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Retained Placenta - American Pregnancy Association

The final stage of labor occurs when the placenta is expelled from the mother’s uterus. For many women, this process happens on its own after the baby has come through the birth canal. However, for some, this process doesn’t happen automatically, resulting in a phenomenon called retained placenta.

Labor takes place in three stages:

1. The first stage of labor begins with contractions that indicate that the uterus is preparing to deliver a baby.
2. Once a woman has given birth, the second stage of labor is complete.
3. The final stage of labor takes place when the placenta is expelled from the woman’s womb. This stage usually takes place within 30 minutes of the baby’s birth.

However, if the woman has not expelled the placenta after 30 minutes of delivery, this is considered a retained placenta. If a retained placenta is not treated, the mother is susceptible to both infection and extreme blood loss, which could be life-threatening.

Two Approaches to Delivering the Placenta

If your pregnancy has moved through the labor and birth stages normally, you can choose how to handle the final stage of labor. This process is usually a part of a woman’s birth plan discussion.

There are generally two approaches used when dealing with the placenta, whether a natural approach or a managed approach.

1. A natural approach allows the woman’s body to naturally expel the placenta on its own.
2. Medical personnel assists the managed approach and usually, occurs when a shot is administered to the thigh while the baby is being born to cause the woman to expel her placenta.

Syntometrine, ergometrine, and oxytocin are the drugs used to cause a woman’s body to contract and push out the placenta. If a woman has had complications like high blood pressure or preeclampsia during her pregnancy, Syntocinon is given.

The benefit of opting for a managed final stage of labor is the reduction in bleeding immediately after the baby is born.

Three Types of Retained Placenta

1. Placenta Adherens: occurs when the contractions of the womb are not robust enough to completely expel the placenta. This results in the placenta remaining loosely attached to the wall of the uterus. This is the most common type of retained placenta.
2. Trapped Placenta: is when the placenta successfully detaches from the uterine wall but fails to be expelled from the woman’s body it is considered a trapped placenta. This usually happens as a result of the cervix closing before the placenta has been expelled. The Trapped Placenta is left inside the uterus.
3. Placenta Accreta: is when the placenta attaches to the muscular walls of the uterus instead of the lining of the uterine walls. Delivery becomes more difficult and often results in severe bleeding. Blood transfusions and even a hysterectomy may be required.

What Causes a Retained Placenta?

• Placenta Percreta occurs when the placenta grows all the way through the wall of the womb.
• Uterine Atony occurs when a woman’s contractions stop or are not strong enough to expel the placenta from her womb.
• Adherent Placenta takes place when all or part of the placenta is stuck to the wall of the woman’s womb. In rare situations, this happens because the placenta has become deeply embedded within the womb.
• Placenta Accreta takes place when the placenta has become deeply embedded in the womb, possibly due to a previous cesarean section scar.
• A Trapped Placenta results when the placenta detaches from the uterus but is not delivered. Instead, it becomes trapped behind a closed cervix or a cervix that has partially closed.

A midwife can help prevent a retained placenta on rare occasions by gently pulling on the umbilical cord. However, the cord may break if the placenta hasn’t completely separated from the uterine walls or if the cord is thin. If this happens, delivery of the placenta can take place by using a contraction to push it out.

What Are the Signs and Symptoms of a Retained Placenta?

The most obvious sign of a retained placenta is when the placenta fails to be completely removed from the womb an hour after the baby’s delivery. Other symptoms may include:

• fever
• a foul-smelling discharge from the vaginal area
• large pieces of tissue coming from the placenta
• heavy bleeding
• pain that doesn’t stop

Who Is At Risk for a Retained Placenta?

Certain factors increase the likelihood of a woman experiencing a retained placenta.
They include:

• A pregnancy that occurs in women over the age of 30
• Having a premature delivery that takes place before the 34th week of gestation
• Experiencing an extremely long first and second stage of labor
• Delivering a stillborn baby

How Is a Retained Placenta Treated?

The treatment for a retained placenta is simply the removal of the placenta from the woman’s womb. Different methods to achieve this include:

• A doctor may attempt to remove the placenta manually. However, this does carry some risk of infection.
• Medications that relax the uterus to make it contract can also be used to help expel the placenta from the womb.
• Breastfeeding can be utilized in some situations because the process causes the uterus to contract and may be enough to expel the uterus from the womb.

Sometimes, something as simple as urinating is effective enough to expel the placenta because a full bladder can sometimes get in the way of expelling the placenta from the womb.

Unfortunately, if none of these methods succeed in removing the placenta from the uterus, emergency surgery may be needed as a last resort. This is usually saved as the last approach because of the complications that surgery can create.

What Are the Potential Complications of a Retained Placenta?

The risk of heavy bleeding increases. This condition is referred to as primary postpartum hemorrhage (PPH). When the managed delivery of the placenta takes longer than 30 minutes, heavy bleeding often results.

You do have the option of requesting a general anesthetic, but you incur more risks, especially if you want to breastfeed right after the procedure. Traces of the drug will still be in your system which means the drug would also be in your breastmilk. You also need to make sure that you are alert enough to hold and support your baby for breastfeeding firmly.

However, if you do opt for the anesthetic, the placenta and any other remaining membranes will be manually removed from your womb while your legs rest in stirrups in the lithotomy position. After the procedure, you will be given antibiotics intravenously to avoid the risk of infection. Additional drugs will be given to help your womb to contract afterward.

What Is the Outlook for Women with a Retained Placenta?

A retained placenta can be treated. Timing is everything. The sooner steps are taken to rectify the problem, the better the outcome.

If you fall into a high-risk category for a retained placenta or have experienced one in the past, talk to your doctor before giving birth again. Your doctor will help you prepare for the possibility of complications.

Can I Prevent a Retained Placenta in My Next Pregnancy?

Your chances of having a retained placenta increase after you’ve already had one. But, you can still have a healthy pregnancy that doesn’t produce this type of complication.

If your child is born premature, the risks increase as well. The placenta is supposed to stay in place for 40 weeks. As a result, premature labor may lead to a retained placenta.

Doctors do everything in their power to prevent a retained placenta by taking actions that hasten complete delivery of the placenta after the birth of the baby.

These steps are as follows:

• Medication that encourages contractions in the uterus to help push out the placenta. Oxytocin (Pitocin) is an example of a medication that might be used
• Control Cord Traction (CCT) after the placenta has released
• Stabilizing your uterus by applying CCT through touch manual touch

These are all standard steps that your doctor may perform before you deliver the placenta. After childbirth, your doctor will also recommend massaging your uterus to encourage contractions that stop the bleeding and allow the uterus return to return to a small size.

In the unfortunate event that your cord snaps or your cervix closes too quickly after the oxytocin injection, consider a physiological third stage if you conceive again.

If you allow the placenta to deliver naturally, the cervix will more than likely close at the appropriate time, instead of closing too quickly. Discuss your options with your doctor.

However, keep in mind that the prolonged use of Syntocinon (artificial oxytocin) during labor has contributed to retained placentas.

This concern may develop if your labor is induced or sped up. However, although the potential for having a retained placenta with future pregnancies is prevalent, it’s not a guarantee that you won’t have a healthy pregnancy and delivery.

Want to Know More?

• Labor & Birth Term to Know
• Stages of Childbirth: Stage III

Compiled using information from the following sources:

1. Begley C. 2014. Physiology and care during the third stage of labor. In: Marshall JE, Raynor MD. eds. Myles Textbook for Midwives 16th ed. Edinburgh: Churchill Livingstone, 395-416.

2. BMagann EF, Lutgendorf MA, Keiser SD, et al. 2013. Risk factors for a prolonged third stage of labor and postpartum hemorrhage. South Med J 106(2):131-5.

3. Coviello, E. M., Grantz, K. L., Huang, C. C., Kelly, T. E., & Landy, H. J. (2015, July 28). Risk factors for retained placenta.

https://www.ajog.org/article/S0002-9378(15)00789-9/abstract

4. Mayo Clinic Staff. Placenta: How it works, what’s normal.

https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/placenta/art-20044425

5. Use of nitroglycerin to deliver a retained placenta.

https://www.cochrane.org/CD007708/PREG_use-nitroglycerin-deliver-retained-placenta

6. Weeks, A. Retained placenta after vaginal birth.

https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth

Anesthesia or analgesia for manual removal of the placenta

We looked for evidence from randomized controlled trials of the efficacy and safety of various types of anesthesia (drugs that result in partial or complete loss of sensation/feeling) and analgesia (drugs that reduce pain) during manual removal (removal of retained) placenta in women who have just given birth to a child.

What is the problem?

During pregnancy, the placenta attaches itself to the lining of the uterus. After the baby is born, the placenta separates and the uterine contractions push it out. When the placenta doesn't come out within 60 minutes of a vaginal delivery, it's called a retained placenta.

Anesthesia may be general or regional, using the spinal or epidural routes of administration; pain and relaxation medications such as fentanyl, midazolam, diazepam, or ketamine may be given intravenously. We wanted to find out which types of anesthesia and analgesics are most effective and safe for women undergoing manual removal of the placenta.

Why is this important?

Delay in removal of the placenta may result in excessive blood loss, which may be life-threatening and may require a blood transfusion. Therefore, it is necessary to quickly remove the preserved (retained) placenta. When the placenta is removed from the uterus by hand, it is called manual separation. This causes significant discomfort and pain.

What evidence did we find?

We searched for evidence up to September 2019. And they found one small randomized controlled trial that was conducted in a hospital in Papua New Guinea. The study involved 30 women who manually removed the retained placenta. It compared injections of the local anesthetic, lidocaine, around the cervix (paracervical block) versus intravenous pethidine and diazepam for pain relief and relaxation.

No pain intensity or adverse events were reported in this study.

The study showed that none of the women had postpartum blood loss exceeding 500 ml.

We are uncertain whether the health care workers were satisfied with the procedure (meaning their perception of good pain relief during the procedure) or whether the women themselves were satisfied with the procedure (assuming their perception of good pain relief during the procedure).

What does this mean?

We found insufficient evidence to determine the efficacy and safety of anesthesia or pain management for manual removal of retained placenta.

There is a need for further well-designed randomized controlled trials that provide results for the important outcomes outlined in this review.

Translation notes:

Translation: Galimova Elina. Editing: Prosyukova Ksenia Olegovna and Ziganshina Lilia Evgenievna. Russian translation project coordination: Cochrane Russia - Cochrane Russia, Cochrane Geographic Group Associated to Cochrane Nordic. For questions related to this translation, please contact us at: [email protected]

Delayed placenta - causes, symptoms, diagnosis and treatment

Delayed placenta is a complication of the third stage of labor, a condition in which the placenta does not fully or partially exfoliate from the uterine walls. Clinically, it can be manifested by pathological bleeding or the absence of bloody discharge normal for this period, soreness, or the absence of attempts. In this case, the standing of the bottom of the uterus corresponds to the period after the expulsion of the fetus, the connection of the umbilical cord with the uterus is indirectly determined. The diagnosis is established on the basis of the results of a physical examination, ultrasound. Most often, manual separation of the placenta or surgical treatment is performed.

General

According to the WHO definition, retained placenta is diagnosed if separation does not occur within half an hour after the end of the second stage of labor. The incidence of pathology is 0.8-1.2% of all births. This complication is more often recorded in multiparous, especially those with a history of caesarean section. The disease is a serious problem of modern obstetrics, as it is often accompanied by postpartum hemorrhage. Bleeding is the cause of maternal death in a quarter of cases, 30% of which are the result of delayed separation of the placenta.

Delayed separation of the afterbirth

Causes

The etiology of delayed separation of the placenta has not been fully understood. Violations of detachment of the placenta and its parts in the afterbirth period, on the one hand, may be due to defects in uterine contractile activity, on the other hand, due to excessively tight attachment of the child's place. Most women in labor fail to detect any visible disorders. The main causes of pathology include:

• Hypotension of the uterus. Weak contractions of the uterine muscles are not enough to start the process of separation of the placenta, even if the placenta does not have specific features that prevent detachment. In the presence of predisposing conditions, a slight decrease in contractile function can become a trigger for the development of pathology.
• Tight attachment of the placenta. Due to the depletion of the basal layer of the decidua and is characterized by a stronger than normal connection with the uterine walls without the germination of the chorionic villi into the myometrium. With the pathology under consideration, the force of uterine contractions is not enough to completely separate the placenta, which leads to bleeding.
• True placenta accreta. Also associated with underdevelopment of the basal layer, however, in this case, there is invasion of the villi into the muscle tissue, and in rare cases, the serous membrane of the uterus. More common with placenta previa. Spontaneous detachment of the adherent child's place is impossible, manual separation can lead to perforation of the uterine wall.
• Anomalies in the development of the placenta. Delayed detachment is often observed with developmental anomalies (lobed, two- and three-lobed or with additional lobules) of the placenta. The separation of the afterbirth is difficult with the so-called "membraneous" placenta, which is characterized by a slight thickness and a large attachment area, often extending to the entire uterine wall.

The most significant risk factors are endometritis transferred before the onset of pregnancy, obstetric history (surgery on the uterus, abortions, multiple births), indicating traumatic injuries. Inflammation and trauma lead to anatomical and histological changes in the uterus, which negatively affects placentogenesis and myometrial tone. Predisposing conditions include hyperandrogenism, malformations of the uterus (bicornuate uterus, intrauterine septum), volumetric formations (myoma, nodular adenomyosis).

Pathogenesis

Normally, after the birth of the fetus, afterbirth contractions appear, in which contractions spread to the entire uterus, including the placental site (previously, the muscles of this zone did not function). Labor activity leads to detachment of the child's place in the area of ​​​​the spongy layer of the mucosa (with the preservation of the basal layer), and then to its exit to the outside. The separation of the placenta is accompanied by damage to blood vessels, physiological bleeding. After his birth, the uterus contracts, which helps to stop the bleeding.

In the presence of unfavorable factors and predisposing conditions, detachment becomes more difficult. With partial detachment, if the process started, but for some reason stopped, the gaping vessels of the uncontracted uterus become a source of pathological blood loss. Ingrown chorionic villi deep into the myometrium lead to thinning of the uterine wall, so an attempt to manually separate the placenta quickly ends in trauma, accompanied by intense bleeding.

Symptoms

Subjective signs of delayed separation of the placenta include prolonged, painful, ineffective attempts after the birth of a child or their complete absence. An objective sign is intense bleeding observed with partial separation. If detachment of the placenta does not occur at all, even in a partial volume (for example, with a complete increment), bloody discharge from the birth canal may be absent.

Complications

The most common complication of delayed separation of the placenta is bleeding. Significant blood loss leads to such a potentially fatal complication as hemorrhagic shock, accompanied by multiple organ failure. Massive bleeding often develops when professional medical care is not provided in time (the risk increases sharply during childbirth outside a medical institution).

Other frequent complications of this pathology include purulent-inflammatory diseases (postpartum endometritis, pelvioperitonitis, obstetric sepsis), which can be the result of both surgical treatment and retention of afterbirth fragments in the uterine cavity. In addition, the remaining ingrown placenta can become a source of late postpartum hemorrhage, uterine rupture during a subsequent pregnancy.

Diagnosis

The diagnosis of retained placenta is made by the obstetrician if there is no discharge of the placenta within thirty minutes after the birth of the infant, with appropriate results of the physical examination. To establish the causes of the pathological condition (which determines the choice of treatment tactics), an ultrasound examination is additionally used.

• Clinical examination. Signs of delayed separation of the placenta are determined by the shape and location of the uterus, the mobility of the umbilical cord. If separation has not occurred, the uterus is rounded, the bottom is located at the navel (Schroeder's sign), the outer segment of the umbilical cord does not lengthen (Alfeld's sign). The umbilical cord retracts with pressure over the womb (Kyustner-Chukalov's sign), after inhalation (Dovzhenko's sign), straining (Klein's sign).
• Ultrasonography. Ultrasound of the uterus is prescribed for the diagnosis of placental accreta. Ultrasound signs of this pathology include deformation of the internal contour of the uterine cavity, its uneven expansion, and the absence of a hypoechoic layer between the myometrium and the placenta. Ultrasound angiography reveals hypervascularization of the anterior wall, chaotic branching of vessels.

When the placenta is retained, the volume of blood lost is estimated (abnormal blood loss is more than 400-500 ml). If a surgical operation is necessary, a coagulogram and a clinical blood test are examined. Differential diagnosis is carried out with a delay in the birth of the separated placenta, primarily with its infringement due to uneven or spastic contractions of the myometrium.

Treatment of delayed separation of the placenta

Conservative therapy

Therapeutic measures to promote the separation of the placenta are carried out only in the absence of pathological bleeding, and can last for 20-30 minutes. With the ineffectiveness of conservative treatment, surgical methods are used; in case of pathological blood loss, replacement blood transfusion is performed. Therapy is aimed at strengthening uterine contractions and includes:

• Bladder catheterization. Since the muscular layer of the bladder is closely connected with the nerve fibers of the uterine muscles, irritation of the urothelial receptors leads to a reflex contraction of the myometrium. Catheterization normalizes the course of the afterbirth period of childbirth, contributes to the timely separation and release of the placenta.
• Medicines. To enhance labor activity, intravenous or intramuscular administration of uterotonic drugs (oxytocin preparations are preferred) is indicated in combination with traction for the umbilical cord. In parallel, intravenous transfusion of crystalloid solutions is performed to correct possible blood loss.

Surgical treatment

Surgical treatment of delayed separation can be performed non-surgical or operatively. Treatment tactics depend on the cause of the pathology. Surgical intervention should be carried out in a timely manner, before the onset of generalized coagulopathy against the background of massive bleeding (otherwise, the operation aggravates the severity of the condition). In order to stop bleeding, embolization of the uterine vessels, the imposition of hemostatic sutures are used.

• Handbook. In case of tight attachment of the child's place or other reasons for the delay in its detachment (with the exception of true increment), manual separation of the placenta is performed with its subsequent removal to the outside. To avoid traumatic shock, intravenous anesthesia is performed before manipulation. Antibiotics (penicillin, cephalosporin) are used to prevent septic complications.
• Surgery. Indicated for failure of conservative bleeding management, true increment. The volume can vary from organ-preserving surgery (excision of the area of ​​a partially ingrown child with affected myometrium and subsequent plasty) to radical (extirpation of the uterus, supravaginal amputation) with complete ingrowth, intractable bleeding.

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