Doctors Revision

Obstetrics

Retained Placenta

Failure of the placenta to deliver within 30 minutes after the birth of the baby, despite active management of the third stage of labour.

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Referral and warning signs

When to refer

Refer if unable to perform MRP or accreta suspected. Urgent referral if uncontrolled PPH.

Red flags

  • Heavy bleeding
  • Signs of shock
  • Inability to manually remove
  • Suspected rupture/inversion

Signs and symptoms

  • Placenta not delivered >30 minutes post-delivery.
  • Umbilical cord visible.
  • May have associated PPH.
  • Uterus may be poorly contracted.
  • Signs of infection if prolonged.

Risk factors

  • Previous retained placenta.
  • Uterine atony.
  • Placenta accreta spectrum.
  • Preterm delivery.
  • Prolonged labour / Augmentation.
  • Previous uterine surgery.
  • Grand multiparity.

Diagnosis

Clinical assessment

Diagnosis based on time elapsed (>30 min) without placental expulsion.

Investigations

  • Clinical diagnosis.
  • Assess for PPH.
  • Examine expelled portion for completeness.

Diagnostic criteria

Failure of placental delivery >30 mins post-baby.

Management

Non-pharmacological management

  • Empty bladder.
  • Encourage breastfeeding.
  • Attempt Controlled Cord Traction (CCT) again.
  • Manage PPH FIRST if heavy bleeding.
  • Manual Removal of Placenta (MRP): Under analgesia/sedation + aseptic technique. Insert hand, find edge, separate gently, remove. Explore uterus after. (LOC: HC3/4/H).
  • If Unable/Accreta suspected: Refer URGENTLY.

Pharmacological treatment

  • Analgesia/Sedation for MRP (Diazepam/Ketamine).
  • Additional Uterotonic: Oxytocin 10 IU IM/IV.
  • Antibiotic Prophylaxis AFTER MRP: Ampicillin 2g IV/IM + Metronidazole 500mg IV/PO.
  • If Unable to remove/Referral: Ceftriaxone 2g IV stat + Oxytocin infusion during transfer.

Monitoring

Monitor vitals, bleeding, uterine tone post-procedure.

Complications

  • PPH.
  • Infection/Sepsis.
  • Uterine perforation (MRP).
  • Uterine inversion (incorrect CCT).
  • Asherman's syndrome (rare).

Prevention

  • Active Management of Third Stage (AMTSL).
  • Avoid inappropriate cord traction.

Patient education

  • Explanation of retained placenta.
  • Need for MRP.
  • Analgesia used.
  • Antibiotics importance.
  • Post-procedure care.
  • Contraception.

Uganda-specific notes

Common cause of PPH. MRP skills essential HC3+. Ensure analgesia/antibiotics. Refer if accreta/failed MRP.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.4.5

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