment is done to control the blood loss
and support the general condition of the patient.
• CCT
• If the placenta is separated but not expelled, then controlled cord
traction should be carried out. In this method, the uterus is held in
place or pushed up gently through the abdominal wall by the left 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.
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20. Treatment and Management…
Manual removal of the placenta
• The placenta may need to be removed manually if controlled cord
traction fails.
• The patient is put under general anesthesia in the operation theatre.
Under all aseptic conditions, the sterile gloved hand of the doctor is
inserted into the uterus. The placenta is stripped from the uterine
muscle gently and brought out.
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21. Treatment and Management…
• Hysterectomy: If the placenta is too deeply embedded into the
uterine musculature (called placenta accrete), a hysterectomy to
remove the uterus may be indicated.
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22. Treatment and Management…
Post procedure care
• 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.
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23. Complications
• Uterine inversion
• Shock (hypovolemic)
• Postpartum haemorrhage
• Puerperal Sepsis
• Subinvolution
• Endometriosis
• Hysterectomy
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24. Key Points
• Retained placenta can be defined as lack of placental expulsion within
30 minutes of delivery of an infant.
• This time period can be extended to 90 to 120 minutes for births in
the 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 haemorrhage is the major complication of retained
placenta.
• Watchful for unexpected Placenta Accreta.
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25. Evaluation
1. What are the risk factors for retained placenta?
2. What are the complications of Retained placenta?
3. What are the treatment and management for retained placenta?
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26. Key Reference
i. Gynecology by Ten teachers
ii. Jones, D. (1992), Fundamentals of Obstetrics and Gynecology, 1sted,
ELBS
iii. Massawe R, et al, Management of Obstetrics Emergencies and
Obstetrics, 1984
iv. Myles, M. (1999), Textbook for Midwives, 13thed, Churchill Livingstone
v. Obstetrics and Gynecology by Dutta
vi. Obstetrics by Ten teachers
vii. MoHCDGEC/ NACTE (2016). Curriculum for Technician Certificate (NTA
Level 5) Curriculum, Dodoma.
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27. Self Study
• Describe the clinical features of a patient with retained placenta
• What are the preventive measures of retained placenta?
• Describe in details the management of retained placenta at a health
centre level
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