EDITORIAL Retained placenta after vaginal birth: How long should you wait to manually remove the placenta? For a woman with a neuraxial anesthetic, 20 minutes post–birth of the newborn may be the best time to diagnose retained placenta and consider manual removal Robert L. Barbieri, MD Editor in Chief, OBG MANAGEMENT Chair, Obstetrics and Gynecology Brigham and Women’s Hospital Boston, Massachusetts Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology Harvard Medical School ou have just safely delivered a uterotonic after delivery of the new- to the vulva.5 The clamp is used to the baby who is quietly rest- born. In the United States, oxytocin is apply judicious tension on the cord Y ing on her mother’s chest. the uterotonic most often utilized for with one hand, while the other hand You begin active management of the the active management of the third is placed on the mother’s abdomen third stage of labor, administering stage of labor. Authors of a recent with the palm and fingers overlying oxytocin, performing uterine mas- randomized clinical trial reported the junction between the uterine sage and applying controlled ten- that intravenous oxytocin is superior corpus and the lower segment. With sion on the umbilical cord. There is to intramuscular oxytocin for reduc- judicious tension on the cord, the no evidence of excess postpartum ing postpartum blood loss (385 vs abdominal hand pushes the uterus bleeding. 445 mL), the frequency of blood loss upward toward the umbilicus. Pla- How long will you wait to deliver greater than 1,000 mL (4.6% vs 8.1%), cental separation is indicated when the placenta? and the rate of maternal blood trans- lengthening of the umbilical cord fusion (1.5% vs 4.4%).2 occurs. The Brandt-Andrews maneu- In addition to administering ver may be associated with fewer Active management of the oxytocin, the active management cases of uterine inversion than the third stage of labor of the third stage often involves Crede maneuver.5-7 Most authorities recommend active maneuvers to accelerate placental Of note, umbilical cord traction management of the third stage of delivery, including the Crede and has not been demonstrated to reduce labor because active management Brandt-Andrews maneuvers and con- the need for blood transfusion or the reduces the risk of maternal hemor- trolled tension on the umbilical cord. incidence of postpartum hemorrhage rhage >1,000 mL (relative risk [RR], The Crede maneuver, described in (PPH) >1,000 mL, and it is commonly 0.34), postpartum hemoglobin lev- 1853, involves placing a hand on the utilized by obstetricians and mid- els < 9 g/dL (RR, 0.50), and maternal abdominal wall near the uterine fun- wives.8,9 Hence, in the third stage, the blood transfusion (RR, 0.35) com- dus and squeezing the uterine fundus delivering clinician should routinely pared with expectant management.1 between the thumb and fingers.3,4 administer a uterotonic, but use of The most important component The Brandt-Andrews maneuver, judicious tension on the cord can be of active management of the third described in 1933, involves placing deferred if the woman prefers a non- stage of labor is the administration of a clamp on the umbilical cord close interventional approach to delivery. CONTINUED ON PAGE 10 8 OBG Management | December 2019 | Vol. 31 No. 12 mdedge.com/obgyn EDITORIAL CONTINUED FROM PAGE 8 Beware of placenta accreta spectrum disorder, and be ready to recognize and treat uterine inversion The retained placenta may prevent the uterine muscle from some cases, the acchoucheur/midwife may recognize the effectively contracting around penetrating veins and arter- presence of a focal accreta and cease attempts to remove ies, thereby increasing the risk of postpartum hemorrhage. the placenta in order to organize the personnel and equip- The placenta that has separated from the uterine wall but is ment needed to effectively treat a potential case of placenta trapped inside the uterine cavity can be removed easily with accreta. In one study, when a placenta accreta was recog- manual extraction. If the placenta is physiologically adher- nized or suspected, immediately ceasing attempts at manu- ent to the uterine wall, a gentle sweeping motion with an ally removing the placenta resulted in better case outcomes intrauterine hand usually can separate the placenta from the than continued attempts to remove the placenta.1 uterus in preparation for manual extraction. However, if a pla- Uterine inversion may occur during an attempt to manu- centa accreta spectrum disorder is contributing to a retained ally remove the placenta. There is universal agreement that placenta, it may be difficult to separate the densely adherent once a uterine inversion is recognized it is critically important portion of the uterus from the uterine wall. In the presence to immediately restore normal uterine anatomy to avoid mas- of placenta accreta spectrum disorder, vigorous attempts to sive hemorrhage and maternal shock. The initial manage- remove the placenta may precipitate massive bleeding. In ment of uterine inversion includes: A B FIGURE 1 Use of the finger tips to guide the uterine wall back to normal anatomy. Following a vaginal birth of the newborn and delivery of authorities recommend that, in term birth, when should the the placenta. In one study the rate of pregnancy, the diagnosis of retained diagnosis of retained blood loss >500 mL was 8.5% when placenta should be made at 20 min- placenta be made? the placenta delivered between 5 utes following birth and consider- The historic definition of retained and 9 minutes and 35.1% when the ation should be given to removing placenta is nonexpulsion of the placenta delivered ≥30 minutes fol- the placenta at this time. For women placenta 30 minutes after delivery lowing birth of the baby.10 In another with effective neuraxial anesthe- of the newborn. However, many observational study, compared with sia, manual removal of the placenta observational studies report that, women delivering the placenta < 10 20 minutes following birth may be the when active management of the minutes after birth, women deliver- best decision for balancing the ben- third stage is utilized, 90%, 95%, and ing the placenta ≥30 minutes after efit of preventing PPH with the risk of 99% of placentas deliver by 9 min- birth had a 3-fold increased risk of unnecessary intervention. For women utes, 13 minutes, and 28 minutes, PPH.11 Similar findings have been with no anesthesia, delaying manual respectively.10 In addition, many reported in other studies.12-14 removal of the placenta to 30 minutes observational studies report that the Based on the association between or more following birth may permit incidence of PPH increases signifi- a delay in delivery of the placenta more time for the placenta to deliver cantly with longer intervals between and an increased risk of PPH, some prior to performing an intervention FOR OBG MAMAGEMENT MARCIA HARTSOCK ILLUSTRATIONS: 10 OBG Management | December 2019 | Vol. 31 No. 12 mdedge.com/obgyn • stopping oxytocin infusion procedure involves using clamps to apply symmetrical • initiating high volume fluid resuscitation tension to the left and right round ligaments and/or uter- • considering a dose of a uterine relaxant, such as nitro- ine serosa to sequentially tease the uterus back to normal glycerin or terbutaline anatomy.2,3 The Haultain procedure involves a vertical inci- • preparing for blood product replacement. sion on the posterior wall of the uterus to release the uterine In my experience, when uterine inversion is immediately constriction ring that is preventing the return of the uterine recognized and successfully treated, blood product replace- fundus to its normal position (FIGURE 3).4,5 ment is not usually necessary. However, if uterine inversion has not been immediately recognized or treated, massive References hemorrhage and shock may occur. 1. Kayem G, Anselem O, Schmitz T, et al. Conservative versus radical manage- Two approaches to the vaginal restoration of uterine ment in cases of placenta accreta: a historical study. J Gynecol Obstet Biol anatomy involve using the tips of the fingers and palm of the Reprod (Paris). 2007;36:680-687. 2. Huntington JL. Acute inversion of the uterus. Boston Med Surg J. 1921;184:376- hand to guide the wall of the uterus back to its normal posi- 378. tion (FIGURE 1) or to forcefully use a fist to force the uterine 3. Huntington JL, Irving FC, Kellogg FS. Abdominal reposition in acute inversion of the puerperal uterus. Am J Obstet Gynecol. 1928;15:34-40. wall back to its normal position (FIGURE 2). If these maneu- 4. Haultain FW. Abdominal hysterotomy for chronic uterine inversion: a record of vers are unsuccessful, a laparotomy may be necessary. 3 cases. Proc Roy Soc Med. 1908;1:528-535. At laparotomy, the Huntington or Haultain procedures 5. Easterday CL, Reid DE. Inversion of the puerperal uterus managed by the Haul- may help restore normal uterine anatomy. The Huntington tain technique; A case report. Am J Obstet Gynecol. 1959;78:1224-1226. FIGURE 2 Use of the fist to force the uterine wall back FIGURE 3 The Haultain procedure for correction of inversion of to its normal position. the uterus. that might cause pain, but the delay ine-placental interface with a gentle 4. use the forceps to grasp the pla- increases the risk of PPH. sweeping motion. The placental mass centa and pull it toward the vagina is grasped and gently teased through 5. stop frequently to re-grasp placen- the cervix and vagina. Inspection tal tissue that is deeper in the uter- Manual extraction of the placenta to ensure complete ine cavity of the placenta removal is necessary. 6.