Retained Placenta : LGH Protocol 2.

33-10WACS
SDMS ID: P2010/0503-001 Description: Management of delay in third stage of labour Audience: Midwifery and Medical Staff, Queen Victoria Maternity Unit Approved By: Directors WACS Custodian: Directors WACS Northern Area Health Service, Launceston General Hospital Version: Effective Date: 2010-01-30 Review Date: 2013-01-30 Replaces : Retained Placenta : LGH Protocol 2.33-06WACS Policies Supported:

P2010/0496-001 Management of Postpartum Haemorrhage P2010/0484-001 Care of Normal (Low Risk) Women in Labour

Purpose:

Retained placenta is a potentially life-threatening condition because of the associated risk of haemorrhage, shock and infection as well as the complications related to manual removal of placenta.

Definition:

The definition of a retained placenta is made according to the type of management used for the third state of labour: o Active management of third stage of labour: the placenta is not delivered within 30 minutes of birth of the infant o Physiological management of third stage of labour: the placenta is not delivered within 60 minutes of the birth of the infant

Causes/Predisposing Factors

Morbid adherence of the placenta o Placenta acreta o Placenta increta o Placenta percreata Uterine abnormality Constriction ring Umbilical cord accident/snapped cord Second trimester induction of labour Intrauterine infection Prematurity Full bladder

Management

Monitor blood loss if bleeding excessive and signs of circulatory collapse call obstetric code and refer to Management of Postpartum Haemorrhage Clinical Guideline WACSClinProc2.9 If the placenta remains undelivered after 30 minutes (following active management of third stage of labour) Consider: o Emptying the bladder o Breastfeeding or nipple stimulation o Change of position - encourage an upright position o Placenta cord drainage Inform obstetric registrar/consultant and RMO V access with large bore cannula Blood for FBC and group & hold Inserted indwelling urinary catheter (if not already inserted) Prepare for transfer to theatre for manual removal of placenta. Commence IV oxytocin (Syntocinon) 40u in 1000ml Normal Saline at 250ml/hr. Manual removal of the placenta should be undertaken under appropriate general or regional anaesthetic.

Antibiotics

In addition to any antibiotics administered for Group B Streptococcus chemoprophylaxis Amoxycillin 1g IV and Metronidazole 500mg IV are recommended 30 minutes preoperatively or intraoperatively. For women with allergy to penicillin an appropriate alternative should be given.

Complications of Retained Placenta

Shock Postpartum haemorrhage Puerperal sepsis Subinvolution Hysterectomy

Complications of MROP

Perforation of the uterus Retained products Infection Uterine inversion

Attachments: 1 2 Clinical notes References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit

Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years Stakeholders: Midwives and medical staff WACS Developed By : Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Dr A Dennis Co-Director (Medical) Date: January, 2010 Sue McBeath Co-Director (Nursing & Midwifery)

APPENDIX 1 Placental cord drainage Placental cord drainage involves clamping and cutting the umbilical cord after the birth of the baby but immediately afterwards, unclamping the maternal side of the cord and allowing the blood to drain freely. This may be in conjunction with other interventions such as routine administration of oxytocic, controlled cord traction or maternal effort. There are appears to be some potential benefit form the use of placental cord drainage in terms of reducing the length of third stage. In one clinical trial the incidence of retained placenta at 30 minutes was reduced (Soltani H, Dickinson R & Symonds I, 2005). Antibiotics No randomised controlled trials that have determined whether prophylactic antibiotics reduce the incidence of endometritis. The World Health Organisation has recently suggested a single dose of ampicillin 2g IV and metronidazole 500mg IV for manual removal of placenta. The bases for this recommendation are that the antibiotics recommended cover aerobic and anaerobic flora commonly seen in the genital tract; they are widely available, are inexpensive and safe; and are used only at the time of procedure to reduce the bacterial load during the procedure in line with the principles of antibiotic prophylaxis for surgery (Chongsomchai C, Lumbiganon P & Laopaiboon M, 2006). Umbilical vein injection for management of retained placenta Umbilical vein injection of saline solution plus oxytocin appears to be effective in the management of retained placenta. Further research into umbilical vein injection is recommended before this practise is introduced (Carroli G & Bergel E, 2001). APPENDIX 2 REFERENCES

Carroli G, Bergel E. Umbilical vein injection for management of retained placenta. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.; CD001337. DOI: 10.1002/14651858.CD001337. Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001337/frame.html Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.:CD004904.DOI: 10.1002/14651858.CD004904.pub2. Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004904/frame.html King Edward Memorial Hospital Clinical Guidelines 2008 Care of the Woman with a Retained Placenta, Online: http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/alpha/index.htm#r (Click R and open document, choose Retained Placenta document) Royal Women's Hospital Clinical Practice Guidelines 2006 Management of Retained Placenta. Online: http://www.thewomens.org.au/RetainedPlacentaManagementof Soltani H, Dickinson R, Symonds I. Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour. Cochrane Database of Systemic Reviews 2005, Issue 4. Art. No.: CD004665. DOI: 10.1002/14651858.CD004665.pub2. Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004665/frame.html