Retained placenta

Approved by the BabyCentre Medical Advisory Board Last reviewed: October 2012 Show references

Highlights

What is a retained placenta? What causes a retained placenta? What problems can a retained placenta cause? What happens if my third stage is taking too long? How is a retained placenta treated? Can I prevent a retained placenta in my next pregnancy?

What is a retained placenta?

If you have a retained placenta, part of the placenta or membranes will remain inside your uterus (womb) after your baby is born. This happens during the third stage of labour. The third stage of labour is when the placenta and membranes are delivered. You can opt for a physiological (natural) third stage or a managed third stage. You'll be able to discuss this with your midwife before the birth. A physiological third stage involves you delivering the placenta by pushing it out yourself. A managed third stage is when your midwife gives you an injection in your thigh, just as your baby is being born. This injection helps your uterus to contract down and push out the placenta and membranes. Having a managed third stage reduces the risk of heavy bleeding immediately after your baby is born. You'll be treated for retained placenta if your midwife suspects that any of the placenta or membranes remains attached to your uterus. Shell examine the placenta after youve delivered it, and most cases are picked up at this stage. Occasionally, theres a delay to the placenta being delivered at all. Your midwife will treat you if the placenta hasn't been delivered:

Within one hour of your baby's birth if you had a physiological third stage (about 13 per cent of cases). Within 30 minutes of your baby's birth if you had a managed third stage (less than five per cent of cases).

What causes a retained placenta?

The three main causes of a retained placenta are:

When the uterus stops contracting, or doesn't contract enough for the placenta to separate from the wall of your uterus. This is called uterine atony. When part or all of the placenta is stuck to the wall of your uterus and doesn't separate. This is called an adherent placenta. In rare cases this happens because the placenta has deeply embedded itself in the wall of your uterus. When the placenta comes away from the uterus, but becomes trapped behind a semiclosed cervix. This is called a trapped placenta.

If you have a full bladder it may prevent the placenta from being delivered. If necessary, your midwife may insert a catheter to drain your bladder. If the placenta has separated and is ready to come out, it will slide easily through your vagina. If it hasn't completely separated, or if the cord is very thin when your midwife pulls, it may break. If this happens, you can usually help to deliver the placenta by pushing with a contraction. However, occasionally the cervix closes too much to allow the placenta out. A small piece of placenta, connected to the main part of the placenta by a blood vessel, may have been left behind in the uterus (a succenturiate lobe). Your midwife will examine the placenta and membranes carefully after your baby is born to ensure that they are complete. If she notices a vessel leading to nowhere, this should alert her to the possibility of part of the placenta being retained. Sometimes, a part of the placenta may stick to a scar from a previous caesarean section. This is a serious condition called a placenta accreta. This should be picked up during your pregnancy. Then plans can be made for you to have your baby in an obstetric unit, where you'll have the right level of care.

What problems can a retained placenta cause?

After the placenta is delivered, your uterus should contract down to close off all the blood vessels inside the uterus. If the placenta only partially separates, the uterus can't contract properly, so the blood vessels inside will continue to bleed. If the managed delivery of the placenta takes longer than 30 minutes after the birth of your baby, your risk of heavy bleeding increases. Heavy bleeding in the first 24 hours after birth is known as primary postpartum haemorrhage (PPH). If fragments of placenta or membrane are retained, and your midwife or doctor miss this, it may cause heavy bleeding and infection later (secondary PPH). Try not to worry about this happening to you. It is rare and happens in less than one per cent of births.

What happens if my third stage is taking too long?

If the third stage is taking a while, you could try breastfeeding your baby or rubbing your nipples, to release the hormone oxytocin. This may cause your uterus to contract and help to expel the placenta. If you're sitting or lying down, you could try changing to a more upright position to allow gravity to help. If you chose a physiological third stage, you can switch to a managed third stage if the placenta doesn't come within an hour. Your midwife will give you an injection of an oxytoxic drug to make your uterus contract. She will then gently pull out the placenta. Following a managed third stage, if the placenta is retained, your midwife can give you another injection of an oxytocic drug. She may also try injecting oxytocin and saline into the umbilical vein of the umbilical cord. Or she may just wait a bit longer to see if it comes away on its own.

How is a retained placenta treated?

If the placenta still hasn't been delivered after you've had oxytocin and saline, your doctor may need to remove it by hand. You won't feel discomfort during this procedure, because an anaesthetist will numb the area for you. You may have a regional anaesthetic such as a spinal or epidural. You can ask for a general anaesthetic if you prefer. However, a general anaesthetic carries more risks for you. You also won't be able to breastfeed immediately after the procedure because the drugs will temporarily taint your breastmilk. Once the anaesthetic is working you'll be taken to the operating theatre. Your midwife or an assistant will lift your legs into stirrups (the lithotomy position). Then your doctor will gently insert her hand to remove the placenta and any remaining membranes from your uterus. You'll have intravenous antibiotics to prevent infection, and you may need more intravenous drugs to help your uterus to contract down. If you have prolonged, heavy bleeding in the days or weeks following the birth, your doctor may refer you for an ultrasound scan. This is to see if there are any fragments of placenta or membrane in your uterus. If any fragments remain, you'll be admitted to hospital so that they can be removed. This is called evacuation of retained products of conception (ERPC) and is carried out under a regional (spinal) anaesthetic or a general anaesthetic. You'll be given antibiotics to treat any infection which may have developed.

Can I prevent a retained placenta in my next pregnancy?

Unfortunately, there isn't much you can do to prevent it. If you had a retained placenta in a previous birth, you do have a higher risk of it happening again. Bear in mind that this doesn't mean it will happen.

You are more likely to have a retained placenta if your baby is premature. This may be because the placenta was designed to stay put for 40 weeks. So if you have another premature labour, it may happen again. However, if the cord snapped, or if your cervix closed too quickly after having the oxytocic injection, you may consider a physiological third stage with your next baby. By allowing the placenta to deliver naturally, you avoid the possibility of the cervix closing too quickly and trapping the placenta. Talk about your options with your midwife. The prolonged use of syntocinon (artificial oxytocin) during labour has been linked to retained placentas. You may have had this if your labour was induced or speeded up. Bear in mind that with your next baby you may not need these interventions at all. http://www.babycentre.co.uk/a562148/retained-placenta#ixzz2dhDB2ykD