MANUAL REMOVAL OF THE PLACENTA
By Laston Kastom,BscBMS(RH),Dip.Clin.Med
WHAT IS A RETAINED PLACENTA?
The retained placenta is when the placenta is not delivered within 30 minutes after the birth of the fetus.
This placenta may be:
Separated but trapped by the cervix
Partially separated
Pathologically adherent, like in placenta accreta, increta, or percreta.
INCIDENCE OF RETAINED PLACENTA
Retained placenta is found in 2 percent of deliveries. The frequency of retained placenta is markedly
increased, about twenty fold, at gestations less than 26 weeks and even up to 37 weeks it remains three
times more common than at term.
At term 90 percent of placentas will not be delivered within 15 minutes. Once the third stage has
exceeded 30 minutes there is 10-fold increase in the risk of haemorrhage.
DIAGNOSIS OF RETAINED PLACENTA
A high fundus
Postpartum haemorrhage
Absent signs of placenta separation
RISK FACTORS OF RETAINED PLACENTA
Preterm deliveries
Grand multiparity
Previous caesarean sections
Previous retained placenta
Placenta implantation abnormalities like accreta, increta, perincreta.
COMPLICATIONS OF RETAINED PLACENTA
Postpartum hemorrhage
Postpartum infections
Hysterectomy
Psychological stress
ACTUAL PROCEDURE OF REMOVAL OF RETAINED PLACENTA
Review the general care principles and start an I.V infusion.
Provide emotional support and encouragement, give pethidine and diazepam I.V slowly ( don’t
mix in the same syringe) or you can use ketamine.
Catheterize the bladder or ensure that it is empty
Give a single dose of prophylactic antibiotics,
Ampicillin 2g I.V plus metronidazole 500mg I.V
Cefazolin 1g I.V plus metronidazole 500mg I.V
Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor
With sterile gloves insert the other hand into the vagina and up into the uterus
Let go of the cord and move the hand up over the abdomen in order to support the fundus of
the uterus and to provide counter-traction during removal to prevent inversion of the uterus.
Move the fingers of the hand in the uterus laterally until the edges of the placenta is located
If the cord has been detached previously, insert a hand into the uterine cavity. Explore the entire
cavity until a line of cleavage is identified between the placenta and the uterine wall.
Detach the placenta from the implantation site by keeping the fingers tightly together and using
the edge of the hand to gradually make a space between the placenta and the uterine wall
Precede slowly all around the placental bed until the whole placenta is detached from the
uterine wall.
If the placenta does not separate from the uterine surface by gentle lateral movement of the
fingertips at the line of cleavage, remove placenta fragments. And if the tissue is very adherent,
suspect placenta accreta and proceed to laparatomy and possible subtotal hysterectomy
Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it.
With the other hand, continue to provide counter-traction to the fundus by pushing it in the
opposite direction of the hand that is being withdrawn
Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed
Give oxytocin 20 units in 1 litre I.V fluids (normal saline or ringers lactate) at 60 drops per minute
Ask an assistant to massage the fundus of the uterus to encourage a tonic uterine contraction.
If there is continued heavy bleeding, give oxytocin drugs or prostaglandins
Examine the uterine surface of the placenta to ensure that it is complete, if any placental lobe or
tissue is missing; explore the uterine cavity to remove it.
Examine the woman carefully and repair any tears to the cervix or vagina or repair episiotomy
POST-PROCEDURE CARE
Observe the woman closely until the effect of I.V sedation has worn off
Monitor vital signs every 30 minute for the next six hours or until the patient is stable
Palpate the uterine fundus to ensure that the uterus remains contracted.
Check for excessive lochia
Continue I.V fluids
Transfuse if it is necessary
COMPLICATIONS OF THE PROCEDURE
Puerperal sepsis
Genital tract trauma.
