# Manual Removal of the Retained Placenta

## Overview

This module describes how to remove a retained placenta to prevent life-threatening haemorrhage and postpartum sepsis.

## Indications

## Contraindications

## Patient information and consent

### How do I explain this procedure?

“The afterbirth is not coming out on its own. I need to give you some medication and perform some manoeuvres to help your body expel it.”

### What can my patient expect?

“You will feel a prick in your arm from the drip and cramps from the medication I will give you. This can be very uncomfortable. If the medication and manoeuvres I perform do not deliver the afterbirth we will need to take you to the operating theatre and put you to sleep, in order to remove it.”

### What is my patient’s role?

“Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible.”

## Preparation

### Documentation

### Equipment

## Site & Positioning

Place the patient in the lithotomy position. This procedure requires strong, focused lighting.

## Procedure

Follow medical asepsis using the arm gloves.

Further management depends on whether or not the mother is actively bleeding.

If little or no bleeding and patient remains haemodynamically stable:

In the case of bleeding:

Once in theatre and the patient is under general anaesthetic, surgical asepsis applies:

## Troubleshooting

I do not have arm gloves.

Don normal sterile gloves. Open another 2-3 pairs of sterile gloves and cut off the cuff portions. Apply these on the forearm, overlapping with the one beneath until the entire forearm is covered.

I do not have theatre facilities.

Manual removal of the placenta is a painful process and should be done in theatre when possible. However, in dire circumstances only, call for help. Anticipate blood loss and have fluid and emergency blood on standby. Have a nurse or colleague call for senior help and arrange a theatre. If not, book a paramedic and an ambulance to the nearest facility with theatre facilities. If this is also not an option, or the patient may exsanguinate while awaiting transport, administer titrated morphine IV in 1-2 ml aliquots (if patient is haemodynamically stable) and attempt manual removal of the placenta.

The cord has snapped during cord traction.

Attempt to clamp the remaining part of the cord with forceps and continue manual traction. If the portion left is too short to clamp, proceed as above with manual removal of the placenta.

I am unable to remove part or all of the placenta.

Consider a placenta accreta or increta. Call a senior. While waiting, if the bleeding continues profusely, administer another 10-20 units of oxytocin in a litre of fluid. If bleeding continues, administer 1000 mg (or five 200 mg tablets) of misoprostol rectally.

## Risks

## References