WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document
MANAGEMENT OF RETAINED PLACENTA
This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance.
INTRODUCTION
This guideline should be used in conjunction with WAHT-OBS-030 (MD13) Management of Post Partum Haemorrhage. Retained placenta is diagnosed when the woman is unable to deliver the placenta by 30 minutes following active management of third stage and by one hour after physiological third stage of labour. Retained Placenta complicates 1-2% of all deliveries and this incidence is much higher in preterm deliveries. In many cases retained placenta is associated with postpartum haemorrhage and can result in significant maternal morbidity and mortality.
THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS : Midwives and Obstetricians
Lead Clinician(s) Lakshmi Consultant Obstetrician
Extended version approved by representatives of the 24 June 2010 Obstetric Guidelines Group on: This version approved at Obstetric Governance 20th February 2015 Committee on: This guideline should not be used after end of: 20th February 2017
Key amendments to this guideline Date Amendment By: 24 June 2010 Extended for a further period without amendment. Miss R Imtiaz 29.07.2012 Reminder that persistent steady blood loss can result Miss R Duckett in an underestimate of a significant PPH January 2015 Reviewed by microbiologist dept agreed to keep Dr Dyas antibiotic cover
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document MANAGEMENT OF RETAINED PLACENTA
INTRODUCTION Retained placenta is diagnosed when the woman is unable to deliver the placenta by 30 minutes following active management of third stage and by one hour after physiological third stage of labour. Retained Placenta complicates 1-2% of all deliveries and this incidence is much higher in preterm deliveries. In many cases retained placenta is associated with postpartum haemorrhage and can result in significant maternal morbidity and mortality. The use of prophylactic oxytocics reduces the length of the third stage compared to physiological management, but there is no difference in the number who requires manual removal. There is a greater incidence of retained placenta when ergometrine is used compared to oxytocin 5 or 10 units alone.
Types of Retained Placenta 1. Trapped placenta - is when the placenta is detached/ separated but merely trapped behind a closed cervix. 2. Adherent Placenta - is when the placenta is adherent to the uterine wall (associated with previous caesarean section, uterine surgery). Patients with prolonged third stage may have different clinical reasons for retained placenta and therefore may require different management.
MANAGEMENT OF RETAINED PLACENTA The most important factor to determine management plan is presence or absence of active bleeding.
In the presence of active bleeding Insert 16G IV cannula and obtain bloods for FBC and Group & save. Monitor and record Pulse and Blood pressure Inform Obstetric Registrar Inform on-call anaesthetist Insert urinary Foley’s catheter Commence and continue oxytocin infusion 40 u/l 250mls/hour Perform vaginal examination to ascertain whether the placenta is already separate in which case it can be removed. Record blood loss and request cross match blood if clinically indicated. (Remember that persistent steady blood loss can result in an underestimate of a significant PPH). Urgently prepare and transfer patient to theatre for manual removal of placenta (MRP)
NB: There is no evidence that repeated bolus doses of oxytocics before placental delivery, assist in the delivery of adherent placenta. Repeated doses of uterotonics may result in contraction of uterine cervix resulting in difficult manual removal.
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document Home Delivery: If the placenta is retained after a home delivery, the woman should be transferred to hospital for further management and manual removal. If there is associated active bleeding usual protocol for PPH after home birth should be followed. Misoprostol 800microgram can be inserted PR while awaiting transfer to the hospital. Misoprostol is effective in the treatment of postpartum haemorrhage, but its uterotonic effect is slower in onset than the oxytocin (probably 30 to 60 minutes) and therefore it is likely to prevent later uterine relaxation than have much effect on the acute loss. It is especially useful in cases where oxytocin infusion is difficult to commence due to poor venous access. Misoprostol can cause pyrexia, nausea and vomiting and it is contraindicated in asthmatic and cardiac patients.
Manual Removal of Placenta ( MRP) MRP should be performed by an experienced obstetrician. It should be performed in theatre under regional / general anaesthetic. Place gloved hand into uterus under aseptic technique with other hand on fundus to control it.
Follow umbilical cord until you find lower edge of placenta.
Gently push the hand between the placenta and the body of the uterus and ease placenta away with a sawing action (N.B. in cases of placenta accreta the placenta will not detach easily and use of excess force can result in life-threatening haemorrhage which may require hysterectomy) If part/ total of the placenta is morbidly adherent and cannot be separated leave it insitu and inform the obstetric consultant on-call who should attend and manage accordingly (See PPH guidelines WAHT-OBS-030).
When fully detached, explore the uterine cavity for damage and other pieces of placenta or membranes.
Massage fundus with one hand whilst extracting placenta and membranes with hand in uterine cavity.
Examine the placenta to be sure that it is complete.
Inject oxytocin 5 units IV and continue oxytocin infusion (as mentioned above).
Give single dose IV antibiotics – 1.2g co-amoxiclav unless otherwise indicated. If patient penicillin allergic give cefuroxime 1.5g IV and metronidazole 500mg IV. If patient known to be severely penicillin allergic i.e. anaphylaxis discuss with consultant microbiologist. Debrief the patient.
Complications of Manual Removal of Placenta o PPH (See guideline WAHT-OBS-030) o Infection/ puerperal sepsis (Maintain aseptic technique for MRP and give antibiotics.) o Perforation of uterus (experienced obstetrician to perform MRP and explore the uterine cavity at the end of procedure.) o Inverted uterus ( See guideline WAHT-OBS-026)
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document In the absence of active bleeding Try breast feeding, nipple stimulation, emptying bladder and change of position – encourage upright position. Check pulse and blood pressure half hourly Do not leave unattended Regularly check for PV loss and any signs of placental separation Catheterise the bladder if not emptied recently Insert 16G IV cannula and obtain bloods for FBC and Group & save as risk of PPH. Inform Obstetric Registrar If experienced in ultrasound scanning on-call obstetrician may perform USS to distinguish between a trapped placenta and an adherent placenta. Trapped Placenta can be treated by obtaining acute uterine relaxation - giving the woman glycerol trinitrate (GTN) - two 400mg puffs sublingually or a single dose of Terbutaline 250 microgram subcutaneously. Followed by delivery of the placenta by controlled cord traction NB: Beware of hypotension and PPH and administer prophylactic oxytocin infusion 40 u/l 250mls/hour afterwards. Adherent Placenta. Effective treatment of adherent placenta is based on stimulating contractions of underlying myometrium, to induce separation of placenta. This may be achieved by injection of 30iu oxytocin in 20 ml normal saline down the umbilical cord by the Pipingas method (see below) Followed by delivery of the placenta by controlled cord traction If this is unsuccessful then manual removal (MRP) should be carried out in theatre with adequate analgesia and antibiotic cover as explained above.
NB: The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta
(Remember that persistent steady blood loss can result in an underestimate of a significant PPH).
The Pipingas Technique
Recut the cord to achieve a clean end Pass a size 10g nasogastric tube along the umbilical vein until resistance is felt Withdraw to the tube by 5cm to allow for any divisions of the vein prior to its insertion in the placenta Dilute 30 iu oxytocin in 20 ml of normal saline and inject directly down the nasogastric tube in the umbilical vein and then wait 5 minutes prior to trying controlled cord traction. The placenta can then be delivered by controlled cord traction
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document MONITORING TOOL
How will monitoring be carried out? Clinical Audit Who will monitor compliance with the guideline? Obstetric Governance Committee
STANDARDS % CLINICAL EXCEPTIONS All placentas should be delivered by 3 hours 100% Patient choice
REFERENCES Weeks A. (2005) The Retained Placenta in Progress in Obstetrics and Gynaecology 16, Chapter 9. Edited By John Studd. Churchill Livingstone. London Am J Obstet Gynecol. 2001 Oct;185(4):873-7 Jackson KW Jr et al High Risk Pregnancy. Management Options. Post partum Hemorrahge and other problems of third stage. Rogers MS et al. Managing Obstetric Emergencies and Trauma: The MOET Course Manual Second Edition, Grady K, Howell C, Cox C. RCOG, 2007.
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document MANAGEMENT OF RETAINED PLACENTA
Placenta not delivered in > 60 min if Physiological 3rd stage > 30 min if Active management
NO ACTIVE BLEEDING PV ACTIVE BLEEDING PV
. Encourage upright position. . Follow Guideline for obstetric haemorrhage. . Try breast feeding, nipple stimulation. . Inform Obstetric Registrar
. Do not leave unattended . Resuscitation + cross match . Empty bladder . Most likely will require transfer to theatre for EUA & MRP. Inform . Regularly check for Pulse, BP , PV loss and any signs of placental on-call anaesthetist separation
. Inform Obstetric Registrar
Oxytocin IVI not necessary. Incr eases risk of trapped placenta. Commence IVI oxytocin infusion 40 u/litre @ 250mls/hour
Check why retained. USS / Clinical signs
TRAPPED (Separated but ADHERENT Consider - Pipingas method retained) Intraumblical injection :30iu oxytocin in 20 ml Try Acute Uterine relaxation normal saline via 10G nasogastric tube along (Terbutaline 0.25mg s/c) . the umbilical vein (Not possible if cord snaps). May require transfer to theatre Wait 30 minutes then try CCT. for EUA & MRP. Inform on-call May require transfer to theatre for EUA & anaesthetist MRP. Inform on-call anaesthetist
Perform vaginal examination to ascertain whether the placenta is already separate in which case it can be removed manually in the delivery room otherwise transfer to theatre.
MANUALLY REMOVE PLACENTA (MRP) Examine the placenta to be sure that it is complete.
BEWARE OF PPH Commence/ continue oxytocin infusion (as mentioned above). Give single dose IV antibiotic.
Debrief the patient
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document
CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Miss R Imtiaz Consultant Obstetrician Circulated to the following individuals for comments Name Designation Mrs A Blackwell Consultant Obstetrician/Gynaecologist Miss R Duckett Consultant Obstetrician/Gynaecologist Mrs S Ghosh Consultant Obstetrician/Gynaecologist Mr J Labib Consultant Obstetrician/Gynaecologist Miss J Meggy Consultant Obstetrician/Gynaecologist Mr P A Moran Consultant Obstetrician/Gynaecologist Mr M D Pickrell Consultant Obstetrician/Gynaecologist Mr B A Ruparelia Consultant Obstetrician/Gynaecologist Mrs J Shahid Consultant Obstetrician/Gynaecologist Miss D Sinha Consultant Obstetrician/Gynaecologist Mr A Thomson Consultant Obstetrician/Gynaecologist Mr J Uhiara Consultant Obstetrician/Gynaecologist Mr J F Watts Clinical Director/Consultant Obstetrician-Gynaecologist R Fletcher Clinical Pharmacist E Newell Head of Midwifery/Supervisor of Midwives K Kokoska Clinical Risk Co-ordinator C Poyzer Matron/Supervisor of Midwives J Byrne Matron/Supervisor of Midwives M Stewart Matron/Supervisor of Midwives J Lucas Matron/Supervisor of Midwives Members of Guideline Group (For consultation with their peers) J A Barratt Clinical Midwife Specialist (Chair) T Cooper Consultant Midwife/Supervisor of Midwives M Chong Matron, WRH/Supervisor of Midwives Y Cowling Community Midwife, West Team/Supervisor of Midwives C Crompton Team Leaders, Ward 15, Alexandra Hospital D Daly Community Midwife, Droitwich Team E Davis Midwife, Transitional Care Unit, WRH J S Farmer Midwife, Antenatal Clinic, WRH G Field/K Perkes Community Midwife Team Leader, Bromsgrove Team M Gough Midwife, Lavender Postnatal, WRH L Heywood Community Midwife, Evesham Team D Hughes Midwife, Lavender Postnatal, WRH B Kavanagh Community Midwife Team Leader, Redditch Team J Martin Midwife, Central Delivery Suite, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital S Tabberer Community Midwife, Kidderminster/Supervisor of Midwives A Tilley Community Midwife Team Leader, Worcester Team V Tristram Midwife, Kidderminster Hospital/Supervisor of Midwives R Williams Midwife, Delivery Suite/PN Ward, WRH Circulated to the chair of the following committee’s / groups for comments Name Committee / group Alison Smith Medicines Safety Committee
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document Supporting Document 1 - Equality Impact Assessment Tool
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WAHT-OBS-091 It is the responsibility of every individual to check that this is the latest version/copy of this document.
Supporting Document 2 – Financial Impact Assessment
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