Retained placenta

In remote setting treat as retained placenta if placenta is not delivered (still inside uterus) after 30 minutes despite controlled cord traction or maternal effort

If placenta retained

Do not

• Do not let woman eat or drink anything — may need operation — consider IV fluids

Check

• Was oxytocin given after birth of baby
• Vaginal bleeding — amount and colour
• Where top of fundus (uterus) is
• Has woman passed urine, does bladder feel full
• If unable to pass urine — may need indwelling urinary catheter

Do

• Put baby to mother’s breast and encourage baby to start sucking
• If woman had oxytocin — try controlled cord traction again
• If cord has lengthened — may need to move clamp closer to vulva
• If woman has not had oxytocin — give oxytocin IM — 10 international units, single dose into thigh
• Wait 5–10 minutes for signs that placenta has separated from wall of uterus and descended — trickle or gush of blood from vagina​, lengthening of cord
• If signs of separation — try controlled cord traction
• If no signs of separation — try controlled cord traction AND take extra care to guard uterus by applying counter traction — put second hand above pubic bone with palm facing away from you. Use arch formed between thumb and first finger to apply counter traction. Push in and up to support uterus and hold it in place — Figure 1.51

• If the cord snaps before the placenta has been delivered — check if it is in the vagina
• If it is — ask the mother to bear down and attempt to extract the  placenta
• If unable to deliver the placenta — manage as if the placenta is still not delivered

If placenta delivers

• See Checking the placenta and Rubbing up a contraction 
• Measure/estimate blood loss — save and weigh pads and clots — 1g increase = 1mL loss
• If more than 500mL loss or ongoing bleeding — medical consult — see Primary postpartum haemorrhage

If placenta still not delivered

Reassure woman and explain that you need to do a vaginal exam because her placenta has not come out — vaginal examination can be painful. Gain consent and only do if skilled

Do First

• Medical consult — may need to go to hospital
• Put in IV cannula — largest possible, if not already in
• Start normal saline 1L at 125mL/hr
• Put in indwelling urinary catheter if not already in place

Check

• Measure/estimate blood loss — save and weigh pads and clots — 1g increase = 1mL loss

Do

• POC test for Hb
• Put in second IV cannula — largest possible, if not already in
• If you can't get IV cannula in — put in intraosseous needle
• Give pain relief
• ​Nitrous oxide if available
• AND/OR Morphine IV — adult 1–2mg.  Naloxone must be available
• If skilled and woman consents — do vaginal exam
• Use sterile gloves and water-based lubricant or obstetric cream
• With your fingers follow cord up into vagina
• If woman uncomfortable — stop examination and give more pain relief
• If you feel placenta in vagina or cervix — grasp and carefully pull out
• If you feel cord going through cervix — stop
• If placenta retained — do not try controlled cord traction again
• Medical consult to send to hospital
• If ongoing heavy bleeding or delay in evacuation — start oxytocin infusion (40 international units in 1L normal saline) at 250mL/hr​. If no infusion pump — monitor carefully
• Continue observations especially blood loss until sent to hospital
• If more than 500mL blood loss — see Primary postpartum haemorrhage
• If placenta delivers — see Checking the placenta and Rubbing up a contraction