Retained placenta

Retained placenta is generally defined as a placenta that has not undergone placental expulsion within 30 to 60 minutes after you give birth where the third stage of labor has been managed actively. Even if you pass the placenta soon after birth, your healthcare provider checks the placenta to make sure it’s not missing any tissue. If tissue is missing and is not removed from the uterus right away, it may cause bleeding. A retained placenta could be life-threatening because it is commonly a cause of postpartum hemorrhage, infection and even death.

The incidence of retained placenta is approximately 2% ¹. The risk for retained placenta may increase if the uterus contains a fibroid, is bicornuate, or has a septum. The placenta may also become retained if trapped in the cervix or lower uterine segment, and if the woman has a full bladder. Morbid adherence of the placenta includes placenta accreta, placenta increta and placenta percreta ². An adherent placenta is associated with absence of bleeding, and on examination the uterine fundus remains broad and high, the contractions may be weak or absent, and there is no lengthening of the umbilical cord.

Labor takes place in three stages:

1. The first stage of labor begins with contractions that indicate that the uterus is preparing to deliver a baby.
2. Once a woman has given birth, the second stage of labor is complete.
3. The final stage of labor takes place when the placenta is expelled from the woman’s womb. This stage usually takes place within 30 minutes of the baby’s birth.

However, if the woman has not expelled the placenta after 30 to 60 minutes of delivery, this is considered a retained placenta because the woman’s body has kept the placenta instead of expelling it.

A midwife can help prevent a retained placenta on rare occasions by gently pulling on the umbilical cord. However, the cord may break if the placenta hasn’t completely separated from the uterine walls or if the cord is thin.

If this happens, delivery of the placenta can take place by using a contraction to push it out.

There are generally two approaches used when dealing with the retained placenta, whether a natural approach or a managed approach.

A natural approach allows the woman’s body to naturally expel the retained placenta on its own.

Medical personnel assists the managed approach and usually, occurs when a shot is administered to the thigh while the baby is being born to cause the woman to expel her placenta.

Syntometrine, ergometrine, and oxytocin are the drugs used to cause a woman’s body to contract and push out the retained placenta. If a woman has had complications like high blood pressure or preeclampsia during her pregnancy, Syntocinon is given.

The benefit of opting for a managed final stage of labor is the reduction in bleeding immediately after the baby is born.

Retained placenta key points

• In the presence of postpartum hemorrhage the placenta must be delivered at once.
• Avoid vigorous cord traction to prevent the cord snapping or causing uterine inversion.
• A full bladder may inhibit delivery of the placenta.
• There are currently no randomized controlled trials to evaluate the effectiveness of prophylactic antibiotics to prevent endometritis prior to manual removal of the placenta ³.

Who is at risk for a retained placenta?

Certain factors increase the likelihood of a woman experiencing a retained placenta.

They include:

• A pregnancy that occurs in women over the age of 30
• Having a premature delivery that takes place before the 34th week of gestation
• Experiencing an extremely long first and second stage of labor
• Delivering a stillborn baby.

Can I prevent a retained placenta in my next pregnancy?

Although you can’t prevent developing a retained placenta again, that doesn’t mean that your next birth will have the same outcome. Although your chances of having a retained placenta again increase after you’ve already had one, you can still have a healthy pregnancy that doesn’t produce this type of complication.

If your child is born premature, the risks increase as well. The placenta is supposed to stay in place for 40 weeks. As a result, premature labor may lead to a retained placenta.

Doctors do everything in their power to prevent a retained placenta by taking actions that hasten complete delivery of the placenta after the birth of the baby.

These steps are as follows:

• Medication that encourages contractions in the uterus to help push out the placenta. Oxytocin (Pitocin) is an example of a medication that might be used
• Control Cord Traction after the placenta has released
• Stabilizing your uterus by applying Control Cord Traction through touch manual touch

These are all standard steps that your doctor may perform before you deliver the placenta. After childbirth, your doctor will also recommend massaging your uterus to encourage contractions that stop the bleeding and allow the uterus return to return to a small size.

In the unfortunate event that your cord snaps or your cervix closes too quickly after the oxytocin injection, consider a physiological third stage if you conceive again.

If you allow the placenta to deliver naturally, the cervix will more than likely close at the appropriate time, instead of closing too quickly. Discuss your options with your doctor.

However, keep in mind that the prolonged use of Syntocinon (artificial oxytocin) during labor has contributed to retained placentas.

This concern may develop if your labor is induced or sped up. However, although the potential for having a retained placenta with future pregnancies is prevalent, it’s not a guarantee that you won’t have a healthy pregnancy and delivery.

Retained placenta types

Retained placenta can be broken into three distinct classifications:

1. Placenta Adherens: Placenta adherens occurs when the contractions of the womb are not robust enough to completely expel the placenta. This results in the placenta remaining loosely attached to the wall of the uterus. This is the most common type of retained placenta.
2. Trapped Placenta: When the placenta successfully detaches from the uterine wall but fails to be expelled from the woman’s body it is considered a trapped placenta. This usually happens as a result of the cervix closing before the placenta has been expelled. The Trapped Placenta is left inside the uterus.
3. Placenta Accreta: When the placenta attaches to the myometrium (muscular walls of the uterus) of the uterus instead of the lining of the uterine walls, delivery becomes harder and often results in severe bleeding. Blood transfusions and even a hysterectomy may be required. There are three forms of placenta accreta, distinguishable by the depth of penetration. The placenta usually detaches from the uterine wall relatively easily, but women that encounter placenta accreta during childbirth are at great risk of obstetrical hemorrhage during its removal. This commonly requires surgery to stem the bleeding and fully remove the placenta, and in severe forms can often lead to a hysterectomy or be fatal. Placenta accreta affects approximately 1 in 2,500 pregnancies.

Retained placenta causes

Common circumstances that result in a retained placenta:

• Placenta Percreta occurs when the placenta grows all the way through the wall of the womb.
• Uterine Atony occurs when a woman’s contractions stop or are not strong enough to expel the placenta from her womb.
• Adherent Placenta takes place when all or part of the placenta is stuck to the wall of the woman’s womb. In rare situations, this happens because the placenta has become deeply embedded within the womb.
• Placenta Accreta takes place when the placenta has become deeply embedded in the womb, possibly due to a previous cesarean section scar.
• Trapped Placenta results when the placenta detaches from the uterus but is not delivered. Instead, it becomes trapped behind a closed cervix or a cervix that has partially closed.

Retained placenta symptoms

When the placenta fails to be completely removed from the womb an hour after the baby’s delivery, this is the most obvious sign of a retained placenta.

The woman may experience symptoms like:

• fever
• a foul-smelling discharge from the vaginal area
• large pieces of tissue coming from the placenta
• heavy bleeding
• pain that doesn’t stop.

Retained placenta potential complications

The risk of heavy bleeding increases. This condition is referred to as primary postpartum hemorrhage (PPH). When the managed delivery of the placenta takes longer than 30 minutes, heavy bleeding often results.

You do have the option of requesting a general anesthetic, but you incur more risks, especially if you want to breastfeed right after the procedure.

Traces of the drug will still be in your system which means the drug would also be in your breastmilk. You also need to make sure that you are alert enough to hold and support your baby for breastfeeding firmly.

However, if you do opt for the anesthetic, the placenta and any other remaining membranes will be manually removed from your womb while your legs rest in stirrups in the lithotomy position.

After the procedure, you will be given antibiotics intravenously to avoid the risk of infection. Additional drugs will be given to help your womb to contract afterward.

Retained placenta treatment

The treatment for a retained placenta is simply the removal of the placenta from the woman’s womb.

Different methods are often employed to achieve this, and they include:

• A doctor may attempt to remove the placenta manually. However, this does carry some risk of infection.
• Medications that relax the uterus to make it contract can also be used to help expel the placenta from the womb.
• Breastfeeding can be utilized in some situations because the process causes the uterus to contract and may be enough to expel the uterus from the womb.

Sometimes, something as simple as urinating is effective enough to expel the placenta because a full bladder can sometimes get in the way of expelling the placenta from the womb.

Unfortunately, if none of these methods succeed in removing the placenta from the uterus, emergency surgery may be needed as a last resort. This is usually saved as the last approach because of the complications that surgery can create.

Retained placenta prognosis

A retained placenta can be treated. Timing is everything. The sooner steps are taken to rectify the problem, the better the outcome.

If you fall into a high-risk category for a retained placenta or have experienced one in the past, talk to your doctor before giving birth again. Your doctor will help you prepare for the possibility of complications.

References

1. Magann EF, Doherty DA, Briery CM, et al. Timing of placental delivery to prevent post-partum haemorrhage: Lessons learned from an abandoned randomised clinical trial. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2006;46:459-551.
2. Lindsay P. Complications of the Third Stage of Labour. In: Henderson C, MacDonald S, editors.Mayes’ Midwifery A textbook for Midwives. 13th ed. London: Bailliere Tindall; 2004. p. 987-1002.
3. Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. The Cochrane Database of Systematic Reviews. 2011(7).