Retained Placenta
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Direct answer
A retained placenta is failure of the placenta to deliver within 30 minutes of the baby's birth (some texts extend to 60 minutes with signs of separation absent), and it threatens haemorrhage the longer it stays. The mechanism is one of three: uterine atony failing to shear the placenta, a trapped placenta behind a closing cervix or spasmodic ring, or placenta accreta spectrum adhering abnormally. Management escalates in order: empty the bladder, put the baby to breast and give a uterotonic — intravenous oxytocin 10 units in saline (or ergometrine 0.2 mg, guarding against hypertension), with misoprostol 400 micrograms sublingual where oxytocin is unavailable — attempt controlled cord traction, and proceed to manual removal of the placenta under anaesthesia within about 30 more minutes if still undelivered, with antibiotic cover.
What you must remember
- Definition: placenta undelivered 30 minutes after birth (the threshold most Indian texts and FMGE keys use); after 60 minutes the haemorrhage risk rises steeply.
- Signs of separation: cord lengthening, gush of blood, uterus becoming globular and firm, and the placenta appearing at the introitus; their absence means it is still attached or trapped.
- First moves (non-anaesthetic): catheterise (a full bladder alone can hold the placenta), breastfeeding or nipple stimulation, oxytocin 10 units intravenously in 20 mL saline as a slow injection or short infusion, controlled cord traction with suprapubic counter-pressure (Brandt-Andrews manoeuvre).
- Pharmacologic options per WHO-style guidance: intravenous oxytocin 10 units is preferred with controlled cord traction; misoprostol 400 micrograms sublingual (or oral) is the alternative uterotonic; intraumbilical oxytocin (10-30 units in 20-30 mL saline) is a described but less favoured route.
- Manual removal: under regional or intravenous anaesthesia (ketamine where anaesthesia is limited), full asepsis, the hand shaped like a cone entering along the cord, finding the cleavage plane, and peeling the placenta off in slices with the other hand guarding the uterus abdominally — performed by 60 minutes at the latest in a bleeding woman.
- Antibiotics: a single dose of a first-generation cephalosporin or equivalent prophylaxis before manual removal (ampicillin 2 g intravenous is a common Indian choice), per WHO recommendation.
- Never forget: examine the placenta for completeness and cotyledons every single time; a retained cotyledon or succenturiate lobe presents as late postpartum haemorrhage.
- If the plane is absent: suspect accreta — stop, ligate or compress, transfer; traction on an accreta placenta avulses vessels.
From third stage to theatre
A woman delivers at a community health centre; the placenta has not delivered at 20 minutes though the cord has lengthened slightly. The clock and checklist run together: bladder catheterised, baby to breast, oxytocin 10 units intravenously, controlled cord traction with counter-traction — no delivery, no gush, uterus softening. At 30 minutes the diagnosis is made. In theatre, spinal anaesthesia if stable, the hand goes in: the plane is present but narrow, the placenta peels with a characteristic "scrunch," and inspection shows one torn vessel on the membranes — a succenturiate lobe, found and removed on re-exploration. Oxytocin infusion continues, ampicillin 2 g given, and she is observed with vital signs and pad counts.
The dangerous variant: the hand meets no plane at all, the placenta adhering like a sheet over a previous caesarean scar. That is accreta until proved otherwise — stop digging, start oxytocin, call for help, transfer for definitive care. The other trap is a closed cervix trapping an already-separated placenta: gentle digital dilatation or sublingual nitroglycerin (200 micrograms, where available) relaxes the ring and the placenta delivers with light traction.
How the exam frames it
Three question shapes dominate: the timing question (30 minutes; 60 for manual-removal deadlines), the drug question (oxytocin 10 units intravenous preferred, misoprostol 400 micrograms sublingual the programme-friendly alternative), and the "next step" ladder — catheterise, breastfeed, uterotonic, controlled cord traction, manual removal; never "immediate manual removal" first. Mechanism-matching also appears: a trapped separated placenta needs ring relaxation; adherent accreta needs restraint and surgery. The completeness examination — succenturiate lobe as a cause of secondary postpartum haemorrhage — is the cross-topic link examiners enjoy.
Frequently asked questions
How long after birth is a placenta considered retained?
Thirty minutes in most teaching and FMGE keys; separation signs absent at that point, or non-delivery by 60 minutes, mandates intervention.
What is the drug of choice for a retained separated placenta?
Intravenous oxytocin 10 units with controlled cord traction; misoprostol 400 micrograms sublingual is the alternative where oxytocin is unavailable, per WHO-aligned guidance.
When is manual removal of the placenta indicated?
When the placenta remains undelivered despite uterotonics and controlled cord traction — typically by 60 minutes or earlier if bleeding — performed under anaesthesia with antibiotic prophylaxis.
What does an absent cleavage plane during manual removal suggest?
Placenta accreta spectrum; the correct response is to stop the procedure, manage haemorrhage expectantly with uterotonics, and arrange definitive care at a higher centre.
How does a succenturiate lobe cause late postpartum haemorrhage?
The accessory lobe retained inside the uterus prevents normal involution and erodes the implantation site, producing secondary haemorrhage days to weeks later — detected by inspecting vessels at the membrane edge.