What is the most appropriate action for a delayed placental delivery (placenta not delivered) 30 minutes after birth?

Management of Retained Placenta at 30 Minutes Post-Delivery

The most appropriate intervention is C. Oxytocin, which should be administered immediately (10 IU intramuscularly or via slow IV infusion) to reduce maternal blood loss and facilitate placental delivery. 1, 2

Understanding Retained Placenta

A retained placenta is defined by the World Health Organization as failure of spontaneous placental delivery more than 30 minutes after fetal expulsion. 1 At exactly 30 minutes post-delivery, you are at the threshold where intervention becomes necessary to prevent postpartum hemorrhage, which increases significantly when placental delivery is delayed beyond this timepoint. 1

Immediate Management Algorithm

First-Line Intervention: Oxytocin

• Administer oxytocin 10 IU intramuscularly as the preferred first-line agent for managing the third stage of labor and preventing postpartum hemorrhage. 2
• Alternatively, use intravenous oxytocin infusion (20-40 IU in 1000 mL at 150 mL/hour) if IV access is already established. 2
• Oxytocin should ideally have been given immediately after delivery of the infant (after anterior shoulder delivery) as part of active management, but if not yet administered, give it now. 2, 3

Why Oxytocin Over the Other Options

• Oxytocin is the gold standard for prevention and management of postpartum hemorrhage with the best safety profile and efficacy. 2, 3
• Misoprostol (Option A) is considered a second-line alternative when oxytocin is unavailable, typically used in low-resource settings at doses of 600-800 mcg orally, sublingually, or rectally. 2
• Carboprost (Option B) is reserved for treatment of established postpartum hemorrhage that has not responded to oxytocin, not as first-line prophylaxis for retained placenta. 2

Concurrent Management Steps

Continue Expectant Management

• Allow for spontaneous placental expulsion without immediate manual intervention while the oxytocin takes effect. 1
• Monitor closely for bleeding - if blood loss approaches 500 mL, this constitutes postpartum hemorrhage requiring escalation. 1
• Do NOT perform manual removal at this stage unless severe hemorrhage develops, as manual removal increases infection risk and should be reserved for cases with significant bleeding. 1, 4

Controlled Cord Traction

• Proceed with controlled cord traction after administering oxytocin to facilitate placental delivery. 5, 3, 6
• This is a safe component of third stage management when combined with uterotonic administration. 6

Escalation for Hemorrhage

If significant bleeding develops (approaching 1 liter):

• Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset to reduce maternal morbidity and mortality. 1
• Proceed to manual removal of the placenta under adequate analgesia if hemorrhage is severe. 4
• Consider suction D&C in the operating room if manual removal is incomplete or bleeding continues. 1
• Implement massive transfusion protocol if blood loss exceeds 1 liter. 1

Critical Pitfalls to Avoid

• Do not rush to manual removal at exactly 30 minutes - give oxytocin first and allow time for it to work, as premature manual intervention increases infection risk without clear benefit. 1, 4
• Do not use carboprost as first-line - it is reserved for refractory uterine atony after oxytocin has failed. 2
• Do not delay oxytocin administration - it should have been given immediately after infant delivery, but if missed, administer now without further delay. 2, 3
• Monitor temperature and coagulation status - keep patient warm (>36°C) as clotting factors function poorly at lower temperatures. 1

Special Considerations

• If the placenta remains undelivered after oxytocin administration and 45 minutes total have elapsed, consider intraumbilical injection of oxytocin (10-30 IU) or misoprostol (800 mcg) as an alternative before proceeding to manual removal. 2
• Have emergency equipment readily available, including intrauterine balloon tamponade devices in case hemorrhage develops. 2
• Ensure blood type and antibody screen were sent on admission, and have blood products available if not already done. 4