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Chapter 5

Manual Removal of the Placenta

Valentin Stefan


Definition

Manoeuvre performed by inserting a hand through the vagina into the uterine cavity after
delivery, in order to separate the placenta from the uterine wall and extract it.

Indications

1. Active haemorrhage before the placenta is expelled, in excess of 500ml. It is important to
be aware of the widespread tendency to underestimate the blood loss at delivery, often by
as much as 50%
2. The placenta is not expelled after 30 minutes from the delivery of the fetus. Delays of over
30 minutes are associated with increased risk of post-partum haemorrhage

Technique

The removal of the placenta should be done under aseptic precautions and should be followed
by an inspection of the birth canal using retractors, under good lighting. These requirements,
combined with the need for adequate analgesia, are only satisfied in the operating theatre.

1. Analgesia. If the patient already has an epidural catheter, the analgesia may need to be
topped up. Otherwise, a spinal or general anaesthesia would be indicated
2. Attention to resuscitation. Should the patient bleed heavily, energic resuscitation measures
need to be instituted, while she is readied for theatre
3. Consent. Informed consent is required as for any intervention
4. Positioning the patient. The patient should be in lithotomy position
5. Scrubbing, dressing and draining the bladder. The skin of the perineum, thighs, buttocks and
lower abdomen are cleaned with antiseptics. The patient is draped in sterile surgical
towels. The surgeon is scrubbed, gowned and gloved. General precautions in the presence
of bodily fluids should be observed: together with the above protection attire, the surgeon
should wear goggles, a waterproof apron and waterproof theatre shoes/boots. To
facilitate the manoeuvre, the bladder should be emptied by Foley catheter. This would also
enable the monitoring of urinary output during resuscitation
6. The manoeuvre. The operator grasps and steadies the fundus of the uterus, through the
abdominal wall, with the non-dominant hand. For ease of insertion in the birth canal, the
fingers of the dominant hand are extended and their tips are brought together in the
shape of a cone (the accoucheurs hand). The hand is then inserted in the vagina, with the
tips of the fingers towards the sacrum. Once inside the vagina, the hand is turned in
supination to bring the fingers in the direction of the cervix. While the uterine fundus is
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held steady, the hand is inserted into the uterus and, by tearing through the membranes,
the operator would start to separate the placenta from the uterine wall. The placenta is
then completely freed by using the cubital margin of the palm like a wedge that opens the
cleavage space. During the manoeuvre, the fingers are kept together, parallel this time,
and the back of the palm is in constant contact with the uterine wall. When the organ is
completely free, it is grasped by the operating hand and pulled out through the cervix and
vagina. A manual control of the uterine cavity is then done, to evacuate possible remaining
cotyledons and membranes. This is followed by an inspection of the vagina and cervix with
right-angled retractors; any bleeding lacerations should be sutured

Accidents and incidents

1. Cervical retraction. Sometimes the cervix is spastic, forming a ring that prevents the
insertion of the hand in the uterus. This is usually transitory and in a minute or two will
disappear. If it persists for longer, any oxytocin drips should be stopped. As the half-life of
oxytocin in the blood is only 3 minutes, the uterus should relax soon afterwards.
Alternatively, the inhalatory anaesthetic rate could be increased, which results in uterine
relaxation
2. Placenta accreta. If no cleavage between the placenta and the decidua can be initiated,
consider the possibility of placenta accreta. Stop performing the manoeuvre as it may
produce intractable bleeding. Hysterectomy would be the usual solution in such cases.
NB. Sometimes, however, only a few cotyledons are adhering morbidly, and it is difficult to
remove them by hand. An instrumental evacuation of the adherent tissue with a large
blunt Bumm curette, together with continued utero-constrictive medication, will usually
control the bleeding

Postoperative care

If indicated, the resuscitation for post-partum bleeding should continue. Remember to check
the Rh status of the mother and baby, as the manual extraction might increase the likelihood of
iso-immunization. Administer anti-Rh immunoglobulins in case of Rh incompatibility. If the
manoeuvre was executed under aseptic circumstances, antibiotics are not necessary.