Management of retained placental fragments (segments/pieces)

A. When diagnosed within 24 hours of delivery

1. Must be an aseptic procedure: use 10% polyvidone iodine or chlorhexidine solution +/-
obstetric cream to disinfect the vagina and cervix.
2. Use sterile drapes, sterile gauze compresses and sterile uterine exploration gloves
(elbow length)
3. Ideally use local anaesthetic (paracervical block)
4. Always empty bladder to reduce risk of bladder damage; either patient on her own or
via sterile urinary catheter.
5. Give antibiotic prophylaxis just before procedure: Ampicillin 2 gram and 500mg
Metronidazole given IV slowly as single dose.
6. If PPH ensure no cervical or vaginal tear is present but perform uterine exploration
before performing repair of any tears, unless bleeding profusely from tear. Undertake
manual exploration of the uterus to remove placental fragments or clots which can
interfere or already are interfering with uterine contraction and cause PPH.
7. With one hand systematically explore the whole internal uterine wall: 2 faces, 2 sides, 1
fundus, 2 horns. Use fingers to search for placenta fragments and clots and remove
these by hand.
8. Once the cavity has been fully explored ensure uterine contraction by abdominal
massage and administer a uterotonic drug ideally oxytocin IM or slow IV injection 5 to
10 IU as a single dose. If bleeding continues give IV infusion of oxytocin over the next 4
hours (40 IU of oxytocin in 500 ml 0.9% saline). If oxytocin is not available, give
misoprostol 800 to 1000 microgram rectally or sub-lingually depending on degree of PPH
and atony.

B. When diagnosed usually longer than 24 hours after delivery and/or where a full hand
cannot be inserted through the cervix (may also occur after late miscarriage)

1. First try digital exploration to gain entry to the uterine cavity which can be achieved if
cervical dilatation allows one or ideally 2 fingers to be inserted.
2. Insert the index finger and middle finger if possible and cup the uterus through the
abdominal wall using the other hand (see Figure 1)
3. Systematically explore and remove any fragments and clots.
4. If successful, give oxytocin 5 to 10 IU IM or slow IV after the procedure to ensure uterine
contraction. If oxytocin is not available, give misoprostol 800 to 1000 microgram rectally
or sub-lingually depending on degree of PPH and atony.

Figure 1
Digital exploration

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5. Instrumental curettage should only be used if the cervix is not dilated enough to allow
manual uterine exploration or digital exploration. There is a high risk of uterine
perforation and organ damage.

6. If there is no evidence of infection (uncommon if more than 24hours after delivery) give
antibiotic prophylaxis just before procedure: Ampicillin 2 gram and 500mg
Metronidazole given IV slowly as single dose.

7. If evidence of potentially severe infection (pelvic sepsis) give the triple antibiotics before
starting curettage, then give the antibiotics for 5 to 7 days— Initially give intravenously
for at least 48 hours:
- Ampicillin 2 grams IV every 6 hours
- plus Gentamicin 80 mg IV/IM every 8 hours or 5 mg/kg body weight IV/IM once
every 24 hours
- plus Metronidazole 500 mg IV every 8 hours.
- Consider adding Ceftriaxone (1 gram IV every 24 hours) if not improving.

If improving after 48 hours consider changing to oral antibiotics to complete at least 5 to

7 days of treatment as follows: Ampicillin or Amoxycillin 1 gram orally 8 hourly plus
Metronidazole 500 mg 8 hourly.

8. Have available the following instruments ready to perform the Curettage and cervical
dilatation (the latter only when necessary):
1 set of 3 blunt-edge curettes
2 vaginal retractors
1 tenaculum or preferably sponge/ring forceps
1 blunt uterine sound
1 vaginal speculum
8 uterine dilators (4, 6, 8, 10, 12, 14, 16, 18).

9. If the cervix is insufficiently dilated for the curette to be passed, perform a paracervical
nerve block.

10. Place sponge/ring forceps (or tenaculum) on the anterior cervix at 12 o’clock and apply
gentle traction to the tip of the cervix to see the junction between the cervix and the
vaginal wall where injections of Lidocaine are to be made. Try to avoid using tenaculum,
if possible, as it is likely to cause more cervical trauma than sponge/ring forceps.

Injections of 1% Lidocaine (2 to 3 ml per injection) are given for the paracervical block in
this transition/junction zone at 4 sites around the cervix at 3, 5, 7 and 9 o’clock
positions. Inject down to a maximum depth of only 2 to 3 mm and do not exceed 20 ml
of 1% Lidocaine in total.

Ensure that the needle is not in a vein with each injection by drawing back the needle
before injection.

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 Wait 2 minutes and check that the cervix is anaesthetised by pinching it gently with
forceps. If the pinch is felt, wait for another 2 minutes.

11. To undertake curettage with sponge forceps/tenaculum attached to the anterior cervix
at 12 o’clock, bring the cervix and body of the uterus into the best possible alignment
(Figure 2)

12. A uterine sound should not be used as it is relatively sharp-tipped and can perforate. It
is safer to ‘sound’ the uterus after dilatation with a curette as it is blunt ended

13. The cervix is likely to be dilated but may need to be further dilated to allow introduction
of the largest size curette (10 – 14mm).

14. Slowly introduce the dilators (starting with the largest dilator than can slide into the
cervix without any force) until the resistance felt on passage through a closed internal os
is released and the dilator is felt to pass through it into the uterine cavity. The smaller
the curette the greater the risk of trauma to the uterine wall.
Proceed slowly and gently to ensure that the cervix is not torn, or a false passage
created by the dilators.

15. Try to obtain sufficient dilatation to permit the passage of the largest size curette.
Usually a dilatation of 10–14 mm is sufficient. Once the cervix is dilated gently introduce
the largest curette and advance until resistance (the fundus) is felt, this determines the
size of the cavity for reference when performing the curettage.

16. Taking great care to avoid perforation, explore the whole uterus systematically with the
curette held between the thumb and index finger and beginning at the fundus and
drawing down any fragments toward the cervix. The aim is to detach fragments without
damaging the internal wall of the uterus, over vigorous curettage can lead to
Asherman’s syndrome (intra-uterine adhesions) and possible future infertility.

Figure 2 Curettage

17. When finished, verify that the uterus is empty (ideally by additional use of ultrasound
provided that you are skilled in its use) and no more tissue comes out with the curette.
There will be a rough feeling as the curette passes over the entire internal uterine
surface.

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18. If successful, give oxytocin 5 to 10 IU IM or by slow IV injection after the procedure to
ensure uterine contraction. If oxytocin is not available, give misoprostol 800 to 1000
microgram rectally or sub-lingually depending on degree of PPH and atony.

Complications of late (more than 24 hours) placental fragment retention

1. Serious and potentially life-threatening infection

Pelvic infection (endometritis, salpingitis, pelvic peritonitis) and septicaemia can all occur as
a result of delayed removal of retained placental fragments.

In a patient with a fever of 37.5 degrees C or more and active endometritis or other pelvic
infection give the following IV treatment for at least 48 hours:

- Ampicillin 2 grams IV every 6 hours

- plus Gentamicin 80 mg IV/IM every 8 hours or 5 mg/kg body weight IV/IM once
every 24 hours
- plus Metronidazole 500 mg IV every 8 hours.
Consider adding Ceftriaxone (1 gram IV every 24 hours) if not improving

If improving after 48 hours consider changing to oral antibiotics to complete at least 5 to 7

days of treatment as follows: Ampicillin or Amoxycillin 1 gram orally 8 hourly plus
Metronidazole 500 mg 8 hourly.

2. Uterine perforation, sometimes indicated by the curette going too far into the uterus.

Symptoms include bleeding, shock, lower abdominal pain and peritonitis.

Bladder injury is also possible and a fistula between uterus and bladder is possible if the
bladder had not been emptied prior to curettage.

Treatment of uterine perforation

If there is, or there develops over the next 24-48 hours, signs of peritonism (pain or
guarding) a laparotomy will be needed to manage possible bowel or other intra-abdominal
organ damage.

If bladder injury is present place an indwelling urinary catheter for at least 7 days.

Give intravenous antibiotics as described for pelvic infection above but give IV for 10 days.