RETAINED PLACENTA

DEFINITION The placenta is said to be retained when it is not expelled out even 30mts after the birth of the baby. C.S. Dawn

Gross anatomy of mature placenta Shape - Circular disc Diameter - 15-20cm Thickness - 2.5cm at its centre, thin off towards the edge By touch - It feels spongy Weights - about 500gm Surface - fetal surface and maternal surface Margin - Peripheral margin

Phases in expulsion of placenta Separation through the spongy layer of decidua Descent into the lower segment and vagina Finally its expulsion to outside

Causes of retained placenta Poor voluntary expulsive efforts Uterine atonicity in cases of grand multipara overdistension of uterus, prolonged labour, uterine malformation Incarcerated placenta following partially or completely separated. It is due to constriction ring (hour – glass contraction)

Morbid adherent placenta – partial or rarely, complete - Placenta accreta - Placenta increta - Placenta percreta

DANGERS: They are: Post-partum haemorrhage. Shock – mainly due to haemorrhage. Puerperal sepsis. Thrombophlebitis – in the pelvic and leg veins. Embolism Placental polyp.

Diagnosis Diagnosis is made by an arbitary time spent following delivery of the baby Dangers Haemorrhage Shock is due to a. Blood loss b. Retained more than one hour c. Frequent attempts of abdominal manipulation 3. Puerperal sepsis 4. Risk of its recurrence in next pregnancy

Management Period of watchful expectancy Watch for bleeding Note the signs of separation of placenta The bladder should be emptied using a rubber catheter Any bleeding during the period should be managed. Placenta is separated and retained - To express the placenta out by controlled cord traction. - - Unseparated retained plaenta - Manual removal of placenta under G.A

Management of unforseen complications during manual removal 1. Hour glass contraction – placenta either inseparated or separated – partially or completely, may be trapped by a localised contraction of circular muscles of the uterus. This ring should be made to relax by a. Deepening the plane of plane of anaesthesia (halothane) b. Subcutaneous injection of .5ml of 1 in 1000 adrenaline Hcl.

c. Inhalation of two amyl nitrate capsules of 5 minim each. If the ring is too tight and bleeding is absent Operation is to be postponed The patient is to be sedated by morphine 15mg Im after the manual removal. Watch for a period of 4-6hrs If the ring is not too tight and bleeding is continuing The ring is to be manually stretched by the cone shaped hand and the separation of the placenta is preferably done from above down wards to minimise bleeding.

Morbid adherent placenta Manual removal Management of complicated retained placenta 1. Retained placenta with shock but no haemorrhage To treat shock Manual removal of placenta when the condition improves. 2. Retained placenta with haemorrhage To assess the amount blood loss and to replace the lost blood

3. Retained placenta with sepsis Intrauterine swabs are taken for culture Administer broad spectrum antibiotic Blood transfusion 4. Retained placenta with an episiotomy wound The bleeding points of the episiotomy wound are to be secured by artery forceps Manual removal of placenta followed by repair of episiotomy wound.

Placenta Acreta (morbid adherent placenta) The placenta is directly anchored to the myometrium partially or completely without any intervening decidna. Probable cause is defective decidual formation The condition is usually associated when the placenta happens to be implanted in lower segment.

Management In case of partial morbid adherent placenta Manual removal if there is effective uterine contractions with haemostasis If the uterus fails to contract an early decision of hystrectomy may have to be taken.

In total placenta accreta hysterectomy is indicated It the patient desiring to have a child conservative management. Antibiotics Placenta accreta – choriomic villi invade up to the myometrium Placenta increta – Choriomic villi invade the myometrium Placenta percreta – chronic villi penetrate the whole uterine wall to the serosal layer.

Manual Removal of the Placenta One hand is inserted through the vagina and into the uterine cavity. Insert the side of your hand in between the placenta and the uterus. Using the side of your hand, sweep the placenta off the uterus. After most of the placenta has been swept off the uterus, curl your fingers around the bulk of the placenta and exert gentle downward and outward traction. You may need to release the placenta and then re-grab it. Then pull the placenta through the cervix. Most placentas can be easily and uneventfully removed in this way. A few prove to be problems.

Placenta Accreta and Percreta When you manually remove the placenta, be prepared to deal with an abnormally adherent placenta (placenta accreta or placenta percreta). These abnormal attachments may be partial or complete. If partial and focal, the attachments can be manually broken and the placenta removed. It may be necessary to curette the placental bed to reduce bleeding. Recovery is usually satisfactory, although more than the usual amount of post partum bleeding will be noted. If extensive or complete, you probably won't be able to remove the placenta in other than handfuls of fragments. Bleeding from this problem will be considerable, and the patient will likely end up with multiple blood transfusions while you prepare her for a life-saving, post partum uterine artery ligation or hysterectomy. If surgery is not immediately available, consider tight uterine and/or vaginal packing to slow the bleeding until surgery is available.

Separate the placenta from the uterus with a sweeping motion

After the placenta is mostly separated, curl your palm around the bulk of it.

Continue to grasp the placenta as you remove it from the uterine cavity

RETAINED PLACENTA ON HOME DELIVERY: Prophylactic IV ergometrine or inj. Ergometrine 0.5mg and oxytocin 5 units IM  controlled cord traction on birth of baby  placenta is delivered. If the nurses are trained she can do manual removal under injection diazepam IV 10-20mg. If she is not trained, patient is sent in a transport to the nearest health unit. ANM accompanies the patient during transport. IV fluid on flow. At hospital, manual removal is done early on resuscitation of the patient. Adequate blood transfusion is given.

THANK YOU