notes for nursing students

1. RETAINED PLACENTA:

2.  DEFINITION: the placenta is said to be retained
when it is not expelled out even 30 minutes after
birth of the baby.

3.  CAUSES: there are three phases involve in the
normal expulsion of the placenta
 Separation through spongy layer of the deciduas
 Decent into the lower segment and vagina
 Finally its expulsion to outside

4.  Interference in any one of these physiological process
leads to its retention.
 Placenta completely separated but retained is due to
poor voluntary expulsive effects
 Simple adherent placenta is due to uterine atonicity in
cases of grand multipara or over distention of uterus,
prolonged labor, uterine malformation or due to bigger
placental surface area. The commonest cause is
atonic uterus.
 Morbid adherent placenta
 Placenta incarcerated following partial or complete
separation due to constriction ring, premature
attempts to deliver the placenta before it is delivered.

5.  DIAGNOSIS: the diagnosis is made by an
arbitrary time spent following delivery of the baby.
features of placental separation are assessed.
the hour glass contraction or the nature of
adherent placenta can only be diagnosed during
manual removal.

6.  DANGERS: the risk involved in prolonged
retention of placenta are:
 Heamorrhage
 Shock is due to blood loss
 At times unrelated to blood loss, specially when
retained more than one hour
 Frequent attempts of abdominal manipulation to
express the placenta out
 Risk of recurrence in next pregnancy.

7.  MANAGEMENT:
 Period of watchful expectancy:
 During the period of arbitrary time limit of half an
hour, the patient is to be watched carefully for
evidence of any bleeding, revealed or concealed
and to note the signs of separation of placenta.
 The bladder should be emptied using a rubber
catheter
 Any bleeding during the period should be
managed as outlined in third stage bleeding.

8.  Retained placenta:
 Separated
 Unseperated
 Complicated

9.  Placenta is separated and retained : to
express the placenta by controlled cord traction
 Unseperated retained placenta: manual
removal of placenta is to be done under general
anesthesia as described earlier.

10. Management of unforeseen
complications during manual
removal:
 Hour glass contraction: the placenta is trapped
by a localized contraction of circular muscles of
the uterus. This may be situated at the junction of
the lower and upper segment or may be placed at
lower cornue. Administration of any oxytocic
specially ergometrine in the active management
of third stage or undue irritability of the uterus by
premature attempts to express the placenta is the
important cause. The diagnosis is only made
during attempted manual removal

11.  Management: the ring should be made relaxed
by - Deepening the plane of anesthesia then the
cone shaped hand is introduced and the
separation of placenta is preferably done from the
above to downwards to minimize bleeding.

12.  Morbid adherent placenta: in majority, the
diagnosis is made only during attempted manual
removal . On rare occasion, however. No
cleavage between the placenta and the uterine
wall is made possible and the diagnosis of a total
placenta accrete is certain.

13.  Complicated retained placenta: the following
guidelines are formulated to manage the cases of
retained placenta complicated by hemorrhage,
shock or sepsis.
 Retained placenta with shock but no
hemorrhage: to treat the shock and when the
condition improves, manual removal of the
placenta is to be done

14.  Retained placenta with hemorrhage: the
management protocol is similar to mention in third
stage hemorrhage
 Retained placenta with sepsis: the patient is
usually delivered outside and is admitted in the
referral hospital after few hours or even days after
confinement. Intrauterine swabs are taken for
culture and sensitivity test and broad spectrum
antibiotics are given. Blood transfusion is helpful.
As soon as the general condition permits
arrangement is made for manual removal of
placenta. The operation should be done by a
senior person.

15.  Retained placenta with an episiotomy wound:
the bleeding points of the episiotomy wound are
to be secured by artery forceps. An early decision
for manual removal should be taken followed by
repair of episiotomy wound.