Retained Placenta: Causes, Diagnosis & Treatment

The placenta is an organ which connects the developing foetus to the uterine wall of the mother. It provides oxygen and nutrients to the little one and removes waste products from the baby’s blood. The placenta is expelled from the body after the birth of the child. For most women, this expulsion happens on its own, but in some cases, this process may not happen automatically. This phenomenon is known as a retained placenta.

What is Retained Placenta?`

The delivery process is not complete with the birth of a child. The expulsion of the placenta is the final stage in the delivery process. Labour takes place in 3 steps:

• The first step begins when the contractions begin. This is the indication that the uterus is preparing to deliver your baby.
• The second step is complete when the baby is delivered.
• The third and the final stage of labour is when the placenta is expelled from the womb. This usually happens within 30 minutes of the baby’s birth.

As the name suggests, a retained placenta is a condition where the placenta is not expelled from the body naturally after the birth of the child. In such a scenario, the process must be manipulated in order to remove the postpartum retained placenta from the woman’s womb. If the body has not expelled the placenta within 30 minutes, it is considered as retained placenta because the body has kept the placenta instead of removing it.

If the retained placental tissue is not treated, the mother is susceptible to health hazards like infections and blood loss.

Types of Retained Placenta

Retained placenta can be of three types:

1. Placenta Adherens: Placenta adherens occurs when the uterus or the womb is unable to completely expel the placenta due to the poor intensity of the contractions. This leaves the placenta loosely attached to the wall of the uterus. Placenta adherens is the most common type of retained placenta.
2. Trapped Placenta: Trapped placenta takes place when the separation of the placenta is not followed by its evacuation from the body. This happens because the cervix acts as a barrier resulting in the placenta getting trapped behind it.
3. Placenta Accreta: Placenta accreta is the situation where the placenta attaches to the muscular layer of the womb instead of the lining of the uterine wall. Delivery becomes more complicated as a result of placenta accreta which may cause severe bleeding. Blood transfusions or even a hysterectomy may be required if the bleeding does not stop.

Causes

Following are the common reasons which can cause retained placenta:

• Uterine Antony: This occurs when the contractions in the uterus are not strong enough for the placenta to come out. This is the most common cause of retained placenta.
• Succenturiate Lobe: Succenturiate lobe is a blood vessel that connects a small chunk of the placenta to the main part. There are instances when the main part of the placenta has been expelled but the lobe remains along with a small part of the uterus.
• Placenta Accreta: This is a situation where the placenta becomes deeply embedded in the womb, possibly due to a scarring from previous caesarean section surgery. This can result in a retained placenta.
• Placenta Percreta: This is a situation when the placenta grows all the way through the womb wall causing retained placenta.
• Closed Cervix: Retained placenta can also be caused by the closing of the cervix before the placenta has been expelled from the uterus.

Signs and Symptoms

The placenta should be discharged completely within 30 minutes after the baby’s delivery. If the placenta fails to be completely removed from the womb within an hour after baby’s delivery, it is a clear sign of retained placenta.

A woman may also experience the following symptoms in case of retained placenta:

• An abhorrent odour emanating from the vagina
• Heavy bleeding
• Continuous pain and tummy cramps
• Discharge of large pieces of tissue from the placenta
• Fever
• Delay in production of milk

You should contact your doctor or midwife if you experience any of the symptoms for a prolonged period after the birth of your child.

Risk Factor for a Retained Placenta

There are certain risk factors which can increase the likelihood of a woman experiencing retained placenta. They are as follows:

• Conceiving a child over the age of 30
• Having a premature delivery or giving birth before the 34^thweek of gestation
• Going through an extremely long labour and delivery process
• Delivering a stillborn baby
• Previous case of retained placenta
• Uterine surgery performed previously

It is not necessary that women who are high on these risks will experience retained placenta, but if you have any of the above risk factors, you should inform your doctor about them in advance.

Diagnosis

A careful examination after delivery can help the midwife or the doctor identify if there is a case of retained placenta.

In some cases, there may be partial retention of the placenta. A careful examination of the expelled placenta can help the doctor identify such a case. If the doctor is unable to notice that a small part is missing from the placenta, the woman will soon display symptoms of retained placenta.

The doctor will perform an ultrasound to look at the uterus they suspect that you have a retained placenta. Immediate treatment will be required to avoid complications in case any part of the placenta is missing.

Complications of Retained Placenta

Durin a vaginal birth, the uterus prevents the blood vessels from bleeding excessively through contractions. A placental tissue that has remained will not allow proper contraction causing a haemorrhage.

How Can You Separate the Retained Placenta?

Exercises to stimulate the release of the oxytocin can be done by gently massaging the nipples. This should be done in the event of delayed labour. The hormone will cause contractions which will help to remove the placenta.

You can also try changing your position and turn upside down to expel the placenta.

The doctor can also give you medication to help with the extraction in the form of an injection of oxytocin. Following an injection, the doctor can manually assist in the removal of the placenta. In case the placental is still not expelled, a saline injection will be administered into the umbilical vein, followed by a second oxytocin injection.

Treatment

There are different methods by which the retained placenta can be removed.

• The doctor can remove the placenta by hand. Your bladder will be emptied by inserting a catheter and intravenous antibiotics will be given to prevent infection. Local anaesthesia will be administered to do this procedure.
• The doctor can use medication to make your uterus contract and remove the placenta.
• In case of placenta accreta, a curette is used to remove placental remains from the uterus through scrapping. This method is known as curettage.
• Another way of removing the retained placenta is through a hysterectomy. The disadvantage of this treatment is that you cannot carry pregnancies in the future.

Retained Placenta After C-Section

There is a chance that a woman might suffer from retained placenta if the previous birth was by a caesarean section surgery. Placenta Accreta is a situation where the placenta becomes deeply embedded in the womb, possibly due to a scar from a previous caesarean section surgery resulting in retained placenta.

Management During Labour

While preparing for delivery, doctors do everything possible to ensure complete delivery of placenta after the birth of the baby. The following steps can be taken during labour to minimise the chances of retained placenta:

• Administration of medication which encourages uterus to contract and release the placenta. Oxytocin is one such medication that can be used.
• Controlled cord traction (CCT) is a procedure where the doctor manually removes the umbilical cord enabling the placenta to be removed after delivery.
• The uterus can be stabilized by touching while applying CCT.

Some doctors may encourage you to gently run your hands over your abdomen in an attempt to reduce the haemorrhaging which would prevent the uterus from expanding.

Prevention

Here are a few precautions that can be taken in order to minimise the chances of retained placenta.

• Inform your doctor if you have experienced retained placenta previously or if you are exposed to any other risk which can result in this situation in advance so that they can take extra care during the third stage.
• Close proximity of the mother and the baby reduces the incidence of retained placenta
• Limiting usage of synthetic oxytocin has shown to reduce the incidence of caesarean sections. .

Removal of placenta is a critical part of the labour process and its complete expulsion is important for ensuring normal delivery without further complications. Special care should be taken to minimise the risk of having a retained placenta. The doctors should be well informed about any risks or past events which expose you to a greater risk of getting affected by this condition.

In case of retained placenta, it is important to get the necessary treatment done immediately and then follow your doctor’s instructions to recover from the implications of this condition.