Failure of delivery of placenta within 30 minutes of delivery of the baby.
Causes
- Poor management of 3rd stage of labour
- Failure of the uterus to contract
- Failure of the placenta to separate, e.g. if it is stuck in uterine muscle; placenta accreta
- Closing of the cervix before the placenta is expelled
Clinical features
- The umbilical cord protrudes from the vagina
- Bleeding may be present (in partial separation)
- Uterus may be poorly contracted and high in the abdomen
- May be signs of infection, e.g. fever, unpleasant bloody discharge if the placenta is retained for long
Differential diagnosis
- Retained second twin
- Ruptured uterus
Investigations
- Blood: Hb, grouping and cross-matching
MANAGEMENT
If woman is bleeding, manage as PPH
If woman not bleeding
- Set up IV normal saline infusion
- Empty the bladder (voluntarily or catheterise)
- Encourage breastfeeding
- Repeat controlled cord contraction
If placenta is not delivered in another 30 minutes
- Perform manual removal of placenta (use diazepam 10 mg IM/IV)
- Repeat Oxytocin 10 IU IM or slow IV injection after manual removal
- If no signs of infection and no obstructed labour Give ceftriaxone 2 g IV stat
- If signs of infection, give antibiotics as in amnionitis
- If obstructed labour, give antibiotic prophylaxis as indicated
If unable to remove placenta manually
- Give ceftriaxone 2 g IV stat
- Give oxytocin 20 IU in Normal saline 500 cc at 30 drops per minute during transfer
- Refer to Hospital