II. Definition

  1. Undelivered placenta in >30 minutes

III. Epidemiology

  1. Incidence: <3% of vaginal deliveries

IV. Causes

  1. Placenta separated but undelivered
    1. Prevent with Active Management of the Third Stage of Labor
      1. Goal is delivery of placenta within first 10 minutes after delivery of the fetus
    2. Signs of separation
      1. Bleeding
      2. Uterus shape
      3. Cord lengthening
    3. 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. Invasive placenta (rare, but increasing Incidence with C-SectionIncidence)
    1. Includes placenta accreta, placenta increta, or placenta percreta
    2. Abnormal adherence of placenta to uterine muscle
    3. Partially or wholly attached placenta
    4. Risk factors
      1. Vaginal Birth after Cesarean (VBAC)
      2. Placenta Previa
      3. Advanced maternal age
      4. High parity
      5. Prior placenta accreta

V. Management

  1. Monitor Vital Signs
  2. Obtain large bore IV (16-18 gauge)
  3. See Active Management of the Third Stage of Labor
  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

VI. 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. Consider placenta accreta (invasive placenta) if tissue plane is not easily distinguished on manual placenta removal
    1. Especially consider in VBAC, Placenta Previa, advanced maternal age, high parity, prior placenta accreta
    2. High risk of life threatening Postpartum Hemorrhage (may require Hysterectomy)
  5. Placenta inspected for completeness
    1. Re-explore for any possible retained products
  6. Administer Pitocin and massage Uterus

VII. Prevention

  1. See Active Management of the Third Stage of Labor
  2. Placenta delivery within first 10 minutes is ideal
    1. Mean time from delivery to placental expulsion is 8-9 minutes
    2. Postpartum Hemorrhage risk doubles after 10 minutes

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window