Retained placenta how long

Postpartum diarrhea after a C-section is normal. Sharing our experiences of pregnancy and infant loss can help us heal. Vitamin D has numerous health benefits, but it's tricky to know which supplement to choose. Here are 13 of the best vitamin D supplements, according…. Health Conditions Discover Plan Connect. Labor occurs in three stages: The first stage is when you begin to experience the contractions that cause changes in your cervix to prepare for delivery. The second stage is when your baby is delivered.

The third stage is when you deliver the placenta, the organ responsible for nourishing your baby during pregnancy. What Are the Types of Retained Placenta? There are three types of retained placenta: Placenta Adherens Placenta adherens is the most common type of retained placenta. Placenta Accreta Placenta accreta causes the placenta to attach to the muscular layer of the uterine wall rather than the uterine lining.

Symptoms of a retained placenta the day after delivery can include: a fever a foul-smelling discharge from the vagina that contains large pieces of tissue heavy bleeding that persists severe pain that persists. Who Is at Risk for a Retained Placenta? Factors that can increase your risk of a retained placenta include: being over age 30 giving birth before the 34th week of pregnancy, or having a premature delivery having a prolonged first or second stage of labor having a stillborn baby.

How Is a Retained Placenta Diagnosed? How Is a Retained Placenta Treated? It can include the following methods: Your doctor may be able to remove the placenta by hand, but this carries an increased risk of an infection.

They may also use medications either to relax the uterus or to make it contract. This can help your body get rid of the placenta. In some cases, breast-feeding can also be effective because it causes your body to release hormones that make your uterus contract.

You doctor may also encourage you to urinate. A full bladder can sometimes prevent the delivery of the placenta. Although retained placenta is an obstetrical complication encountered relatively infrequently on the labor and delivery floor, recognizing patient risk factors and understanding management are important steps in mitigating this morbidity. Normal placentation begins with blastocyst implantation into the maternal endometrium. In preparation for this implantation, the endometrium develops the decidua under the influence of progesterone and estrogen in early pregnancy.

As the blastocyst invades this decidua, the layer of cells forming the surface of the blastocyst develops into the chorionic membrane. Cytotrophoblast cells proliferate from the chorionic membrane and form multinucleated aggregates called syncytiotrophoblast cells. These cells form the placental villi, allowing fetal—maternal interchange between the villi—decidual interaction.

With delivery of the infant, both a hormonal cascade and uterine contractions allow for separation of these layers and expulsion of the placenta. Retained placenta is generally attributed to one of three pathophysiologies. First, an atonic uterus with poor contraction may prevent normal separation and contractile expulsion of the placenta.

Finally, a separated placenta may be trapped or incarcerated due to closure of the cervix prior to delivery of the placenta. Estimates of retained placenta put the incidence at between 0. Many studies have attempted to define risk factors for retained placenta, which are listed in Table 1. Established risk factors include prior retained placenta, preterm delivery, prior uterine surgery, previous pregnancy termination, miscarriage or curettage, grand multiparity greater than five prior deliveries , and congenital uterine anomalies often unrecognized prior to delivery.

Some studies have suggested that prolonged oxytocin use could be a potentially modifiable risk factor for retained placenta, with one study reporting that oxytocin use for over mins increased the odds ratio of the retained placenta by 2.

Placental under perfusion disorders have been implicated as risk factors for retained placenta. Some research suggests that women may be predisposed to retained placenta. Retained placenta in a prior delivery appears to be an important risk factor for recurrence. Retained placenta requiring invasive procedures is associated with obstetrical morbidities.

Of arguably greatest significance is the risk of postpartum hemorrhage, with retained placenta the second leading cause of significant and even fatal hemorrhage in the obstetric population. Further research additionally suggests that the longer the third stage of labor, the greater the risk of postpartum hemorrhage. The authors found that both manual removal of the placenta and PPH decreased with increasing gestational age, and that the two were related.

However, causal association could not be determined. If the placenta or pieces of the placenta remain in situ following attempt at manual removal, a patient may require surgical management. These can include delayed postpartum hemorrhage or endomyometritis. Evidence of infection risk, particularly endometritis, following manual or surgical removal of retained placenta has been inconsistently demonstrated.

Retained placenta is clinically diagnosed when the placenta fails to spontaneously separate during the third stage of labor, with or without active management, or in the setting of severe bleeding in the absence of placental delivery. Selection of a clinical time definition can be based either on a population curve of observed spontaneous placental delivery times or on a time at which morbidity significantly increases.

Thirty minutes have been used as a loose guideline, which comes from a study by Combs et al. This timing has been supported by other studies as well. Because PPH incidence did not increase until after 30 minutes, Combs et al recommended this timing for initiation of manual removal of the placenta. However, this guidance is not uniformly supported. In a subsequent study by Deneux-Tharaux, surveys from 14 European countries exhibited wide variations in wait time prior to manual placental removal, largely by country but also by the hospital.

Practices also varied considerably depending on whether or not the patient in question had prior epidural anesthesia. For instance, the National Institute for Health and Clinical Excellence suggests a wait time of 30 minutes in the United Kingdom prior to manual removal of the placenta, 24 while the World Health Organization guidelines propose a wait time of 60 minutes.

The most significant risk of waiting a prolonged amount of time before removing the placenta is postpartum hemorrhage. In , Magann and colleagues undertook a prospective observational study in which all women delivering vaginally were assessed for PPH. At times the bulk of the placenta will deliver spontaneously or manually, but small portions or an accessory lobe may be retained.

This may be suspected when the placenta appears fragmented after delivery or when there is ongoing heavy uterine bleeding. In this situation, the uterine cavity may be evaluated with manual exploration or with ultrasound. The utility of ultrasound in this situation has yet to be established, with a focal endometrial mass, particularly with Doppler flow, being the findings of interest.

After delivery of the infant and prior to diagnosis of retained placenta, active management is recommended to facilitate spontaneous placental separation, including oxytocin, controlled cord traction, and uterine massage.

Once diagnosed, the placenta is usually manually extracted from the uterus. Because this procedure is painful, adequate analgesia should be achieved via epidural, conscious sedation, or general anesthesia prior to an attempt at extraction.

Once the patient is comfortable, she should be appropriately positioned in lithotomy. The operator should make every attempt to wear gown and gloves and maintain sterility, both for personal and for patient protection.

The provider should then use one hand to follow the umbilical cord through the vagina and cervix until the placenta is palpated. If the placenta is separated but not expelled, such as in the case of uterine atony, the tissue can be firmly grasped and brought through the cervix. Uterotonic medications, such as oxytocin, methylergonovine, carboprost, or other prostaglandins, should be given to facilitate contraction once the placenta is removed.

Nitroglycerine NTG has been used to facilitate manual extraction by relaxing uterine smooth muscle. The medication can produce hypotension and tachycardia, which can confound assessments of maternal stability. Once the placenta is delivered, uterotonics should be promptly given to restore uterine tone and avoid significant atony. If the placenta remains attached to the uterine decidua, an attempt should be made to separate it manually. Using one hand to provide counter pressure on the fundus through the maternal abdomen, the provider should then use the internal hand to manually create a cleavage plane between the placenta with the attached decidua and the myometrium.

Once separated, the placenta can be removed as described above. If a separation plane cannot be created behind all or part of the placenta, the provider should suspect a morbidly adherent placenta MAP and prepare for potential hemorrhage. If placental removal is refractory or only partially successful ie the placenta or parts of the placenta remain in the uterus , or if bleeding persists despite placental delivery, often the next step is surgical management with curettage.

This may be best achieved in an operating room, with optimal access to surgical equipment, analgesia, and patient resuscitation aids, if needed. Suction curettage is generally used, though a sharp curette may be needed to facilitate a separation plane. Access to uterine tamponade supplies with either a large intrauterine balloon or surgical packs should be immediately accessed in the event of hemorrhage.

Crossmatched blood products should be made imminently available if placental separation is difficult or blood loss exceeds 1 L, and the care team should attend to uterotonic administration and attention to coagulopathy as the extraction is performed. Due to the risk of endometritis, routine antibiotics are generally administered just before or shortly after manual removal of the placenta. Patients who are febrile at the time of extraction should be fully treated for chorioamnionitis with broad-spectrum antibiotics.

A systematic review by Chibueze and colleagues attempted to summarize the literature on the efficacy of antibiotics for preventing adverse maternal outcomes related to manual placenta removal following vaginal birth. None of the three studies found evidence to suggest beneficial effects for routine antibiotic use in women undergoing intervention for retained placenta.

The authors concluded that further research is required to adequately answer this question. Occasionally, a portion of placental tissue may remain in the uterus, either knowingly or unbeknownst to the providers. This can present as abnormal bleeding days to weeks after delivery and should be suspected in the setting of a delayed postpartum hemorrhage. In a series of case reports, Lee and colleagues reported a higher risk of complications with blind curettage compared to hysteroscopic morcellation.

The photo on the left A shows a retained portion of placenta approximately 8 weeks after delivery. You begin active management of the third stage of labor, administering oxytocin, performing uterine massage and applying controlled tension on the umbilical cord.

There is no evidence of excess postpartum bleeding. The most important component of active management of the third stage of labor is the administration of a uterotonic after delivery of the newborn. In the United States, oxytocin is the uterotonic most often utilized for the active management of the third stage of labor. Authors of a recent randomized clinical trial reported that intravenous oxytocin is superior to intramuscular oxytocin for reducing postpartum blood loss vs mL , the frequency of blood loss greater than 1, mL 4.

In addition to administering oxytocin, the active management of the third stage often involves maneuvers to accelerate placental delivery, including the Crede and Brandt-Andrews maneuvers and controlled tension on the umbilical cord.

The Crede maneuver, described in , involves placing a hand on the abdominal wall near the uterine fundus and squeezing the uterine fundus between the thumb and fingers. The Brandt-Andrews maneuver, described in , involves placing a clamp on the umbilical cord close to the vulva.

With judicious tension on the cord, the abdominal hand pushes the uterus upward toward the umbilicus.