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.
Aboubakr Elnashar
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.
Aboubakr Elnashar
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}.
Aboubakr Elnashar
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.
Aboubakr Elnashar
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.
Aboubakr Elnashar
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.Aboubakr Elnashar
11. After the placenta is mostly separated, curl your palm around
the bulk of it. Aboubakr Elnashar
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.
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
Aboubakr Elnashar
15. 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
16. 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.
Aboubakr Elnashar
17. a retained placenta with absent
sonolucent area between the plaenta
and uterine wall suggestive of
plaenta increta. Aboubakr Elnashar
