RETAINED PLACENTA

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