# 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

1. A retained placenta is one that is undelivered 20-30 minutes after the delivery of the newborn

## Contraindications

1. None

## 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

1. Patient notes

2. Prescription chart

### Equipment

1. Alcohol-based hand rub

2. Sterile

   arm gloves
   arm gloves

   These are sterile gloves usually found in the labour ward that extend up to the elbows.

3. Supplies for IV cannulation

4. Intravenous administration set and bag of intravenous fluid

5. Infusion pump
   Infusion pump

   If unavailable, use a dial-a-flow or any infusion set where the fluid dosage can be preset and controlled. This is crucial to avoid over administration of drugs.

6. Blood tubes
   Blood tubes

   These usually include tubes for full blood count, group and screen and clotting profile

7. Blank labels and a marker

8. Supplies for urinary catheterisation

9. Medication:

   1. Oxytocin
   2. Tranexamic acid

## Site & Positioning

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

## Procedure

Follow medical asepsis using the arm gloves.

1. Check that the placenta is not already in the vagina.

2. Put up
   Put up

   You can draw blood while obtaining IV access.

   two large bore IV lines.

3. Run an intravenous line with

   20 units/litre oxytocin
   20 units/litre oxytocin

   Common practise is to use a litre of a volume expander such as plasmalyte and add 20 units of Oxytocin to the bag.

   at 30-60 drops per minute.

4. Insert a Foley’s catheter.

5. Label the bag containing oxytocin.

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

If little or no bleeding and patient remains haemodynamically stable:

1. Allow

   1 hour
   1 hour

   Usually by the time the nursing staff have called you, a notable amount of time has passed. Take this into consideration.

   for separation of the placenta.

2. Monitor

   vital signs
   vital signs

   Use the shock index to assist you. The shock index (SI) is defined as the heart rate (HR) divided by systolic blood pressure (SBP). The normal range is 0.5 to 0.7 in healthy adults. Anything more than this should alert you to haemorrhagic shock.

   as there may be concealed bleeding.

3. If unsuccessful, maintain

   steady cord traction
   steady cord traction

   Do not pull to hard as the cord may snap.

   with uterine counter-pressure for 10-15 minutes.

4. If unsuccessful, transfer the patient to theatre for manual removal of the placenta.

5. Once the placenta has been removed, check that it is complete. Also check the membranes for completeness.

In the case of bleeding:

1. Continue
   Continue

   In massive haemorrage (500ml) where a large amount of blood is lost, call for help in stabilising the patient. This includes putting up an infusion in the other arm containing a crystalloid such as Plasmalyte or Ringers Lactate and assessing the need for emergency blood.

   IV infusion of oxytocin with 20 units/litre at 30 drops per minute.

2. Give face mask oxygen.

3. Send bloods for group and save.

4. Administer 1 g tranexamic acid IV.

5. Prepare the patient for theatre for manual removal.

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

1. Place your patient again in the lithotomy position.

2. Insert a Foley’s catheter and empty the bladder if not already done.

3. With one hand on the uterine wall, stabilise the uterine fundus.

4. Insert the other hand into the vagina and follow the umbilical cord through the vagina and cervix into the uterus, until the placenta is palpated.

5. Separate the placenta from the uterine wall with a

   cleaving movement
   cleaving movement

   Do not simply pull or tear the placenta out as this will cause it to break off in pieces and cause haemorrhage.

   , using the ulnar side of your hand.

6. Once the placenta has been separated, remove it from the uterus and check that it is complete. Also check the membranes for completeness.

7. Reinsert your hand back into the uterus and feel for any retained products.

8. If retained products are present, remove these using the largest available

   sharp curette
   sharp curette

   Use a uterine sound and 'sound' the uterus first. This will indicate the height of the uterine fundus and give you an indication of how far to advance the curette.

   until you achieve a gritty feel and a scraping sound on curettage.

9. Monitor the patient’s vitals throughout and anticipate bleeding. Assess the need for a blood transfusion.

10. Cover with broad spectrum antibiotics.

11. Record completion of the procedure in patient notes.

12. Continue the oxytocin infusion for a minimum of 8 hours.

## 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

1. Delayed postpartum haemorrhage

2. Endomyometritis

3. Uterine perforation

4. Uterine adhesions

5. Puerperal sepsis

6. Sharps injury to healthcare personnel

## References

1. Perlman N, Carusi D. Retained placenta after vaginal delivery: risk factors and management. Int J Women’s Health. 2019 (11): 527-534. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789409/

2. Steinberg H. How to manually remove the placenta. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010:281-282.

3. Pretorius MS. Postpartum Haemorrhage. In: Clinical Obstetrics: a South African Perspective. 3rd ed. Pretoria: Van Schaik Publishers; 2011: 224-226