Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18–60 mins. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. If hemorrhage is encountered, deployment of a massive transfusion protocol, uterine evacuation with suction, and use of intrauterine tamponade, as with an intrauterine balloon, should be initiated immediately. When a separation plane between the placenta and uterus is particularly difficult to create, PAS should be considered, and preparations should be made for hemorrhage and hysterectomy. Patients with risk factors for retained placenta should have a laboratory sample sent for blood type and antibody screening on admission to labor and delivery, and plans should be made for appropriate analgesia and preparations for hemorrhage if a retained placenta is encountered.

1. RETAINED PLACENTA
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S.DR ALKA MUKHERJEE 1

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee
Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics
association(IMLEA), ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN
SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/ Achievement
 Winner of NOGS GOLD MEDAL –
2017-18
 Winner of BEST COUPLE AWARD
in Social Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN 2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. INTRODUCTION
• Retained placenta is a condition in which all or part of
the placenta or membranes remain in the uterus during
the third stage of labour.
• Retained placenta can be broadly divided into:
1. failed separation of the placenta from the uterine lining
2. placenta separated from the uterine lining but retained
within the uterus
• A retained placenta is commonly a cause of
postpartum haemorrhage, both primary and secondary.
• Retained placenta is generally defined as a placenta that
has not undergone placental expulsion within 30 minutes
of the baby’s birth where the third stage of labor has been
managed actively.
DR ALKA MUKHERJEE 3

4. RISKS OF RETAINED PLACENTA
• Risks of retained placenta:
1. Hemorrhage and
2. Infection.
• After the placenta is delivered, the uterus should
contract 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.
• A retained placenta thereby leads to hemorrhage
DR ALKA MUKHERJEE 4

5. PLACENTAL SEPARATION & EXPULSION
Normally the placenta is expelled in three stage
1.It first separates from the uterine muscle,
2. Then it descends into lower uterine segment of
uterus & vagina
3. Then it is expelled outside.
Problems can occur at any of these stages
DR ALKA MUKHERJEE 5

6. 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.
DR ALKA MUKHERJEE 6

7. RISK FACTORS
Previous retained placenta
Previous injury or surgery to the
uterus
Preterm delivery
Induced labor
Multiparity
DR ALKA MUKHERJEE 7

8. CAUSES
• Placenta separated but not expelled out
• Simple adherent placenta
• Morbidly adherent placenta – placenta accreta
• – placenta increta
• – placenta percreta
DR ALKA MUKHERJEE 8

9. DR ALKA MUKHERJEE 9

10. INITIAL MANAGEMENT
Drugs, such as intraumbilical or
intravenous oxytocin, are often used
in the management of placental
retention.
It is useful ensuring the bladder is
empty.
Avoid Ergometrine as it causes tonic
uterine contractions which may
delay placental expulsion.
Controlled cord traction has been
recommended as a second
alternative after more than 30
minutes have passed after
stimulation of uterine contractions,
provided the uterus is contracted.
Manual extraction may be required
if cord traction also fails, or if heavy
ongoing bleeding occurs.
Very rarely a curettage is necessary
to ensure that no remnants of the
placenta remain (in rare conditions
with very adherent placenta such as
a placenta accreta.
However, in birth centers and
attended home birth environments,
it is common for licensed care
providers to wait for the placenta's
birth up to 2 hours in some
instances.
DR ALKA MUKHERJEE 10

11. 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.
DR ALKA MUKHERJEE 11

12. MANAGEMENT DETAILS
 If the placenta is undelivered after 30 minutes
Consider As retained placenta
 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}.
 Breastfeeding or nipple stimulation
 Change of position - encourage an upright position
DR ALKA MUKHERJEE 12

13. IN STABLE WOMEN WITH MINIMAL BLEEDING
• 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.
DR ALKA MUKHERJEE 13

14. 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}.
b. Sometimes, IV narcotic analgesia will prove helpful in
relieving this discomfort.
c. 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.
d. Ultrasound may be useful in select cases.
MANUAL REMOVAL OF THE PLACENTA
DR ALKA MUKHERJEE 14

15. 1. An elbow-length glove is worn and attention is paid to asepsis.
2. The perineum and vagina must be prepared.
3. The vaginal hand may be immersed in povidone- iodine solution
to facilitate easier entry.
4. The hand is passed into the vagina through the cervix and into the
lower segment following the umbilical cord.
5. 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.
6. Control of the uterine fundus with the nonvaginal hand is
essential.
7. If the placenta is encountered in the lower segment, it is
removed. If the placenta is not encountered, the placental edge is
sought
8. Separate the placenta from the uterus with a sweeping motion
9. After the placenta is mostly separated, curl your palm around the
bulk of it.
MANUAL REMOVAL OF THE PLACENTA - PROCEDURE
DR ALKA MUKHERJEE 15

16. 10. Continue to grasp the placenta as you remove it from
the uterine cavity.
11. 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.
12. 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.
13. Once uterine contraction is established, examine the
placenta and membranes to determine whether further
exploration or curettage is necessary.
14. Antibiotics
DR ALKA MUKHERJEE 16

17. Placenta Accreta and Percreta
I. partial and focal:
a. the attachments can be manually broken and
the placenta removed.
b. 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.
DR ALKA MUKHERJEE 17

18. 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.
DR ALKA MUKHERJEE 18

19. A retained placenta with absent sonolucent area
between the placenta and uterine wall suggestive of
placenta increta.
DR ALKA MUKHERJEE 19

20. DR ALKA MUKHERJEE 20

21. Morbid adhesion of the placenta:
Morbid adhesion of the placenta can occur wh
en the placenta is implanted deeply into the
uterine muscles and thus fails to separate.
The placenta can burrow upto different depths
in the uterine muscle.
In simple cases, it is only attached firmly to
muscle and can be stripped off by hand.
In severe morbid adhesion, the placenta can b
urrow through the full thickness of the muscle
In this case, the uterus may be needed to be
removed ('hysterectomy') to control the bleedi
ng.
DR ALKA MUKHERJEE 21

22. DR ALKA MUKHERJEE 22

23. Three types of morbid adhesion of the placenta
1.Placenta Accreta: In this condition, the placenta pen
etrates deep into the uterine endometrium and reach
es the muscles but does not penetrate into the muscl
es.
2.Placenta Increta: Here, the placenta reaches even de
eper into the uterine wall and penetrates into the ute
rine muscle.
3.Placenta Percreta: In this condition, the placenta not
only penetrates through the full thickness of the uter
ine muscles but also
Reaches to another organ such as the bladder or the
rectum.
Placenta percreta is very rareDR ALKA MUKHERJEE 23

24. DR ALKA MUKHERJEE 24

25.  CALL FOR HELP
 Inform Anesthetist
 Insert large bore 18 no cannula
 Catheterize patient
 IV 20UNITS OXYTOCIN DRIP @ 60 DROPS/MT
 ESTIMATE BLOOD LOSS
 COAGULATION PROFILE ALONG WITH CBC
 ARRANGE FOR BLOOD
 PREPARE PATIENT FOR MRP, SOS HYSTERECTOMY
 TAKE INFORMED CONSENT
1.If bleeding profusely
DR ALKA MUKHERJEE 25

26. Risks of Retained Placenta
There may be severe bleeding which may be life-
threatening.
Attempts at manual removal of the placenta can cause
multiple
injuries to the mother such as like vulvar hematoma,
perineal tears, cervical tears and vaginal wall tears.
Complications of a Retained Placenta
 Uterine inversion
 Shock (hypovolemic)
 Postpartum hemorrhage
 Puerperal Sepsis
 Subinvolution
 Hysterectomy
DR ALKA MUKHERJEE 26

27. POST-PROCEDURE CARE
1. Observe the woman closely until the effect of IV
sedation has worn off.
2. Monitor the vital signs (pulse, blood pressure,
respiration) every 30 minutes for the next 6 hours
or until stable.
3. Palpate the uterine fundus to ensure that the
uterus remains contracted.
4. Check for excessive lochia.
5. Continue infusion of IV fluids.
6. Transfuse as necessary.
DR ALKA MUKHERJEE 27

28. DR ALKA MUKHERJEE 28