- What are the mechanisms of placental separation? (10 marks)
Following delivery uterine retraction causes thickening of myometrium, reduction in uterine
volume and shrinkage of placental bed, the non-contractile placenta is undermined,
detached, and propelled into the lower uterine segment. (5)
– Separation through haematoma formation- due to venous occlusion and vascular rupture in placental bed caused by uterine contraction. (5)
2. What are the signs of placental separation? (5 marks)
Lengthening of umbilical cord- placing a clamp on the cord near the perineum makes it easier to appreciate this lengthening (2)
– Uterus takes globular shape and become firm (this change may be difficult to appreciate clinically) (1)
– A gush of blood (but may also occur before separation if blood find a path to escape) (2)
3. What are the components of active third stage management? (15 marks)
Controlled cord traction (5)
– Brandt Andrew maneuver This involve one hand on the lower abdomen which secure the uterine fundus to prevent inversion and steady traction on the cord with the other hand – Crede manoeuvre ) in which hand holding the cord is fixed and the hand on the lower abdomen apply upward traction
Administration of oxytocin at the time of anterior shoulder delivery
– 5 IU IV slow bolus or IM 10 IU (5)
Early cord clamping no longer recommended
Delayed cord clamping whenever possible (Cord clamping not before 1 minute or until cord pulsation cease unless baby is born in a poor condition or if the other is bleeding or Rh isoimmunized (5)
4. What are advantages and disadvantages of delayed cord clamp
Advantages – Decrease the risk of intraventricular haemorrhage, NEC, Sepsis – Decrease the need for blood transfusion for anaemia or low blood pressure
– Increases hematocrit, hemoglobin, cerebral oxygenation – Improve iron stores
Disadvantages – small risk of neonatal jaundice ping? (12 marks)
5. What is the definition of retained placenta? Or delayed third stage of labour? (2 marks)
Retention of placenta in utero for more than 30 minutes following birth of the baby, with active
management or 60 min with physiological expectant management.
6 . What are the risk factors? (10 marks)
Previous history of retained placenta and manual removal of placenta
– Previous CS
– Previous uterine curettage
– History of uterine infection
– Uterine fibroids
– Premature delivery
– Uterine atony/ uterine constriction ring
– Uterine anomalies
– Full bladder
– Mismanagement of 3rd stage of labour
– Induction of labour & use of oxytocin
– Multi parity and advanced age (>35yrs)
– Morbidly Adherent Placenta
7. What are types of retained placenta? (6 marks)
Completely detached and retained inside
– Partially detached
– Non-detached
8. What are the complications of retained placenta? (10 marks)
PPH
– Uterine inversion
– Perforation
– Trauma to uterus, cervix
– Rhesus isoimmunisation
– Anaesthetic complications
– Sepsis
– Severe maternal morbidity
– loss of uterus
– Maternal death
9. What are the steps involved in the management of retained placenta ? (Demonstrate using the given model) (30 marks) (20+10)
Explain the woman and her birth companion what is happening.
– If no bleeding, expectant management can be considered for another 30 mins.
– No evidence for umbilical cord injection of saline or oxytocin (NICE 2014: CG190)
– An intravenous infusion of oxytocin should not be used to assist the delivery of the placenta unless there is bleeding.
– MRP should be done in OT under regional or GA or (adequate pain relief)
– anesthetist should be informed
– Consent (informed, written)
– Get IV access, Blood for FBC and DT
– Catheterize bladder or empty the bladder
– Single dose of IV antibiotics
– Continuous monitoring of vital parameters using the MEOWS chart
– Elbow-length glove is worn and attention is paid to asepsis
– Lithotomy position, perineum is prepared aseptically, the vaginal hand is lubricated to
facilitate easier entry
– The hand is passed in the vagina and through the cervix into the lower segment of uterus, following the umbilical cord, Care is taken to minimize the profile of the hand as it enters, keeping the thumb and finger together in the shape of a cone to avoid trauma.
– Control of the uterine fundus with the other hand is essential. If the placenta is encountered in the lower segment, it is removed, if not, the placental edge is sought.
– Once found, the fingers gently develop the space between the placenta and uterus and
shear off the placenta
– The placenta is pushed to the palmar aspect of the hand and when it is entirely separated,
the hand is withdrawn with the placenta in the palm
– If the placenta does not separate from the uterine surface by gentle lateral movement of the fingertips at the line of cleavage, suspect placenta accreta.
Call for expert help to confirm the findings.
If necessary, consider laparotomy with a view to hysterectomy
– Hold the placenta and slowly withdraw the hand from the uterus bringing the placenta with it, examine the uterine surface of the placenta to ensure it is complete, if any placental lobe or tissue missing explore the uterine cavity to remove it.
❖ A vessel leading to the edge of the membrane suggests a retained succenturiate lobe. As a rule of thumb, the membranes should be large enough to cover the placenta one and a half times
– Palpate inside of the uterine cavity to ensure the all the placental parts has been removed
– Perform uterine massage and commence oxytocin 20 – 40 IU infusion
❖ If the placenta is retained due to constriction ring or if hours or days have passed since delivery, it may not possible to get the entire hand in to the uterus, extract the placenta using two fingers, ovum forceps or wide curette
❖ Uterine relaxants (tocolysis) can be used
Post procedure care (10 marks)
Continuous monitoring of maternal vital parameters, evaluation of any vaginal bleeding, monitoring of fundal height
Fundal massage until uterus hard
Continue oxytocin infusion, consider ergometrine or misoprostol if bleeding persist
IV fluids
Blood transfusion if necessary
Documentation and Debriefing
Future pregnancy
❖ Patients are advised to deliver in an obstetric unit if there has been a history of a retained placenta
requiring MROP in a previous pregnancy
❖ Retained placenta is also a risk factor for PPH in any future pregnancy
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