RETAINED PLACENTA.pptx for nursing students

notes for nursing students

1. RETAINED PLACENTA:

2. DEFINITION: the placenta is said to be retained when it is not expelled out even 30 minutes after birth of the baby.

3. CAUSES: there are three phases involve in the normal expulsion of the placenta Separation through spongy layer of the deciduas Decent into the lower segment and vagina Finally its expulsion to outside

4. Interference in any one of these physiological process leads to its retention. Placenta completely separated but retained is due to poor voluntary expulsive effects Simple adherent placenta is due to uterine atonicity in cases of grand multipara or over distention of uterus, prolonged labor, uterine malformation or due to bigger placental surface area. The commonest cause is atonic uterus. Morbid adherent placenta Placenta incarcerated following partial or complete separation due to constriction ring, premature attempts to deliver the placenta before it is delivered.

5. DIAGNOSIS: the diagnosis is made by an arbitrary time spent following delivery of the baby. features of placental separation are assessed. the hour glass contraction or the nature of adherent placenta can only be diagnosed during manual removal.

6. DANGERS: the risk involved in prolonged retention of placenta are: Heamorrhage Shock is due to blood loss At times unrelated to blood loss, specially when retained more than one hour Frequent attempts of abdominal manipulation to express the placenta out Risk of recurrence in next pregnancy.

7. MANAGEMENT: Period of watchful expectancy: During the period of arbitrary time limit of half an hour, the patient is to be watched carefully for evidence of any bleeding, revealed or concealed and to note the signs of separation of placenta. The bladder should be emptied using a rubber catheter Any bleeding during the period should be managed as outlined in third stage bleeding.

8. Retained placenta: Separated Unseperated Complicated

9. Placenta is separated and retained : to express the placenta by controlled cord traction Unseperated retained placenta: manual removal of placenta is to be done under general anesthesia as described earlier.

10. Management of unforeseen complications during manual removal: Hour glass contraction: the placenta is trapped by a localized contraction of circular muscles of the uterus. This may be situated at the junction of the lower and upper segment or may be placed at lower cornue . Administration of any oxytocic specially ergometrine in the active management of third stage or undue irritability of the uterus by premature attempts to express the placenta is the important cause. The diagnosis is only made during attempted manual removal

11. Management: the ring should be made relaxed by - Deepening the plane of anesthesia then the cone shaped hand is introduced and the separation of placenta is preferably done from the above to downwards to minimize bleeding.

12. Morbid adherent placenta: in majority, the diagnosis is made only during attempted manual removal . On rare occasion, however. No cleavage between the placenta and the uterine wall is made possible and the diagnosis of a total placenta accrete is certain.

13. Complicated retained placenta: the following guidelines are formulated to manage the cases of retained placenta complicated by hemorrhage, shock or sepsis. Retained placenta with shock but no hemorrhage : to treat the shock and when the condition improves, manual removal of the placenta is to be done

14. Retained placenta with hemorrhage : the management protocol is similar to mention in third stage hemorrhage Retained placenta with sepsis : the patient is usually delivered outside and is admitted in the referral hospital after few hours or even days after confinement. Intrauterine swabs are taken for culture and sensitivity test and broad spectrum antibiotics are given. Blood transfusion is helpful. As soon as the general condition permits arrangement is made for manual removal of placenta. The operation should be done by a senior person.

15. Retained placenta with an episiotomy wound: the bleeding points of the episiotomy wound are to be secured by artery forceps. An early decision for manual removal should be taken followed by repair of episiotomy wound.