MANUAL REMOVAL OF PLACENTA.

The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby

Manual placenta removal is a procedure to remove a retained placenta from the uterus after childbirth.

1. Manual removal of placenta Ms. khushboo singh Nursing tutor Gold medalist

2. DEFINITION OF MANUAL REMOVAL OF PLACENTA The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby Manual placenta removal is a procedure to remove a retained placenta from the uterus after childbirth .

3. If the placenta is undelivered after 30 minutes consider: Emptying bladder Breastfeeding or nipple stimulation Change of position - encourage an upright position The management is done according to condition of placenta as Seperated , Unseparated , complicated If the placenta is separated and retained :express placenta by controlled cord traction Unseparated retained placenta :manual removal of placenta under general anesthasia

4. Indications Previous retained placenta Previous injury or surgery to the uterus Preterm delivery Induced labor Multiparity Placenta separated but not expelled Simple Adherent Placenta Morbid adherence of the placenta: Placenta Accreta , Placenta Increta , Placenta Percreta

5. Prepare the necessary equipment Antiseptic solution Sterile gloves Blood and subtitutes Anasthesia and analgesics Ergometrine and oxytocin Antibiotics

6. Give anesthetic and analgesic as per need Give anesthesia (IV pethidine (25-50mg) and diazepam (10 mg), or ketamin e Give a single dose of prophylactic antibiotics: Ampicillin 2 g IV PLUS metronidazole 500 mg IV, OR Cefazolin 1 g IV PLUS metronidazole 500 mg IV Put on personal protective equipment.

7. STEP-I Use antiseptic hand rub or wash hands and forearms Put high-level disinfected or sterile surgical gloves on both hands. Hold the umbilical cord with a clamp. Pla ce the fingers of one hand into the vagina in the shape of cone by drawing the fingers and the thumb together and into the uterine cavity, following the direction of the cord until the placenta is located.

8. STEP-II W hen the placenta has been located, let go of the cord and move that hand onto the abdomen to support the fundus abdominally and to provide counter- traction to prevent uterine inversion As soon as the placental margin is reached, the fingers are insinuated between the placenta and the uterine wall with the back of the hand in contact with the uterine wall. the placenta is gradually separated with a side ways slicing movement of the fingers, until whole of the placenta is separated

9. STEP-I II When the placenta is completely separated Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed. Slowly withdraw the hand from the uterus bringing the placenta with it. Continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn

10. STEP IV Give oxytocin 20 units in 1 L IV fluid (normal saline or Ringer’s lactate) at 60 drops/minute. Massage the fundus to encourage atonic uterine contraction. If there is continued heavy bleeding. Give ergometrine 0.2 mg IM or give prostaglandins Intravenous methergine 0.2 mg isgiven . Examine the uterine surface of the placenta to ensure that it is complete. Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy . Check for contracted uterus

11. POST-PROCEDURE CARE 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 excessive lochia. Continue infusion of IV fluids. Transfuse as necessary.