Initial Management of Retained Placenta
For retained placenta, administer intraumbilical oxytocin (30-100 IU in 30 mL saline) as first-line medical management, which reduces the need for manual removal by approximately 20-30%, and reserve manual removal for cases that fail to respond within 30 minutes or when severe hemorrhage is present. 1, 2, 3
Timing and Definition
- Retained placenta is defined as failure of spontaneous placental delivery occurring more than 30 minutes after fetal expulsion 1
- Manual removal should be performed at 30-60 minutes postpartum if medical management fails 1
- Outside specialized structures, manual removal should NOT be routinely performed to reduce postpartum hemorrhage risk, except in cases of severe and uncontrollable bleeding 4
Medical Management Algorithm
First-Line: Intraumbilical Oxytocin
- Administer 30-100 IU oxytocin diluted in 30 mL saline via umbilical vein injection 1, 2, 3
- This reduces manual removal rates from 67.7% to 30% (p < 0.05) 2
- Placental delivery typically occurs within 3-18 minutes if successful 2, 5
- Significantly reduces uterine atony incidence (3.3% vs 25.8%, p < 0.05) and need for additional uterotonics (33.3% vs 64.5%, p < 0.05) 2
Alternative Uterotonic Options
- Intravenous carbetocin shows comparable efficacy (71.3% success rate) with shortest time to placental delivery (16.61 ± 3.76 minutes) and requires less additional uterotonics 6
- Sublingual misoprostol has similar success rates (63.7%) but longer time to delivery (23.00 ± 3.38 minutes) 6
- Intraumbilical prostaglandin shows promise (RR 0.05 for manual removal, 95% CI: 0.00-0.73) but limited evidence 3
For Trapped Placenta Specifically
- Glyceryl trinitrate 500 mcg sublingually may facilitate cervical relaxation and placental delivery 1
- Gentle, persistent, controlled cord traction can be attempted 1
Systemic Oxytocin Administration
- Administer 5-10 IU oxytocin via slow IV or intramuscular injection immediately postpartum as part of active management of third stage 7, 8
- For postpartum bleeding control: 10-40 units oxytocin added to 1,000 mL non-hydrating diluent, infused at rate necessary to control atony 8
- Avoid oxytocin in cases of cephalopelvic disproportion 7, 8
Manual Removal Indications
Proceed to manual removal when:
- Medical management fails after 30 minutes 1
- Severe, uncontrollable postpartum hemorrhage is present 4
- Patient is hemodynamically unstable 4
Anesthetic Considerations for Manual Removal
- If functioning epidural catheter is in place and patient is hemodynamically stable, epidural anesthesia is preferred 4
- In cases of major maternal hemorrhage, general anesthesia with endotracheal tube is preferable to neuraxial anesthesia 4
- Assess hemodynamic status before administering neuraxial anesthesia 4
- Consider aspiration prophylaxis 4
Uterine Relaxation Techniques
- Nitroglycerin (incremental IV or sublingual metered-dose spray) is effective for uterine relaxation during manual removal 4
- Nitroglycerin serves as alternative to terbutaline or halogenated general anesthetics 4
- Minimizes complications such as hypotension when given incrementally 4
Postpartum Hemorrhage Management
If hemorrhage develops:
- Administer 1 g tranexamic acid IV within 1-3 hours of bleeding onset to reduce maternal morbidity and mortality 4
- Uterine massage and additional uterotonics as needed 4
- Active management with uterotonics enhances uterine contraction and promotes placental separation 7
Critical Pitfalls to Avoid
- Do not use bimanual compression as primary treatment for retained placenta—this technique is for uterine atony, not placental retention 4
- Avoid ergometrine in women with respiratory conditions (causes bronchospasm) 7
- Avoid prostaglandin F2α in asthmatic patients (causes bronchoconstriction) 7
- Do not delay manual removal beyond 60 minutes in appropriate clinical settings 1
- Careful titration of uterotonics is essential to avoid uterine hyperstimulation 7