Retained placenta

Retained placenta

1. R E T AINED PLACENTA Mrs. U SREEVIDYA Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2.  Failure of placental delivery within 30 minutes after delivery of the fetus.  Longer the placenta remains in uterus after delivery of baby, the greater is the risk of PPH

3. Normally the placenta is expelled in th ird stage – it first separates from the uterine muscle, then it descends into the lower segment of the uterus and vagina and then it is expelled outside. Problems can occur at any of these stages

4. Risk Factors Previous retained placenta Previous injury or surgery to the uterus Preterm delivery Induced labor Multiparity

5. Causes Placenta separated but not expelled Simple Adherent Placenta Morbid adherence of the placenta: Placenta Accreta Placenta Increta Placenta Percreta Constriction ring-reforming cervix Full bladder Uterine abnormality

6. Causes of Retained Placenta Placenta separated but not expelled: The placenta may separate completely from the uterine muscle but may still be retained within the uterus. There are three causes for this retention: Failure of the woman to push out the placenta due to exhaustion or prolonged labour. Closure of the cervix preventing the placenta from being expelled. A constriction ring in the uterus can hold up the placenta

7. Simple Adherent Placenta: The placenta may fail to separate completely from the uterine muscle due to lack of contraction of the uterine muscles. This condition, is called 'uterine atonicity ' occurs in cases where the uterine muscles have become lax, either due to repeated pregnancy, prolonged labor or overdistension of the uterus during pregnancy, as in twin pregnancy. Simple Adherent Placenta is the commonest cause for retention of placenta.

8. Morbid adhesion of the placenta : Morbid adhesion of the placenta can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate. The placenta can burrow upto different depths in the uterine muscle. In simple cases, it is only attached firmly to muscle and can be stripped off by hand. In severe morbid adhesion, the placenta can burrow through the full thickness of the muscle. In this case, the uterus may be needed to be removed ('hysterectomy') to control the bleeding. There are three types of morbid adhesion of the placenta

9. Placent Accreta: In this condition, the placenta penetrates deep into the uterine endometrium and reaches the muscles but does not penetrate into the muscles. Placent Increta: Here, the placenta attaches even deeper into the uterine wall and penetrates into the uterine muscle. Placent Percreta: In this condition, the placenta not only penetrates through the full thickness of the uterine muscles but also attaches to another organ such as the bladder or the rectum. Placenta percreta is very rare .

10. Risks of Retained Placenta There may be severe bleeding which may be lifethreatening. Attempts at manual removal of the placenta can cause multiple injuries to the mother such as like vulva l hematoma, perineal tears, cervical tears and vaginal wall tears.

11. Management Details If the placenta is undelivered after 30 minutes consider: Emptying bladder Breastfeeding or nipple stimulation Change of position – encourage an upright position

12. If bleeding: immediately Inform Anaesthetist Insertion of large bore IV (18g) cannula Insert urinary catheter Commence/continue oxytocin infusion 20 units in 1 litre / rate – 60drops per min Measure and accurately record blood loss Prepare and transfer patient to theatre for manual removal of placenta (MROP)

13. The management is done according to condition of placenta as  Seperated  Unseparated  complicated  I f t he p l a c e n ta :express placenta i s s ep a rate d and r e t a in e d by controlled cord traction  Unseparated retained placenta :manual removal

14. Management / Treatment of Retained Placenta Treatment will depend on the cause of the retention of the placenta. If bleeding is present, active treatment is done to control the blood loss and support the general condition of the patient. Controlled Cord Traction If the placenta is separated but not expelled, then controlled cord traction should be carried out. In this method, the uterus is held in place or pushed up gently through the abdominal wall by the left hand. The cut umbilical cord hanging from the vagina is held in the right hand and pulled steadily and slowly to pull out the placenta.

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

16.   Use antiseptic handrub or wash hands and forearms thoroughly with soap and water and dry with a sterile cloth or air dry. Put high-level disinfected or sterile surgical gloves on both hands. (Note: elbow-length gloves should be used, if available.)   Hold the umbilical cord with a clamp Pull the cord gently until it is parallel to the floor

17. Place the fingers of one hand into the vagina i n 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. Do not go in and out of the uterus as these increase the risk of infection

18.  Whe n t h e p l a c e n ta has been located, let go of the cord and move that hand onto the abdomen to support the fundus abdominally and to provide c o u n t e r -t r ac t i on t o prevent uterine inversion  Move the fingers of the hand in the uterus laterally until the edge of the placenta is located. Supporting the fundus while detaching the placenta

19.  Keeping the fingers tightly together, ease the edge of the hand gently between the placenta and the uterine wall, with the palm facing the placenta.  Gradually move the hand back and forth in a smooth lateral motion until the whole placenta is separated from the uterine wall: Withdrawing the hand from the uterus

20.  If the placenta does not separate from the uterine wall by gentle lateral movement of the fingers at the line of c l e avag e, s u s p e c t pl ac e n t a acc re t a a n d arrange for surgical intervention

21.  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.

22.   G i ve o x y t o ci n 2 un i t s i n 1 L I V fl u i d ( n o r m a l saline or Ringer’s lactate) at 60 drops/minute. H a ve a n a ss i st a n t m a ss ag e t h e f u n d u s to encourage atonic uterine contraction.  I f t he r e i s c o n t i nu e d h e a vy b l e edi n g , gi ve ergometrine 0.2 mg IM or give prostaglandins.   Ex a m i n e t h e u t e r i n e s u r f ac e o f t h e pla c e n t a to ensure that it is complete. Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy.

23. 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.

24. Hysterectomy: If the placenta is too deeply embedded into the uterine musculature (called placenta accrete), a hysterectomy to remove the uterus may be indicated.

25. Shock Postpartum haemorrhage Puerperal Sepsis Subinvolution Hysterectomy         Embolism Thrombophlebitis Risk of reoccurence

26.  Umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta. Saline solution alone does not appear be more effective than expectant management. The difficulties in implementing this intervention are related to the training of personnel in the technique of giving injections into the umbilical vein.

27. 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 PLACENTA ACCRETA

28. Risk factors for placenta accreta include : placenta previa with or without previous uterine surgery. previous myomectomy. previous cesarean delivery. submucous leiomyomata. maternal age of 36 years and older.

29.  Active Mx of third stage can prevent & reduce the incidence of retained placenta.  In case of risk factors,always consider placenta accreta & usg /doppler features in antenatal period & plan accordingly.

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