The document discusses retained placenta, which is defined as the placenta remaining in the uterus for more than 30 minutes after delivery. Signs of placental separation are listed. Management of retained placenta includes ensuring an empty bladder, injecting oxytocin or other substances into the umbilical cord, and manually removing the placenta while massaging the uterus. Complications like placenta accreta can cause extensive attachment making manual removal difficult and potentially requiring uterine artery ligation or hysterectomy. Ultrasound may help identify accreta cases.

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Aboubakr Elnashar

2. After delivery of the baby, the placenta
normally
detaches from the uterus and is expelled,
often with additional pushing efforts by the
mother.
Normally this occurs within a few minutes of
delivery of the baby.
Aboubakr Elnashar

3. 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.
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4. Definition
Retention of the placenta in utero for more
than 30 minutes.
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5. Management
•Depend on severity of bleeding. The retained or
partially detached placenta interferes with uterine
contraction and retraction and leads to bleeding.
•Bleeding may be visible or may manifest only by
the increasing size of the uterus.
In the absence of any evidence of placental
detachment, consider the diagnosis of complete
placenta accreta or a variant. This condition may be
present with bleeding if only a portion of the
placenta is abnormally implanted.
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6. 1.Ensuring that the bladder is empty {may speed
the delivery of the placenta and at least aid in
the assessment and control of the uterus}.
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7. 2. In stable women with minimal bleeding while
preparations for a manual removal are being made.
Injection into the umbilical cord vein (Carroli, 2002).
Saline,
oxytocin and saline,
prostaglandin and saline, and
dextran 70.
The studies comparing injection of oxytocin
(commonly, 10 IU) and saline (commonly, 20 mL)
with expectant management or saline injection alone
suggest that this practice indeed reduces the need
for manual removal of the placenta.
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8. 3. Manual removal of the placenta
if the above maneuvers have failed to deliver the
placenta or
if significant bleeding occurs.
a.Anesthesia (regional or general) {manual removal
can cause considerable abdominal cramping}.
Sometimes, IV narcotic analgesia will prove helpful
in relieving this discomfort.
Nb: The cessation of an oxytocin infusion or the administration
of uterine relaxants to promote uterine exploration and
manual removal is of questionable value and may lead to
increased bleeding. Ultrasound may be useful in select
cases.
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9. b. an elbow-length glove is worn and attention is paid to
asepsis. The perineum and vagina must be prepared.
The vaginal hand may be immersed in povidone-
iodine solution to facilitate easier entry. The hand is
passed into the vagina through the cervix and into the
lower segment following the umbilical cord. Care is
taken to minimize the profile of the hand as it enters,
keeping the thumb and fingers together in the shape
of a cone to avoid damage.
Control of the uterine fundus with the nonvaginal hand is
essential.
If the placenta is encountered in the lower segment, it is
removed. If the placenta is not encountered, the
placental edge is sought.
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10. Separate the placenta from the uterus with a sweeping motionAboubakr Elnashar

11. After the placenta is mostly separated, curl your palm around
the bulk of it.
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12. Continue to grasp the placenta as you remove it from the
uterine cavity. Aboubakr Elnashar

13. c. Once found, the fingers gently develop the
space between the placenta and uterus and
shear off the placenta. The placenta is pushed
to the palmar aspect of the hand and wrist;
when it is entirely separated, the hand is
withdrawn.
d. an oxytocin infusion is running rapidly as
the hand is withdrawn {encourage strong
uterine contraction}, and then perform uterine
massage.
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14. Care must be taken to tease out the
membranes.
e. Once uterine contraction is established,
examine the placenta and membranes to
determine whether further exploration or
curettage is necessary.
f. Antibiotics
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15. Aboubakr Elnashar

16. Placenta Accreta and Percreta
I. partial and focal:
a.the attachments can be manually broken and the
placenta removed.
b. It may be necessary to curette the placental bed
to reduce bleeding. Recovery is usually
satisfactory, although more than the usual amount
of post partum bleeding will be noted.
Aboubakr Elnashar

17. II. extensive or complete:
• you probably won't be able to remove the
placenta in other than handfuls of fragments.
• Bleeding from this problem will be
considerable, and the patient will likely end
up with multiple blood transfusions while you
prepare her for a life-saving,
• post partum uterine artery ligation or
hysterectomy.
• If surgery is not immediately available,
consider tight uterine and/or vaginal packing
to slow the bleeding until surgery is
available.
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18. a retained placenta with absent
sonolucent area between the plaenta
and uterine wall suggestive of
plaenta increta. Aboubakr Elnashar

19. Repeat USG showing
increased echogenicityAboubakr Elnashar

20. Aboubakr Elnashar

21. Thanks
Aboubakr Elnashar