I. Definition

  1. Undelivered placenta in >30 minutes

II. Causes

  1. Placenta separated but undelivered
    1. Signs of separation
      1. Bleeding
      2. Uterus shape
      3. Cord lengthening
    2. Missed signs of separation results in
      1. Uterus unable to retract
      2. Uterus becomes broad and boggy
      3. Significant Uterine bleeding follows
  2. Placenta partly or wholly attached
    1. Completely failed separation
    2. No bleeding as contrasted with Cornual implantation
  3. Partial separation
    1. Bleeding but fundus still broad
    2. Hour glass constriction
      1. Pitocin constricts lower segment
  4. Placenta accreta (rare)
    1. Abnormal adherence of placenta to uterine muscle
    2. Partially or wholly attached placenta

III. Management

  1. Monitor Vital Signs
  2. Obtain large bore IV (16-18 gauge)
  3. Expectant Management for 20-30 minutes
  4. Brandt-Andrews maneuver (Cord traction)
    1. Umbilical Cord is pulled gently with one hand
    2. Other hand pushes Uterus up from pubis
      1. Prevents Uterine Inversion
    3. Use See-Saw motion between the two hands
  5. Umbilical Vein Pitocin
    1. Pitocin 10 IU in 20 ml Normal Saline
    2. Wait for 5 minutes
  6. Consider Obstetrics Consultation
    1. Placenta accreta
    2. Increta
    3. Percreta
  7. Observe for signs significant bleeding
    1. See Postpartum Hemorrhage

IV. Management: Manual extraction of the placenta

  1. Conscious Sedation or anesthesia
  2. Hand covered with antiseptic cream into Uterus
    1. Fingers separate placenta from Uterus
    2. Never grasp placenta until it is separated
  3. Abdominal hand presses uterine fundus into placenta
    1. Prevents tearing of lower segment
  4. Placenta inspected for completeness
    1. Re-explore for any possible retained products
  5. Administer Pitocin and massage Uterus

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