Dangerous bleeding
Due to retained placenta
Giving birth is a miracle of nature, and is loaded with many uncertainties which can develop at any stage of the process One- such problem is the retained placenta which may occur in the third stage of labor when the placenta and membranes are supposed to be delivered.
Nature of the third stage of labor
This stage involves one actively delivering the placenta and its membranes by actively pushing it out. It usually takes 10 to 20 minutes but may take up to an hour by natural effort. This process can, however, can be speeded up by giving an injection (syntocinon) in the thighs. This helps the uterus to contract, separate the placenta, assist in placental delivery and reduce the risk of heavy bleeding. This treatment shortens placental delivery to within five to 10 minutes.
Retained placenta means
All or part of the placenta or membranes are left behind in the womb during its delivery. The delivery of the tissues takes longer than usual. They should normally be completely delivered within one hour of baby birth by natural third stage process or 30 minutes if by managed third stage.
How does retained placenta happen?
• Uterine atony – The uterus stops contracting or doesn‘t contract enough to aid the placenta to separate.
• Trapped placenta – The placenta is separated but trapped behind the cervix This usually occurs when the umbilical cord is cut or snaps off or when the cervix closes too early before the placenta is delivered.
• Placenta accrete – An area of the placenta remains attached because it is deeply embedded in the uterine wall.
• Succenturiate placenta – A small piece of the placenta connected to the main part of the placenta with blood vessels is left inside the uterus
• Part of the placenta adheres to the fibroids or scars (e.g of previous Caesarean section) within the uterine cavity.
• Full bladder – This alone may cause placental retention.
Associated problems
•The uterus is not well contracted. Blood vessels in the uterus are therefore not well closed and the mother continues to bleed.
• Delivery of the placenta after more than 30 minutes when the baby has been born increases the risk of excessive bleeding (a condition known as post partum hemorrhage – PPH). If this type of bleeding occurs within 24 hours it is called primary PPH.
. Small retained pieces of placental tissue may not be detected immediately This may cause heavy bleeding after 34 hour (secondary PPH). Such an occurrence may even take place six weeks after delivery.
• Infection is also a known complication of retained placenta After removal, the mother should be put on antibiotics.
Treatment of retained placenta
• Breastfeeding and nipple rubbing causes the uterus to contract. This helps the placenta to separate and therefore to be expelled.
• Changing to more upright position from a sitting or lying position helps the placenta to separate due to force of gravity.
• Injection of oxytocin and controlled core traction prevent retention of the placenta. This is active management in placental delivery.
• Manual removal of the placenta under anaesthesia can be done in theatre. Bladder must be emptied first before this is done After the procedure, drugs are given to maintain uterine contraction.
• Emptying the bladder. This alone can effectively assist in the removal of the placenta.
• In case of prolonged heavy bleeding, pelvic ultrasound scan can be done to study the uterine cavity. If there are any retained parts, evacuation can be done in hospital followed by giving antibiotics.
Prevention
Once placenta is retained, there are high chances of it happening again. Retained placenta is more common in premature births. This should therefore be closely evaluated after such delivery.
Due to the cord snapping or the cervix closing up too quickly managed third stage/natural third stage may be offered in the next delivery.
END: PG38/50