Retained placenta is generally defined as a placenta that has not undergone expulsion within 30 minutes of the baby's birth

Retention of placenta takes place under 2 different set of circumstances:

1.           The placenta though completely detached, is not expelled. This maybe due to Uterine inertia or

•           Formation of a contraction ring

2.           Adherent placenta

•           Simple adhesion

•           Morbid adhesion

1)         Adherent Placenta

•           Simple adhesion - The placenta remains in union with the uterine wall although its attachments are not abnormal. The condition tends to recur in the same patient.

•           Morbid adhesion - The placental attachments are abnormal (pathological). There is no line of cleavage between the placenta and the uterine wall. It is a rare condition. May be of following types;

-          Placenta accreta- Chorionic villi are anchored to myometrium without intervening decidua

-          Placenta increta- Chorionic villi invade the myometrium but not beyond

-          Placenta percreta- Chorionic villi penetrate the whole uterine wall up to the serosal layer

Management of Retained Placenta( To be done at FRU)

-          If placenta is felt in the vagina, ask woman to push, remove

-          Ensure bladder is empty, catheterize if necessary

-          Start oxytocun drip

-          Attempt controlled cord traction If not successful proceed with

-          Manual removal of placenta

Manual removal of placenta (MROP)

-             Done under GA

-             Pt is placed in luthotomy position and bladder catheterized with aseptic measures.

-             One hand is introduced in cone-shaped manner into the uterus following the cord.

-             When placental margin is reached, fingers are insinuated between placenta and uterine wall with the back of hand in contact with the wall.

-             Support the fundus of uterus while detaching the placenta

-             When placenta is completely separated, extracted by traction on cord.

-             Uterine hand explores the cavity to be sure nothing is left behind.

-             I/V methergin 0.2 mg is given and massage done.

-             Inspect placenta and membranes for completeness.

Note: If plane of cleavage is not found no attempt should be made to deliver placenta and patient referred to higher center as this can provoke massive hemorrhage

 Post procedure care:

-                   Give antibiotics.

-                   Observe the woman closely until the effect of IV sedation has worn off.

-                   Monitor the vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6 hours or until stable.

-                   Palpate the uterine fundus to ensure that the uterus remains contracted.

-                   Check for bleeding P/V.

-                   Continue infusion of IV fluids. - Transfuse as necessary.

Complications

-                   Shock

-                   Postpartum hemorrhage

-                   Puerperal Sepsis

-                   Subinvolution of the uterus

Morbid adhesion of the placenta (placenta accreta)

-                   The incidence of placenta accreta has increased 10-fold in the past 50 years, to a current frequency of 1 per 2,500 deliveries, largely as a result of the increase in the number of cesarean sections

-                   Because of the fact that many of these cases become evident only at the first attempt to separate the placenta at delivery, it is essential to attempt to identify antenatally both placenta accreta and its attendant risk factors, the most common of which is concurrent placenta praevia & previous CS.

-                   Such cases should be referred timely to higher center for management

Management of Retained Placental Fragments

-                   Under GA

-                   Feel inside uterus for placental fragments.

-                   Remove placental fragments by hand, ovum forceps or large curette

-                   Give oxytocics, do uterine massage and observe for bleeding P/V

-                   Transfuse as the need be