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Retained Placenta
The third stage of labour commences with the completed delivery of the fetus and ends with the completed
delivery of the placenta and its attached membranes. The length of the third stage itself is usually 5-15 minutes.
The National Institute for Health and Care Excellence (NICE) recommends that the third stage is diagnosed as
delayed if it takes longer than 30 minutes to deliver the placenta with active management or 60 minutes if allowed
to deliver the placenta physiologically with maternal effort. [1]

Retained placenta is important as it is one of the causes of postpartum haemorrhage, which is the third leading
cause of maternal mortality in the UK. [2] Retained placenta increases the risks of a postpartum haemorrhage by
five-fold (3.36-7.87; 99% confidence interval (CI)). [3]

Aetiology
There are three main types of retained placenta following vaginal delivery, which can all be treated by manual
removal of the placenta: [4]

Placenta adherens, when the myometrium fails to contract behind the placenta.
Trapped placenta, when a detached placenta is trapped behind a closed cervix.
Partial accreta, when there is a small area of adherent placenta preventing detachment.

Rarely there is an abnormality of the placenta (placenta accreta) which leads it to penetrate the myometrium to a
varying degree preventing manual removal without risking significant postpartum haemorrhage.

Epidemiology
The incidence and importance of retained placenta vary greatly around the world: [4]

In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate.
In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely
associated with mortality. Retained placenta was identified as the cause of 18% of severe obstetric
haemorrhages in one American series. [5]

Management
Active management of the third stage is encouraged as it is associated with a lower risk of postpartum
haemorrhage and blood transfusion. If the labour has progressed normally and the mother requests physiological
management of the third stage, she should be supported in this request. [1, 6] However, if there has been
significant haemorrhage, try to discover if the placenta has separated - as indicated by:

A sudden rush of blood.

Fundus moves higher and becomes rounded.
Increase in length of part of the umbilical cord visible at the vulva.
Raising of fundus does not cause the cord to decrease in length.

If the placenta has separated:

Try to deliver the placenta by 'rubbing up' the uterus.

Then push it towards the vagina to help with expulsion of the placenta and membranes.
These are held and twisted whilst pulling constantly so that membranes are kept intact.
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If the placenta does not deliver, offer a vaginal examination and if this finds no evidence that the placenta has
detached, IV access should be obtained. If there is excessive bleeding,give IV oxytocic agent to produce a
contraction but it should not be used routinely. If the woman is not already in an obstetric unit, she should be
transferred urgently. She should be observed frequently to assess the need for resuscitation. [1]

If the placenta needs to be removed manually, this must be done under anaesthetic:

Place a gloved hand into the uterus, with the other hand on the fundus to control it.
Follow the umbilical cord until you find the lower edge of the placenta.
Push the hand between the placenta and the body of the uterus and ease the placenta away with a
sawing action (NB: in cases of placenta accreta, the placenta will not detach easily and use of
excessive force can result in life-threatening haemorrhage which may require hysterectomy).
When fully detached, explore the uterine cavity for damage and for other pieces of placenta.
Massage the fundus with one hand whilst extracting the placenta and membranes with the hand in the
uterine cavity.
Look carefully at the placenta to be sure that it is complete.
Inject ergometrine IV and IM.

Complications
Retained placenta is, in itself, life-threatening because of its association with infection and postpartum
haemorrhage.
Manual removal of a retained placenta is not without risk. Although it increases the likelihood of
bacterial contamination in the uterine cavity, there are no randomised controlled trials to evaluate the
effectiveness of antibiotic prophylaxis to prevent endometritis after manual removal of placenta. [7]

Prevention
Since manual removal of a retained placenta is invasive and carries risks of damage to the genital tract, infection
and haemorrhage, many attempts have been made to increase the ability of the uterus to expel a retained
placenta without recourse to surgery.

Umbilical vein injections of saline, plasma expander or prostaglandins with or without oxytocin have all
been studied. Unfortunately, a Cochrane review found no evidence of any beneficial effect of any of
these. [8] Also, NICE no longer recommends umbilical vein injection of oxytocin. [1]
There is conflicting evidence from small studies that nitroglycerine, sublingual or IV, may reduce the
need for a manual removal of retained placenta; the true effect is uncertain.
Sulprostone is a potent stimulator of uterine smooth muscle contractions with high abortifacient
activity. It is not licensed in the UK but has been shown in one small study (n=50) to reduce the need
for the manual removal of the placenta by 49% [9] and in a study of 126 women, all of whom received
sulprostone, by 39.7%.
Misoprostol does not reduce the need for manual removal for retained placenta. [10]

Further reading & references

1. Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
2. Saving Lives, Improving Mothers Care - Lessons learned to inform future maternity care from the UK and Ireland
Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012; MBRRACE-UK, Dec 2014
3. Prevention and management of postpartum haemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009
with revisions April 2011)
4. Weeks AD; The retained placenta. Best Pract Res Clin Obstet Gynaecol. 2008 Sep 13.
5. Al-Zirqi I, Vangen S, Forsen L, et al; Prevalence and risk factors of severe obstetric haemorrhage. BJOG. 2008
Sep;115(10):1265-72.
6. Antenatal care for uncomplicated pregnancies; NICE Clinical Guideline (March 2008, updated 2017)
7. Chongsomchai C, Lumbiganon P, Laopaiboon M; Prophylactic antibiotics for manual removal of retained placenta in
vaginal birth. Cochrane Database Syst Rev. 2014 Oct 20;10:CD004904. doi: 10.1002/14651858.CD004904.pub3.
8. Nardin JM, Weeks A, Carroli G; Umbilical vein injection for management of retained placenta. Cochrane Database Syst
Rev. 2011 May 11;(5):CD001337. doi: 10.1002/14651858.CD001337.pub2.
9. van Beekhuizen HJ, de Groot AN, De Boo T, et al; Sulprostone reduces the need for the manual removal of the placenta in
patients with retained placenta: a randomized controlled trial. Am J Obstet Gynecol. 2006 Feb;194(2):446-50.
10. van Stralen G, Veenhof M, Holleboom C, et al; No reduction of manual removal after misoprostol for retained placenta: a
double-blind, randomized trial. Acta Obstet Gynecol Scand. 2013 Apr;92(4):398-403. doi: 10.1111/aogs.12065. Epub 2013
Jan 21.
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Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Hayley Willacy Dr Jacqueline Payne Dr John Cox
Document ID: Last Checked: Next Review:
1724 (v23) 01/07/2015 29/06/2020

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