This is a presentation regarding the risks associated with retained placenta, its causes and the management.

1. RETAINED PLACENTA AND
HOW TO MANAGE IT?

2. • Retained placenta is a significant cause of post partum hemorrhage,
maternal mortality and morbidity throughout the developing world.
• DEFINITION- When the placenta does not expel after 30 minutes of
delivery of the fetus, it is said to be retained.
• It is an event of the third stage of labour.

3. PHYSIOLOGY OF THIRD STAGE OF LABOUR
1. Stage of placental separation-
• Reduction in the surface area of placental site.
• Separation of the placenta by either Schultze or Duncan method.
• By uterine contraction it is forced through the passive lower segment
and then through the open cervix.
• Living ligatures.

4. Reduction of the area of placental site after
delivery of fetus.

5. Separation of Placenta
• By two methods-
1. By fetal surface- Schultze
2. By maternal surface- Duncan
Mnemonic- Dirty Duncan

6. Living ligatures

7. Active management of third stage of labour
1. Prophylactic uterotonics after the delivery of the baby.
(Oxytocin 10 IU, IM)
2. Expulsion of placenta by controlled cord traction.
3. Uterine massage
Oxytocin excites powerful uterine contraction, aids in early separation
of placenta, minimizes blood loss and duration of third stage of labor,

8. Retained placenta
• Is a condition in which all or part of the placenta or membranes
remain in the uterus during/ after the third stage of labour.
• When does it occur?
It occurs when there is abnormality in any of the three steps
mentioned above.
1. Failure of placenta to separate from the uterine lining.
2. Placenta separated from the uterine lining but failed to expel.

9. Causes of retained placenta
• Partial or completely adherent placenta
• Retention of cotyledon/ part of placenta ( Placenta Succenturiate)
• Untimed ergometrine/ Oxytocin
• Constriction ring- hourglass contraction
• Incompletely separated placenta
• Simple adhesions

10. Risk factors of retained placenta-
• Parallel to those for uterine atony (the retro-placental myometrium
fails to contract)
PAS
Prolonged oxytocin use
High parity
Preterm delivery
History of a prior retained placenta and congenital uterine anomalies

11. Complications of Retained Placenta
• Primary PPH
• Secondary PPH
• Sepsis and infection
• Uterine rupture- Unscarred uterine rupture possibly occurs due
to the weakness of uterine layers caused by placenta accreta
spectrum in the third and even second trimester.
• Placental polyp

12. Adherent Placenta
• Incidence- 4%.
• Etiology- Partial or total absence of decidua basalis and imperfect
development of fibrinous layer (Nitabuch’s layer). Chorionic villi
invade the myometrium.
• Retention interferes with contraction and retraction. Keep blood
sinuses open.
• Attached area does not retract.
• No correlation between amount of placenta retained and severity of
bleeding.

13. • Focal, partial or complete.
• Placenta accreta- Villi attach to the superficial layer of the myometrium.
• Placenta increta- Villi invade or penetrate into the myometrium.
• Placenta percreta- Villi penetrate the myometrium up to the serosal surface (Can
invade nearby structures like bladder)

14. • Histology – placental villi anchored directly on or invading the
myometrium without an intervening decidual plate.

15. • Causes-
1. Implantation over previous scar ( Caesarean, myomectomy)
2. Previous manual removal of placenta
3. Placenta previa
4. Previous vigorous/ repeated curettage
5. Previous h/o uterine synechiae
6. Submucous myoma
7. Uterine diverticulum
8. Grand multigravida

16. Contraction Ring
The placenta gets trapped within
the contraction ring.

17. Clinical Picture of Retained Placenta
• Depends on the amount of blood loss
• Bleeding occurs only if the placenta is separated partially or
completely
• Uterine is lax in case of atony
• Examination may reveal:
Constriction ring
Rupture uterus
Morbid placental adherence where there is no plane of cleavage

18. Screening in high risk cases
• Antenatal suspicions and diagnosis is an important factor in
decreasing morbidity of adherent placenta.
Clinical suspicion
Ultrasound
MRI

19. Management of retained placenta
• Catheterize the bladder
• Perform gentle controlled cord traction and if failed.
• Give Oxytocin i/v 20 units ( upto 40 units have been in intractable
bleeding) in one litre of ringer lactate/ normal saline
• Brandt Andrew’s maneuver – only if failed
• Manual separation of placenta
Crede’s method of separation of placenta is abandoned.

20. BRANDT ANDREW MANEUVER CREDE METHOD

21. • Constriction Ring- Manual separation of placenta under anesthesia.
• Simple adhesion and partial Placenta Accreta- Manual separation of
placenta can be tried.
• Morbid Adherence of the Placenta- In parous patient: Hysterectomy is
the treatment.
• Rupture Uterus- Manage accordingly
• Injection of Oxytocin into the umbilical vein- has been suggested as
an alternative. This method relies on the injected oxytocin 10 units
passing through the placenta to contract the retro-placental
myometrium and cause its detachment.
No firm conclusion have been reached regarding its efficacy

22. Manual Removal of The Placenta
• The procedure is done under general anaesthesia.
• The right hand is introduced along the umbilical cord into the uterus.
• The lower edge of the placenta is identified and by a sawing
movement from side to side the placenta is separated from its bed.
• Grasp the placenta and deliver it out.
• As it is delivered out Inj Methergine is given to prevent uterus
inversion (occurring due to relaxed uterus)
• Examine the placenta and membranes for completeness.
• The left hand supports the uterus abdominally throughout the
procedure.

24. Failure of removal of placenta be due to-
• Obesity
• Placenta accreta
• Rigidity of the abdominal wall
• Constriction ring
Post procedure care-
• Observe the woman closely until the effect 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 that the uterus remains contracted
• Check for excessive lochia
• Continue infusion of IV fluids
• Transfuse, as necessary

25. Complications of MRP-
• Incomplete Removal of placenta and membranes
• Post- partum hemorrhage- pre and intra-op
• Inversion of uterus
• Embolism
• Thrombophlebitis
• Secondary infection
• Shock
• Perforation
• Placental polyp

26. Presentation in the post- partum period
• Can come with secondary PPH
• Foul smelling discharge, passing placental tissue
• Fever and pain
• Ultrasound shows retained placental bills
• Management-
1. Antibiotic cover
2. Necessary cultures
3. Curettage associated with risk of perforation and dense adhesion due to
super added infection
4. Blood transfusion if indicated
5. Hysterectomy if required

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