From the Guidelines
In the event of a cord avulsion, manual removal of the placenta should not be carried out unless there is severe and uncontrolled hemorrhage, in which case the administration of tranexamic acid is recommended. When considering the management of a retained placenta after cord avulsion, it is crucial to prioritize the risk of post-partum hemorrhage and the potential difficulties in ensuring satisfactory analgesic and aseptic conditions, especially in settings outside specialized structures 1.
Given the potential risks, the approach to removing the placenta after a cord avulsion should be cautious. Key considerations include:
- Ensuring the administration of uterotonic medications to help contract the uterus, although the specific approach may vary based on the clinical context and availability of resources.
- The use of tranexamic acid in cases of severe hemorrhage, as suggested by recent guidelines 1.
- The importance of adequate analgesia or anesthesia before any intervention, to minimize discomfort and risk of complications.
- Monitoring for postpartum hemorrhage, which is a significant risk with cord avulsion, and being prepared for potential surgical interventions if necessary.
It's also important to consider the setting in which the cord avulsion occurs. In settings outside specialized structures, the technical difficulties and risks associated with manual removal of the placenta are heightened, supporting a more conservative approach unless absolutely necessary 1. Ultimately, the decision to proceed with manual removal of the placenta after a cord avulsion must be made with careful consideration of the potential risks and benefits, prioritizing the well-being and safety of the patient.
From the Research
Removing Placenta after Cord Avulsion
- The process of removing the placenta after a cord avulsion is crucial to prevent postpartum hemorrhage and other complications 2, 3, 4.
- Controlled cord traction (CCT) is a technique used to deliver the placenta, and its effectiveness in preventing postpartum hemorrhage has been studied 3, 4.
- According to a study published in the BMJ, CCT did not significantly reduce the incidence of postpartum hemorrhage, but it did reduce the need for manual removal of the placenta and decreased the duration of the third stage of labor 3.
- Another study published in The Cochrane database of systematic reviews found that CCT reduced the risk of manual removal of the placenta, blood loss, and duration of the third stage of labor, but did not significantly reduce the risk of postpartum hemorrhage 4.
- The use of uterotonic medications, such as oxytocin, methylergonovine, carboprost, and misoprostol, is also important in preventing and treating uterine atony, a common cause of postpartum hemorrhage 5, 6.
- A study published in the American journal of obstetrics & gynecology MFM found that combined therapy with oxytocin and other uterotonics was more effective in preventing postpartum hemorrhage than oxytocin alone 5.
Techniques for Removing Placenta
- Controlled cord traction (CCT) is a technique used to deliver the placenta, which involves gently pulling on the umbilical cord to help separate the placenta from the uterus 3, 4.
- Manual removal of the placenta is a procedure where the healthcare provider manually separates the placenta from the uterus, which may be necessary if CCT is not effective or if there are complications 3, 4.
- Uterine massage is another technique used to help control bleeding and promote uterine contractions after delivery, which can help prevent postpartum hemorrhage 4.
Prevention of Postpartum Hemorrhage
- The use of uterotonic medications, such as oxytocin, methylergonovine, carboprost, and misoprostol, is important in preventing and treating uterine atony, a common cause of postpartum hemorrhage 5, 6.
- Combined therapy with oxytocin and other uterotonics has been shown to be more effective in preventing postpartum hemorrhage than oxytocin alone 5.
- Delayed cord clamping and early skin-to-skin contact have also been shown to be beneficial in preventing postpartum hemorrhage and promoting maternal and neonatal health 2.