Retained placenta after vaginal birth
- Andrew Weeks, MD, MRCOG
Andrew Weeks, MD, MRCOG
- Professor of International Maternal Health
- Sanyu Research Unit
- University of Liverpool
The third stage of labor is the interval from delivery of the infant to expulsion of the placenta. Delayed separation and expulsion of the placenta is a potentially life-threatening event because it interferes with normal postpartum contraction of the uterus, which can lead to hemorrhage.
Retained placenta can be defined as lack of expulsion of the placenta within 30 minutes of delivery of the infant [1,2]. This is a reasonable definition in the third trimester when the third stage of labor is actively managed (ie, administration of a uterotonic agent before delivery of the placenta, controlled cord traction) because 98 percent of placentas are expelled by 30 minutes (figure 1) in this setting .
In the second trimester, however, the risk of retained placenta at 30 minutes is higher (figure 2). In addition, with physiological management of the third stage (ie, delivery of the placenta without the use of uterotonic agents or cord traction), it takes about 60 minutes before 98 percent of placentas are expelled. These findings suggest that the definition, or the timing of intervention, should take into account the gestational age at delivery and how the third stage of labor is managed. In part for these reasons, the World Health Organization (WHO) concluded that the length of time before making a diagnosis of retained placenta should be “left to the judgement of the clinician” . (See "Pharmacologic management of the third stage of labor" and 'Indications for intervention' below.)
TYPES OF RETAINED PLACENTA
The three types of retained placenta, in order of increasing morbidity, are:
●Trapped or incarcerated placenta – The incarcerated or trapped placenta is simply a separated placenta that has detached completely from the uterus, but not delivered spontaneously or with light cord traction because the cervix has begun to close.
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- TYPES OF RETAINED PLACENTA
- RISK FACTORS
- CLINICAL FINDINGS AND DIAGNOSIS
- Placental pathology
- INDICATIONS FOR INTERVENTION
- Patients with severe bleeding
- Patients without severe bleeding
- Apply controlled cord traction
- Manage bleeding
- Address contributing uterine factors
- - Excessive cervical/uterine contraction
- - Atony
- Perform manual extraction
- - Instrument extraction
- - Incomplete extraction
- - Unexpected placenta accreta
- Other approaches
- SUMMARY AND RECOMMENDATIONS