What is retained placenta?

Retained placenta means that all or part of the placenta or membranes are left
behind in the uterus (womb) during the third stage of labour. The third stage is
when you deliver the placenta and membranes. You'll be treated for a retained
placenta if the third stage takes longer than usual or if there are signs that any of
the placenta or membrane is still attached to the uterus.

A natural third stage, which involves you actively delivering the placenta by pushing
it out, normally takes about 10 to 20 minutes but it can take up to an hour. The
third stage can be speeded up with an injection in your thigh, given just as your
baby is being born. This is known as a managed third stage and usually takes about
five to 10 minutes. Managing the third stage reduces the risk of you experiencing
heavy bleeding.

You'll be treated for retained placenta if you have not completely delivered the
placenta:

• within one hour of your baby's birth, if you have a natural third stage - this
happens in about 13 per cent of cases

• within 30 minutes of your baby's birth, if you have a managed third stage - this
happens in less than five per cent of cases

Why and how does a retained placenta happen?

There are three main causes of retained placenta:

• uterine atony - this means that the uterus stops contracting or doesn't contract
enough for the placenta to separate from the wall of the uterus

• trapped placenta - the placenta comes away from the uterus successfully but
becomes trapped behind a closed cervix

• placenta accreta - an area of the placenta remains attached because it is deeply

embedded into the uterus wall

A trapped placenta can happen during a managed third stage if the cord snaps
during "controlled cord traction". Your midwife gives you an injection and then waits
for signs that the placenta has separated. Controlled cord traction is when she puts
one hand on your tummy to keep your uterus steady whilst pulling gently on the
cord with her other hand.

If the placenta has separated and is ready to come out, it will slide easily through
the vagina. If it has not completely separated, if the cord is very thin or if your
midwife pulls too hard, the cord may snap, leaving the placenta inside the uterus. If
this happens you can usually help to deliver the placenta by pushing with a
contraction when the midwife tells you to, but occasionally the cervix will have
closed too much to let the placenta out.

Retained placenta may be due to a small piece of placenta, connected to the

main part of the placenta by a blood vessel, being left behind in the uterus. This is
called a succenturiate lobe. The midwife will examine the placenta and membranes
carefully after delivery to ensure that they are complete. If she notices a vessel
leading to nowhere, this should alert her to the possibility of part of the placenta
being retained.

Sometimes a part of the placenta may adhere to a fibroid, or a scar from a previous
caesarean section.

Sometimes a full bladder will prevent the placenta from being delivered, so your
midwife may insert a catheter to drain your bladder.

What are the problems associated with retained placenta?

Normally after the placenta is delivered, your uterus contracts down to close off all
the blood vessels inside the uterus. If the placenta only partially separates, the
uterus cannot contract properly, so the blood vessels inside will continue to bleed.

If the third stage is managed and delivery of the placenta takes longer than 30
minutes after the birth of your baby, your risk of heavy bleeding increases
substantially. Heavy bleeding in the first 24 hours after birth is known as primary
postpartum haemorrhage (PPH).

If small fragments of placenta or membrane are retained and are not detected
immediately, this may cause heavy bleeding and infection later on. This is known as
secondary PPH and happens in just under one per cent of births.

How is it treated?

If the third stage is taking a while, you could try breastfeeding your baby or rubbing
your nipples, as this can cause the uterus to contract and may help to expel the
placenta. If you're sitting or lying down, try changing to a more upright position so
that gravity can help.

If you choose a managed third stage, you'll be given an injection of an oxytoxic drug
to make your uterus contract and your midwife will use controlled cord traction to
gently pull the placenta out.
If the placenta still can't be removed, it may need to be removed manually. You'll
be given a regional anaesthetic such as a spinal or epidural, or you can ask for a
general anaesthetic if you prefer.

Before the placenta is removed manually your midwife will insert a catheter in to
empty your bladder and you'll be given intravenous (IV) antibiotics to prevent
infection. After manual extraction, you may need more drugs which are given
intravenously to help the uterus contract down.

If you have prolonged heavy bleeding in the days or weeks following the birth, you
may be referred for an ultrasound scan to see if there are any fragments of
placenta or membrane in your uterus. If so, you will be admitted to hospital for
removal under anaesthetic - a procedure known as evacuation of retained products
of conception (ERPC), and treated with antibiotics.

I had a retained placenta with my first labour. Can I do anything to stop it

happening again?

If you have already had a retained placenta in a previous birth, you have a higher
risk of it happening again. There is not much you can do to prevent it happening
again if it was due to the placenta adhering to an old caesarean scar, or placenta
accreta.

Retained placenta is more common in premature births than those born full term,
probably because the placenta was designed to stay put for 40 weeks, so if you
have another premature labour, it may happen again.

However, if the retained placenta happened because the cord snapped or the cervix
closed too quickly after having the oxytocic injection, you may wish to discuss with
your midwife whether or not to have a natural third stage with your next baby. By
allowing the placenta to deliver naturally, you avoid the possibility of the cervix
closing too quickly and trapping the placenta.

Retained Placenta

After delivery of the baby, the placenta normally detaches from the inside of 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, but may take as
long as an hour.

The four signs of placental separation are:

Apparent lengthening of the visible portion of the umbilical cord.

Increased bleeding from the vagina.

Change in shape of the uterus from flat (discoid) to round (globular).

The placenta being expelled from the vagina.

Commonly, after about 30 minutes of waiting or if there is increased bleeding

without evidence of placental separation, a manual removal of the placenta is
undertaken. Anesthesia (regional or general) is typically used for this as manual
removal can cause considerable abdominal cramping. Sometimes, IV narcotic
analgesia will prove helpful in relieving this discomfort

Manual Removal of the Placenta

One hand is inserted through the vagina and into the uterine cavity.

Insert the side of your hand in between the placenta and the uterus. You may need
to push through the placental membranes to accomplish this.

Using the side of your hand, sweep the placenta off the uterus.

After most of the placenta has been swept off the uterus, curl your fingers around
the bulk of the placenta and exert gentle downward and outward traction. You may
need to release the placenta and then re-grab it.

Then pull the placenta through the cervix. Most placentas can be easily and
uneventfully removed in this way. A few prove to be problems.

Placenta Accreta and Percreta

When you manually remove the placenta, be prepared to deal with an abnormally
adherent placenta (placenta accreta or placenta percreta). These abnormal
attachments may be partial or complete.

If partial and focal, the attachments can be manually broken and the placenta
removed. 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.

If 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.

Hypertonic Uterine Dysfunction

An elevated tone of the uterus that generally occurs in the latent phase of labor.
The condition causes frequent and intense contractions, but they are not effective.
This may be caused by the mid segment of the uterus contracting with such a force
that is greater than the fundus or a lack of nerve impulse synchronization.
Synonym(s):

Uterine hyperstimulation or hypertonic uterine dysfunction is a potential

complication of labor induction. It is defined as either a series of single contractions
lasting 2 minutes or more or a contraction frequency of five or more in 10 minutes.
Uterine hyperstimulation may result in fetal heart rate abnormalities, uterine
rupture, or placental abruption. It is usually treated by administering terbutaline.

Hypotonic Uterine Dysfunction

Uterine dysfunction that typically occurs during the active phase of labor, after the
cervix has dilated to more than 4 cm. Contractions are usually irregular and are not
forceful enough to dilate cervix at a satisfactory rate, which will lead to prolonged
labor.
Definition

The uterine contractions are infrequent, weak and of short duration

Etiology

Unknown but the following factors may be incriminated:

General factors:

> Primigravida particularly elderly.

>Anaemia and asthenia.

> Nervous and emotional as anxiety and fear.

> Hormonal due to deficient prostaglandins or oxytocin as in induced labour.

> Improper use of analgesics.

Types

Primary inertia: weak uterine contractions from the start.

Secondary inertia: inertia developed after a period of good uterine contractions

when it failed to overcome an obstruction so the uterus is exhausted.

Clinical picture

* Labour is prolonged.

* Uterine contractions are infrequent, weak and of short duration.

* Slow cervical dilatation.

* Membranes are usually intact.

* The foetus and mother are usually not affected apart from maternal anxiety due
to prolonged labour.

* More susceptibility for retained placenta and postpartum haemorrhage due to

persistent inertia.

* Tocography: shows infrequent waves of contractionswith low amplitude.

Management :
1. General measures

> Examination to detect disproportion,malpresentation or malposition and manage

according to the case.

> Proper management of the first stage (see normal labour).

> Prophylactic antibiotics in prolonged labourparticularly if the membranes are

ruptured.

Amniotomy:

a.Providing that;

> vaginal delivery is amenable,

>the cervix is more than 3 cm dilatation and

> the presenting part occupying well the lower uterine segment