Retained placenta

Retained placenta

1. RETAINED PLACENTA

2. RETAINED PLACENTA DEFINITION – Defined as inability to expelling out of placenta from uterus or birth canal over 30 minutes after baby birth . According to WHO – after 15 min considered as RETAINED PLACENTA

3. NORMAL PHYSIOLOGY OF PLACENTA EXPULSION Involve three phases- Separation from spongy layer of decidua Decent into lower uterine segment and vagina expulsion to outside world Abnormality /interference in normal physiology leads to retaining of placenta .

4. CAUSES OF RETAINDED PLACENTA Placenta retention may be due to - poor voluntary expulsive efforts . uterine atonicity (loss of tone or strength –impaired retraction and contraction ) over distended uterus (in multiple pregnancy ), prolonged labour (poor retraction , infection ) . large placental surface area involvement .

5. Types of Retained PlacenTA ReTAINED PLACENTA Separated Retained I ncarcerated PLACENTA PLACENTA ( poor voluntary ( premature attempts , efforts ) separation ) Adherent placenta ( atonicity , large placental area over distended uterus)

6. ADHERENT PLACENTA ADHERENT PLACENTA - Two types - 1 ) Simple –is due to atonicity or large placental surface area. 2) Morbid - firm adherence -partial adherence is rare ,complete adherence. and of three types on base of chorionic villi relation to myometrium - 1) placenta accreta (adherent) 2) placenta increta (invade in) 3) placenta percreta (invade through myometrium)

7. DIAGNOSIS of RetaiNed PLACENTA Assessing the separation of placenta By arbitrary time ( above 15 min. ) spent after the delivery of baby . But the nature of adherence (simple /morbid) and hour- glass contraction are diagnosed during manual removal .

8. DANGERS /RISKS Prolonged Retention may lead to – Hemorrhage SHOCK - due to 1) blood loss 2)when retained for >1 hr (unrelated to blood loss) 3) frequent abdominal efforts to expel out the placenta PUERPERAL SEPSIS –infection in genital tract from the rupture of membrane /labor upto 42 days of postpartum Reoccurance in the next pregnancy .

9. MANAGEMENT PERIOD of Watchful expectancy Depending on type of retention management are – Controlled cord traction ( separated ,retained ) Manual removal ( unseparated ,uncomplicated) Manual removal with some guidelines ( complicated , unseparated retained placenta).

10. PERIOD of Watchful expectancy In arbitrary time ( upto an hour) a) watch patient carefully for any blee - ding , revealed or concealed b) note signs of separation of placenta. Bladder should be emptied by using rubber catheter 3. And should be managed depending on type of RETENTION .

11. Controlled cord traction Method use for separated but retained placenta and in hard or contracted uterus . ProcedurE - 1) Palmar surface of fingers of left hand is Placed over at the junction of upper and lower uterine segment. 2) And Body of uterus is pushed upward , backward towards the umblicus . By Right hand steady tension is applied in downward and backward towards the holding clamp till the placenta comes out from the introitus . Uterine elevation facilitates expulsion of the placenta .

12. Controlled cord Traction

13. FUNDAL PRESSURE if baby is macerated or premature then this method is preferable to cord traction - as the tensile strength is reduced in both of these cases , thus the cord traction may break the umbilical cord . PROCEDURE – 1. placenta is pushed downward and backward after placing four fingers behind the fundus and thumb in front of uterus 2. Pressure given only when the uterus becomes hard , then make it hard by gentle rubbing . 3. Pressure is withdrawn when the placenta pass the introitus .

14. Fundal Pressure

15. Manual R emoval of PlacentA Under general anesthesia ,then patient in lithotomy postion under all aseptic measure and bladder is catheterised . One hand is introduced in and finger should locate the margins of placenta . Other hand on abdomen which steady the fundus and guide movement of finger inside. Placenta is separated gradually by sideways slicing movement of finger . Then extracted by traction of cord . i.v. methergine 0.2 mg is given .

16. Manual Removal of Placenta Hand introduction in uterus in cone-shaped manner follows the taut of umbilical cord Separation of placenta a) Back hand on uterine wall b)Slicing movement of hand

17. Management of complication during MANUAL REMOVAL 1) Hour –glass contraction – contraction of circular muscle of uterus (forming a ring ) which lead to retention of placenta or difficulty in removing the placenta . So the ring should be relax – by halothane (GA) . 2) Morbid adherent – difficulty in getting the cleavage of placental separation . IN S uch case placenta should remove gently in fragments using ovum forceps . hemorrhage , shock , injury , infection can be complicated in some cases.

18. Complicated Retained PlacentA May be with shock , hemorrhage , sepsis . With shock – a) First to treat the shock ( i.v. blood transfusion/ normal saline . b) when condition improves –manual removal of placenta should be done . With hemorrhage – due to injury to capillaries or uterine artery . Can be managed first by – a) iv. Oxytocin(10 IU) / methergine (.2mg)/PGs b) and then manual removal after condition are favourable .

19. RETAINED PLACENTA with sepsis Patient usually delivered outside and admitted in refferal hospital after few hours or even few days . Management - 1) Intrauterine swabs –for culture and senstivity testing and broad spectrum antibiotic is given . 2) Blood transfusion is helpful . 3) Then Manual Removal should be done after the condition are good.

20. RETAINED PLACENTA with Episiotomy WOUND Episiotomy wound -is surgical planned incision on perineum and vaginal opening during 2 nd stage of labor to aid difficult delivery and prevent rupture of tissues . MANAGEMENT 1) Bleeding points of Episiotomy wounds are secured by artery forceps . 2) MANUAL Removal should be done earlier which is followed by repairing of Episiotomy wound .