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DOI: 10.1111/j.1471-0528.2008.01996.

x
www.blackwellpublishing.com/bjog
Short communication

Policies for manual removal of placenta at vaginal


delivery: variations in timing within Europe
C Deneux-Tharaux,a A Macfarlane,b C Winter,c W-H Zhang,d S Alexander,d
M-H Bouvier-Colle,a the EUPHRATES Group*
a INSERM, UMR S149, IFR 69, UPMC, Epidemiological Research Unit on Perinatal Health and Women’s health, Hopital Tenon, Paris, France
b Department of Midwifery, City University, London, UK c School of Nursing and Midwifery, University of Dundee, Dundee, UK d Perinatal
Epidemiology Research Unit, Université Libre de Bruxelles, Brussels, Belgium
Correspondence: Dr C Deneux-Tharaux, INSERM U149 Batiment de recherche, Hopital Tenon 4 rue de la chine, 75020 Paris, France.
Email cdeneux.u149@chusa.jussieu.fr

Accepted 22 September 2008.

The length of the third stage of labour is a potential modifiable risk divergent policies were identified. A randomised controlled trial is
factor for postpartum haemorrhage at vaginal delivery, but there is needed to provide definitive evidence on the risks and benefits of
no definitive evidence that early intervention to remove the placenta manual removal of placenta at different timings after vaginal delivery.
manually will prevent postpartum haemorrhage. We report a wide
variation between countries in Europe in policies about the timing of Keywords Manual removal of placenta, prevention policies, post-
manual removal of placenta. Two groups of countries with clearly partum haemorrhage, third stage of labour.

Please cite this paper as: Deneux-Tharaux C, Macfarlane A, Winter C, Zhang W, Alexander S, Bouvier-Colle M, the EUPHRATES Group. Policies for manual
removal of placenta at vaginal delivery: variations in timing within Europe. BJOG 2009;116:119–124.

health indicators may be associated with variations in prac-


Introduction
tice. From this perspective, international comparisons can
Postpartum haemorrhage remains a major cause of maternal provide valuable information and generate new hypotheses
mortality and morbidity in both low- and high-income coun- by identifying areas where policies or practices vary.
tries. In this group, and in particular in Europe, disparities In the area of prevention of postpartum haemorrhage,
between countries in maternal mortality and morbidity a number of randomised controlled trials have concluded that
attributed to postpartum haemorrhage have been reported.1,2 active management of the third stage of labour decreases the
Individual risk factors have been described, but they poorly risk of postpartum haemorrhage, although there are differ-
predict the occurrence of postpartum haemorrhage.3,4 Inter- ences in the definition of active management and the individ-
est has focused on risk factors related to care provided as they ual components have not all been tested separately.5–7 Despite
are potentially amenable to change, with the hypothesis that this, it is now commonly recommended for prevention of
variations in postpartum haemorrhage-related maternal postpartum haemorrhage.8,9
Conversely, the evidence about manual removal of placentas
that have not delivered spontaneously is less convincing. A
*EUPHRATES (European Project on Obstetric Haemorrhage, Reduction, number of observational studies on vaginal deliveries have
Attitudes, Trial and Early Warning System) collaborators: Sophie Alexander
shown an association between the length of the third stage of
(Project leader, Belgium), Diogo Ayres-de-Campos (Portugal), Istvan Berbik
labour and the incidence of postpartum haemorrhage.8–12
(Hungary), Marie-Hélène Bouvier-Colle (France), Gérard Bréart (France),
These associations do not necessarily imply causality, and it
Peter Brocklehurst (UK), Vicencx Cararach (Spain), Mario Chiechi (Italy),
Catherine Deneux-Tharaux (France), Risto Erkkola (Finland), Mathias Klein
is not known whether retained placenta is a cause of postpar-
(Austria), Jens Langhoff-Roos (Denmark), Alison Macfarlane (UK), Walter tum haemorrhage or whether it is only a marker of an impaired
Prendiville (Ireland), Jos van Roosmalen (Nederlands), Babill Stray-Pedersen uterine contractility that will itself increase the risk of postpar-
(Norway), Carolyn Troeger (Switzerland), Clare Winter (United Kingdom) tum haemorrhage, or both. In addition, manual removal of
and Wei-Hong Zhang (Belgium). placenta per se may increase the risk of postpartum haemorrhage

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 119
Deneux-Tharaux et al.

compared with spontaneous placental delivery,10 and this poten- included. A postal questionnaire was sent to each unit in
tial risk has to be balanced against the equally hypothetical risk of 2003, addressed to the midwife or obstetrician with overall
a prolonged third stage of labour. In consequence, there seems to management responsibility. The number of questionnaires
be no definitive evidence as to how long clinicians should wait sent out ranged from 29 in Denmark to 719 in Italy. Table 1
before manual removal of the placenta in cases where the woman shows the exact number of questionnaires sent in each coun-
is not bleeding. try. Respondents were asked whether they undertook specific
In this context, the purposes of this study were to compare procedures usually, sometimes, rarely or never.
policies about manual removal of placenta at vaginal delivery in The main results of the EUPHRATES survey about policies
maternity units of different European countries and to com- on the management of the third stage of labour have already
pare these policies with the available evidence. These analyses been published elsewhere.13 This article describes the replies
were designed to complement those in an earlier article about to three questions about policies for manual removal of the
policies for management of the third stage of labour and the placenta at vaginal delivery in the absence of abnormal bleed-
immediate management of postpartum haemorrhage.11 ing. The questionnaire first asked whether the unit had a pol-
icy on how long to wait before undertaking manual removal
of the placenta at vaginal delivery in the absence of abnormal
Methods
bleeding. If the answer was yes, two further questions were
This article is based on data collected as part of the asked about policies about the length of time after delivery
EUPHRATES project (European Project on Obstetric Hae- when this would be performed in women who did and did not
morrhage, Reduction, Attitudes, Trial and Early Warning already have an epidural. Since analgesia/anaesthesia is
System), a European collaboration involving 14 countries: required to perform manual removal of placenta, the presence
Austria, Belgium, Denmark, Finland, France, Hungary, of an epidural may facilitate an early decision to manually
Ireland, Italy, the Netherlands, Norway, Portugal, Spain, remove the placenta. Maternity units may have had different
Switzerland and the UK. policies for manual removal of the placenta (MRP) depending
The overall focus of this project was on prevention and on whether the woman already had an epidural.
management of postpartum haemorrhage. One of its compo- The distributions of the answers to these questions for each
nents was a survey undertaken to describe current policies for country were described and compared. Associations between
management of the third stage of labour and the immediate these policies and policies about early administration of oxy-
management of postpartum haemorrhage in the maternity tocics were then examined at the unit level. For this analysis,
units of the 14 countries. The method has been fully described lengths of time before manual removal were subdivided into
elsewhere.11 The survey covered all maternity units in most 30 minutes and less and more than 30 minutes. Units that had
participating countries, except for Spain where it was under- a policy of usually administering oxytocics prophylactically at
taken in Catalonia, Portugal where only public units were the delivery of the anterior shoulder or immediately after
surveyed and France where a sample of six regions was birth were compared with those that did not.

Table 1. Samples and response rates

Country Maternity units Number of units Number of questionnaires Response


sampled surveyed received rate (%)

Austria All 104 33 31.7


Belgium All 129 105 81.4
Denmark All 29 23 79.3
Finland All 33 33 100.0
France Six regions 132 109 82.6
Hungary All 98 98 100.0
Ireland All 22 22 100.0
Italy All 719 215 29.9
The Netherlands All 99 91 91.9
Norway All 55 46 83.6
Portugal All public maternity units 52 37 71.2
Spain Catalonia 62 53 85.5
Switzerland All 130 68 52.3
UK All 354 242 68.4

120 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Policies for manual removal of placenta at vaginal delivery in Europe

The data were analysed using STATA version SE 9 for Most countries had a dominant policy, reported by a vast
Windows (Stata Corporation, College Station, TX, USA). majority of the units.
In the Netherlands, Denmark, Finland and Norway, more
than 80% of the units reported a policy of waiting 60 minutes
Results
or more after delivery before manually removing the placenta,
Table 1 shows the response rate for each country. Response in cases where the woman had an epidural. In Spain, Belgium,
rates varied from 30% in Italy and Austria to 100% in Fin- France, Hungary and Portugal, 70% or more of the units had
land, Hungary and Ireland, and were above 65% in 11 of 14 policies of waiting 30 minutes or less before manually remov-
countries. ing the placenta in cases where the woman had an epidural. In
this group of countries, the median recommended time for
Policy about manual removal of the placenta manual removal was 30 minutes, except for Spain where the
In all countries, the majority of units had a policy about how median recommended time was 20 minutes. In the remaining
long to wait before undertaking manual removal of the pla- countries, UK, Ireland, Switzerland, Austria and Italy, there
centa at vaginal delivery in the absence of abnormal bleeding. was much less sign of a national consensus.
This proportion varied from 63% of units in UK to 100% in Policies were not very different for women who already had
Denmark and Norway, and was greater than 87% in 10 of 14 epidural analgesia, although there was a tendency for the time
countries (Table 2). to be slightly longer for women without an epidural.

Length of time before manual removal Association with policy of early administration of
Policies for the timing of manual removal of the placenta uterotonics
varied widely between countries. The majority of respondents In units with a policy of early prophylactic administration of
and their policies showed marked digit preference, and uterotonics, 53% had a policy of waiting more than 30
answers were given in terms of round numbers of minutes. minutes before manual removal of the placenta, compared
The proportion of units with policies of waiting less than 30 with 37% of other units (x2 = 12.7, P < 0.001).
minutes, usually 20 minutes, if the woman had an epidural,
varied from none in Denmark, Finland and Norway, to 54%
Discussion
in Spain. The proportion of units with policies of waiting at
least 60 minutes varied from none in Spain and Portugal to This study shows that policies about manual removal of pla-
94% in the Netherlands (Table 2; Figure 1). centa at vaginal delivery varied widely between countries of

Table 2. Policies about timing of manual removal of the placenta at vaginal delivery, in the absence of abnormal bleeding

Country Total number Percentage having Length of wait, with epidural, Length of wait, without epidural,
of participating a policy in minutes (percentage of units in minutes (percentage of units
units that had a policy) which had a policy)

Less than 30 30 31–59 60 Less 30 30 31–59 60


and over and over

Austria 33 97.0 10.0 26.7 16.7 46.6 7.7 30.7 15.4 46.2
Belgium 105 87.6 33.7 36.0 10.5 19.8 17.4 33.7 19.8 29.1
Denmark 23 100.0 0.0 5.6 5.6 88.9 0.0 5.3 15.8 78.9
Finland 33 93.9 0.0 9.7 6.4 83.9 0.0 9.7 6.4 83.9
France 109 88.9 30.5 57.9 10.5 1.1 20.4 70.5 6.8 2.3
Hungary 98 88.8 30.7 61.3 4.8 3.2 31.5 64.4 2.7 1.4
Ireland 22 72.7 20.0 13.3 6.7 60.0 6.2 6.2 6.2 81.2
Italy 215 94.9 16.0 32.1 8.5 43.4 7.4 33.0 13.3 46.3
The Netherlands 91 96.7 1.2 3.6 1.2 94.0 1.2 1.2 2.3 95.3
Norway 46 100.0 0.0 12.5 0.0 87.5 0.0 9.1 0.0 90.9
Portugal 37 78.4 10.0 70.0 10.0 10.0 3.6 60.7 21.4 14.3
Spain 53 77.4 53.7 39.0 7.3 0.0 32.3 54.8 9.7 3.2
Switzerland 68 91.2 10.0 40.0 18.3 31.7 5.6 35.2 25.9 33.3
UK 242 63.1 5.8 30.6 7.4 56.2 3.1 27.6 8.7 60.6

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 121
Deneux-Tharaux et al.

The Netherlands

Denmark

Finland

Norway

Ireland

UK

Austria

Italy

Switzerland

Belgium

Portugal

France

Hungary

Spain

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of units
30 minutes and less 31–59 minutes 60 minutes and over

Figure 1. Distribution of units by policy of length of wait before manual removal of placenta at vaginal delivery with epidural.

Europe, but that there was consensus within many but not all a third stage labour longer than 30 minutes.7 A number of
countries. observational studies have found that longer third stages have
Two groups of countries with clearly contrasting policies been associated with a higher risk of postpartum haemor-
can be distinguished. In the Netherlands, Denmark, Finland rhage.12–15 One reported a higher incidence of postpartum
and Norway, a great majority of units had a policy of waiting haemorrhage with third stages longer than 30 minutes com-
60 minutes or more before manually removing the placenta. pared with 30 minutes or less but no significant association
On the other hand, in Spain, Belgium, France, Hungary and with the length of the third stage for durations shorter than 30
Portugal, the usual policy was to perform manual removal of minutes.12 In a population-based study from the Netherlands,
the placenta in the first 30 minutes after delivery. This diver- a third stage longer than 30 minutes was associated with a 2.6
gence in national policies illustrates how international com- times higher rate of postpartum haemorrhage, defined as an
parisons can highlight areas where differences in clinical estimated blood loss of 500 ml or more, and a 4.9 times higher
practice are a reflection of gaps in knowledge and ambiguities rate of severe postpartum haemorrhage, defined as an esti-
in the available evidence. mated blood loss of 1000 ml or more, after adjustment for
The spontaneous length of the third stage of labour after other risk factors compared with a third stage of 30 minutes
vaginal delivery has been described in four studies, mostly or less.14 A more recent study from a single centre where all
based on deliveries that occurred in the 1980s and 1990s.12–15 women were actively managed reported a significantly higher
These studies reported a median duration of between 5 and 7 rate of postpartum haemorrhage, which is defined as a mea-
minutes with between 3 and 8% of women having third stages sured blood loss greater than 1000 ml, for shorter durations of
longer than 30 minutes. This spontaneous length varies with third stage of labour.15 Third stages longer than 10 minutes
gestational age at delivery, preterm birth being associated with were associated with a two times higher rate of postpartum
longer third stages.12,13 Randomised trials of active manage- haemorrhage, and those that were longer than 20 minutes
ment of the third stage of labour have shown that it can with a four times higher rate, compared with rates for third
significantly shorten it.5,6 Shorter median durations of the stages of 10 minutes or less.
third stage, down to 4 minutes, have been reported in the We suggest that these findings have been interpreted dif-
most recent studies.16 These could be explained by an in- ferently by maternity units in Europe and that the definition
creased use of active management. of retained placenta varies among European countries.
It is unclear how these factors should be taken into account In some countries, it is likely that the reported association
in the definition of a retained placenta. According to the of an increased risk of postpartum haemorrhage with a longer
World Health Organization definition, retained placenta is third stage has led to a policy of manual extraction of

122 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
Policies for manual removal of placenta at vaginal delivery in Europe

placentas that have not been expelled within 30 minutes after birth were more likely to recommend a longer length of time
delivery. Such an association does not imply causality, how- before manual removal of the placenta. On the one hand, this
ever, and there is no evidence that artificial reduction of the may appear surprising as preventive uterotonics have been
length of third stage by manually removing placentas that shown to shorten the third stage of labour.19 On the other
have not been spontaneously expelled will reduce the risk of hand, this result may reflect differences in the strategies for
postpartum haemorrhage. Retained placenta may be the con- the prevention of postpartum haemorrhage at vaginal deliv-
sequence of an impaired uterine contractility that will also ery, with some units performing more invasive interventions
lead to postpartum haemorrhage. In this hypothesis, a long such as manual removal of the placenta, while others opt for
third stage would be more a risk marker than a cause of post- less invasive management such as uterotonics.
partum haemorrhage. These questions can only be answered
by performing a randomised controlled trial testing the Limitations
impact of manual removal of the placenta at different timings This survey was conducted in 2003. It is possible that mater-
after vaginal delivery. Such a trial should include a stratifica- nity units’ policies about manual removal of the placenta have
tion and a subgroup analysis by gestational age. It is likely that changed since then and that the results given here do not
the current lack of evidence for a beneficial effect of early reflect their current policies. Since no major new results have
manual removal of the placenta has led to the common policy been published on the topic in the meantime, such a change
of waiting 60 minutes or more in other countries. seems unlikely, however. In addition, this survey did not
It is possible that manual removal of the placenta may attempt to collect data about actual clinical practice.
actually increase the risk of postpartum haemorrhage. A sys- Although the EUPHRATES survey attempted to collect
tematic review of randomised controlled trials has shown data about outcomes in terms of postpartum haemorrhage
that, compared with spontaneous separation and controlled rates, the data were incomplete and were of poor quality. In
cord traction, manual removal of placenta at caesarean deliv- an attempt to see if incidence rates of postpartum haemor-
ery is associated with a clinically important and statistically rhage reflect differences in national policies, we looked at the
significant higher level of maternal blood loss.10 Although correlation between the proportion of units waiting 60
these results cannot be directly extrapolated to vaginal deliv- minutes or more before performing manual removal of the
ery, in particular because the actual timing of manual removal placenta from this survey and the incidence of severe
of placenta greatly differs between the two routes of delivery, postpartum haemorrhage reported in the MOMS-B study
they suggest that further research is needed to determine (MOthers’ Mortality and Morbidity Study) conducted in
whether manual removal of placenta is also associated with the late 1990s1 for the nine countries included in the two
a higher level of blood loss after vaginal delivery. studies. No significant association was found, but the number
Manual removal of the placenta may also increase the risk of countries was limited, and the geographical areas did not
of infection in the uterus. An increased incidence of endome- match exactly as many of the data in MOMS-B relate to
tritis after manual removal of placenta at caesarean delivery, regions rather than to whole countries.
as compared to cord traction, has been observed in a number
of randomised controlled trials.17 Conclusions
It is unclear whether this is true for vaginal delivery as
the evidence from observational studies is heterogeneous, The length of the third stage of labour constitutes a potential
however.18 In the current context of ambivalent evidence modifiable risk factor for postpartum haemorrhage at vaginal
about risks and benefits of manual removal of placenta at delivery, but evidence about the optimal lag time to manual
vaginal delivery, national policies appear to be in accordance removal of placenta is ambivalent. The marked differences
with other choices made for the management of delivery in observed between the 14 participating European countries
general. Northern European countries are more in favour of in policies about manual removal of placenta may reflect
a noninvasive approach, while obstetric intervention forms differences in the interpretation of this available evidence. A
a larger role in standard care in Central and Southern Europe. randomised controlled trial is needed to provide definitive
These contrasting policies may also result from practical con- evidence on the risks and benefits of manual removal of the
siderations that make it more or less easy to wait for placenta placenta at different timings after vaginal delivery.
separation. For example, there may be time constraints on the
Contribution to authorship
occupation of the delivery room or on midwifery time, or
C.D.-T. participated in the design of the survey and the question-
decisions may be influenced by the active presence of an naire, the implementation of the survey in her country, the analysis
obstetrician in the delivery room. of the data, undertook the drafting and revision of the paper and has
Interestingly, this survey showed that maternity units with seen and approved the final version of the article.
a policy of usually administering oxytocics prophylactically at A.M. participated in the design of the survey and the questionnaire,
the delivery of the anterior shoulder or immediately after the implementation of the survey in her country, undertook the

ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology 123
Deneux-Tharaux et al.

cleaning and analysis of the data, participated in the revision of the 6 Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D.
draft paper and has seen and approved the final version of the article. Active versus expectant management of third stage of labour: the
C.W. participated in the design of the survey and the questionnaire, the Hinchingbrooke randomised controlled trial. Lancet 1998;351:693–9.
7 Prendiville WJ, Elbourne D, McDonald S. Active versus expectant man-
implementation of the survey in her country, the cleaning and analysis
agement in the third stage of labour. Cochrane Database Syst Rev
of the data and the revision of the draft paper and has seen and
2000;CD000007.
approved the final version of the article. 8 International Confederation of Midwives, International Federation of
W.-H.Z. participated in the design of the survey and the question- Gynecologists and Obstetricians. Joint statement: management of the
naire, the implementation of the survey in her country and the revi- third stage of labour to prevent post-partum haemorrhage. J Mid-
sion of the draft paper and has seen and approved the final version of wifery Womens Health 2004;49:76–7.
the article. 9 World Health Organization. Managing Complications in Pregnancy
S.A. initiated the collaborative project; participated in the design of and Childbirth. Geneva, Switzerland: World Health Organization,
the survey and the questionnaire, the implementation of the survey 2000 [www.whoint/making_pregnancy_safer/publications/archived_
in her country and the revision of the draft paper and has seen and publications/mcpcpdf]. Accessed 30 June 2008.
10 Wilkinson C, Enkin MW. Manual removal of placenta at caesarean
approved the final version of the article.
section. Cochrane Database Syst Rev 2000;CD000130.
M.-H.B.-C. participated in the design of the survey and the ques-
11 Winter C, Macfarlane A, Deneux-Tharaux C, Zhang WH, Alexander S,
tionnaire, the implementation of the survey in her country and the Brocklehurst P, et al. Variations in policies for management of the third
revision of the draft paper, and has seen and approved the final stage of labour and the immediate management of postpartum hae-
version of the article. morrhage in Europe. BJOG 2007;114:845–54.
12 Combs CA, Laros RK Jr. Prolonged third stage of labor: morbidity and
risk factors. Obstet Gynecol 1991;77:863–7.
Funding 13 Dombrowski MP, Bottoms SF, Saleh AA, Hurd WW, Romero R. Third
The Euphrates project was funded by the European Union under stage of labor: analysis of duration and clinical practice. Am J Obstet
Framework 5, contract number QLG4-CT-2001-01352. j Gynecol 1995;172:1279–84.
14 Bais JM, Eskes M, Pel M, Bonsel GJ, Bleker OP. Postpartum haemor-
rhage in nulliparous women: incidence and risk factors in low and
high risk women. A Dutch population-based cohort study on standard
References
(> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage.
1 Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A. Incidence of Eur J Obstet Gynecol Reprod Biol 2004;115:166–72.
severe pre-eclampsia, postpartum haemorrhage and sepsis as a surro- 15 Magann EF, Evans S, Chauhan SP, Lanneau G, Fisk AD, Morrison JC.
gate marker for severe maternal morbidity in a European population- The length of the third stage of labor and the risk of postpartum
based study: the MOMS-B survey. BJOG 2005;112:89–96. hemorrhage. Obstet Gynecol 2005;105:290–3.
2 Salanave B, Bouvier-Colle MH, Varnoux N, Alexander S, Macfarlane A. 16 Magann EF, Doherty DA, Briery CM, Niederhauser A, Morrison JC.
Classification differences and maternal mortality: a European study. Timing of placental delivery to prevent post-partum haemorrhage:
MOMS Group. MOthers’ Mortality and Severe morbidity. Int J Epide- lessons learned from an abandoned randomised clinical trial. Aust N
miol 1999;28:64–9. Z J Obstet Gynaecol 2006;46:549–51.
3 Sherman SJ, Greenspoon JS, Nelson JM, Paul RH. Identifying the 17 Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the pla-
obstetric patient at high risk of multiple-unit blood transfusions. centa at caesarean section. Cochrane Database Syst Rev 2008;
J Reprod Med 1992;37:649–52. CD004737.
4 Mathai M, Gulmezoglu AM, Hill S. Saving womens lives: evidence- 18 Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic anti-
based recommendations for the prevention of postpartum haemor- biotics for manual removal of retained placenta in vaginal birth.
rhage. Bull World Health Organ 2007;85:322–3. Cochrane Database Syst Rev 2006;CD004904.
5 Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third 19 Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophy-
stage trial: active versus physiological management of third stage of lactic use of oxytocin in the third stage of labour. Cochrane Database
labour. BMJ 1988;297:1295–300. Syst Rev 2001;CD001808.

124 ª 2008 The Authors Journal compilation ª RCOG 2008 BJOG An International Journal of Obstetrics and Gynaecology
WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital

CLINICAL GUIDELINES
WOMEN AND NEWBORN HEALTH
OBSTETRICS SERVICE
AND MIDWIFERY
King Edward Memorial Hospital
INTRAPARTUM CARE

THIRD STAGE OF LABOUR MANAGEMENT

RETAINED PLACENTA
Keywords: retained placenta, manual removal of placenta, third stage of labour,
placenta not delivered

AIM

To guide the appropriate care of a woman experiencing a retained placenta

DEFINITION

The definition of a retained placenta is made according to the type of management


used for the third stage of labour:
Active management of the third stage of labour: the placenta is not delivered
within 30 minutes of birth of the infant.1
Expectant (physiological) management of the third stage of labour: the placenta
is not delivered within 60 minutes of the birth of the infant. 1

BACKGROUND INFORMATION

The incidence of retained placenta is approximately 2%. The risk for retained
placenta may increase if the uterus contains a fibroid, is bicornuate, or has a septum.
The placenta may also become retained if trapped in the cervix or lower uterine
segment, and if the woman has a full bladder. Morbid adherence of the placenta
includes placenta acreta, placenta increta and placenta percreta.2 An adherent
placenta is associated with absence of bleeding, and on examination the uterine
fundus remains broad and high, the contractions may be weak or absent, and there
is no lengthening of the umbilical cord.

KEY POINTS

1. In the presence of postpartum haemorrhage (PPH) the placenta must be


delivered at once.
2. Avoid vigorous cord traction to prevent the cord snapping or causing uterine
inversion.
3. A full bladder may inhibit delivery of the placenta.
4. There are currently no randomised controlled trials to evaluate the effectiveness
of prophylactic antibiotics to prevent endometritis prior to manual removal of the
placenta.3

B 5.10 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 1 of 3
PROCEDURE ADDITIONAL INFORMATION

1 Notify the Medical team of


suspected retained placenta
Notify the midwifery Co-ordinator if: A third stage of labour which exceeds
 The woman is bleeding or 10 minutes is associated with a
significant increased risk for PPH.4
 If the placenta has not delivered
50% of placental deliveries will occur
within 10 minutes of the birth of
within 5 minutes, and 90% deliver
the baby.
within 15 minutes from birth of the
 Notify the medical team if the infant.
placenta is not delivered at 20
minutes.
2 Bladder assessment
Perform bladder catheterisation A full bladder may interfere with the
descent and delivery of the placenta.2
3 Assess for placental separation
3.1 If the placenta is separated: Avoid vigorous cord traction as this
 Encourage maternal position may cause the cord to snap or
change uterine inversion.
 Encourage maternal effort to
deliver placenta
 A vaginal examination may An upright position may assist
determine if the placenta is maternal effort in placental delivery.
trapped in the cervix or lower
segment.
 Rub up the uterus to induce a
contraction
 Encourage breastfeeding or
nipple stimulation
When these methods are
unsuccessful an experienced
operator may apply fundal pressure
on the contracted uterus to push the
placenta from the lower segment or
vagina.
4 Management if placenta remains
retained.

B 5.10 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 2 of 3
PROCEDURE ADDITIONAL INFORMATION

 Establish intravenous access with A retained placenta increases the risk


a 16 gauge cannula and for PPH.
commence an intravenous
infusion of oxytocin 40IU in
Hartmann’s 500mL.
 Administer at a rate of 120mL/
hour
 Collect blood for full blood picture
and cross-matching.
 Commence the woman fasting
 Perform 5 minutely observations A significant amount of blood may be
of vital signs. lost within an expanding uterus and /
 Check the fundal height and or in the vagina and not be seen
uterine tone every 5 minutes externally.
4.1 Manual removal of the placenta in
theatre
Prepare the woman for manual Effective regional analgesia (or
removal of the placenta in theatre. general analgesia) is required for
manual removal of the placenta.
Note the time of placenta delivery in
theatre for documentation

REFERENCES (STANDARDS)
1. National Institute for Clinical Excellence. Intrapartum care. Care of healthy women and their babies during
childbirth. London; 2007.
2. Lindsay P. Complications of the Third Stage of Labour. In: Henderson C, MacDonald S, editors. Mayes' Midwifery A
textbook for Midwives. 13th ed. London: Bailliere Tindall; 2004. p. 987-1002.
3. Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic antibiotics for manual removal of retained placenta in
vaginal birth. The Cochrane Database of Systematic Reviews. 2011(7).
4. Magann EF, Doherty DA, Briery CM, et al. Timing of placental delivery to prevent post-partum haemorrhage: Lessons
learned from an abandoned randomised clinical trial. Australian and New Zealand Journal of Obstetrics and
Gynaecology. 2006;46:459-551.

National Standards – 1 Clinical Care is Guided by Current Best Practice


Legislation - Nil
Related Policies - Nil
Other related documents – Nil
RESPONSIBILITY
Policy Sponsor HoD Obstetrics
Initial Endorsement May 2008
Last Reviewed October 2014
Last Amended April 2016
Review date October 2017

B 5.10 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 3 of 3
BAB I

PENDAHULUAN

A. Latar belakang

Angka Kematian Ibu (AKI) di Indonesia berdasarkan data yang diperoleh dari

Profil Kesehatan RI (2015) mengalami penurunan. Tercatat tahun 2012 sebanyak

359 kasus menjadi 305 kasus di tahun 2A015. Lalu data dari Dinas kesehatan

Jawa Tengah (2015), menunjukan bahwa Angka Kematian Ibu (AKI) mengalami

penurunan tercatat mulai dari tahun 2012 sebanyak 675 kasus hingga tahun 2015

menjadi 437 kasus. Sedangkan Angka Kematian Ibu di Banyumas menurut data

dari Profil kesehatan Kab. Banyumas (2015;h.9), angka Kematian Ibu (AKI)

sebesar 101 per 100.000 kelahiran hidup. Terpusat lagi pada wilayah Puskesmas

1 Kembaran, berdasarkan data dari Dinas Kesehatan Kab. Banyumas (2016)

Angka Kematian Ibu (AKI) adalah 2 per 629 kelahiran hidup. Hal ini menjadi salah

satu permasalahan AKI yang ada diwilayah Puskesmas 1 Kembaran pada tahun

2016 (Dinas Kesehatan Kab. Banyumas, 2015).

Hasil Survei Penduduk Antar Sensus (SUPAS) 2015 dalam Profil Kesehatan

RI, (2015) menunjukkan AKB di Indonesia sebesar 22,23 per 1.000 kelahiran

hidup. Sedangkan Angka Kematian Bayi di Jawa Tengan berdasarkan data dari

Dinas Kesehatan Jawa Tengah, (2015) menyatakan bahwa terjadi penurunan

angka kematian bayi dari tahun 2012 ke tahun 2015 yaitu sebanyak 5865 kasus

kematian bayi menjadi 5571 kasus. Lalu berdasarkan data yang diperoleh dari

Dinas Kesehatan Kab. Banyumas, (2015) menyatakan bahwa Angka kematian

bayi (AKB) di Kab. Banyumas tahun 2015 sebesar 4 per 1.000 kelahiran hidup dan

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
2

Angka Kematian Bayi Di Puskesmas 1 Kembaran pada tahun 2015 tercatat

sebanyak 4 bayi.

Berdasarkan pada permasalahan tersebut pemerintah membentuk program

SDGs (Sustainable Development Goals) yang merupakan kelanjutan dari MDGs

(Millenium Development Goals) yang berakhir pada tahun 2015. Menurut

Kemenkes RI(2015), terdapat 17 Tujuan SDGs yang salah satu tujuannya adalah

Sistem Kesehatan Nasional yaitu pada Goals ke 3 menerangkan bahwa pada

2030 mengurangi angka kematian ibu hingga di bawah 70 per 100.000 kelahiran

hidup, mengakhiri kematian bayi dan balita yang dapat dicegah, mengurangi

sepertiga kematian prematur akibat penyakit tidak menular melalui pencegahan

dan perawatan, serta mendorong kesehatan dan kesejahteraan mental dan

menjamin akses semesta kepada pelayanan kesehatan seksual dan reproduksi,

termasuk keluarga berencana (KB), informasi dan edukasi, serta integrasi

kesehatan reproduksi ke dalam strategi dan program nasional (Kemenkes RI,

2015).

Upaya percepatan penurunan AKI dapat dilakukan dengan menjamin agar

setiap ibu mampu mengakses pelayanan kesehatan ibu yang berkualitas, seperti

pelayanan kesehatan ibu hamil, pertolongan persalinan oleh tenaga kesehatan

terlatih di fasilitas pelayanan kesehatan, perawatan pasca persalinan bagi ibu dan

bayi, perawatan khusus dan rujukan jika terjadi komplikasi, kemudahan

mendapatkan cuti hamil dan melahirkan, dan pelayanan keluarga berencana

(Kemenkes RI, 2016).

Upaya lain yang dilakukan untuk menurunkan kematian ibu dan kematian bayi

yaitu dengan mendorong agar setiap persalinan ditolong oleh tenaga kesehatan

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
3

terlatih yaitu dokter spesialis kebidanan dan kandungan (SpOG), dokter umum,

dan bidan, serta diupayakan dilakukan di fasilitas pelayanan kesehatan.

Pertolongan persalinan adalah proses pelayanan persalinan yang dimulai pada

kala I sampai dengan kala IV persalinan (Kemenkes RI,2016).

Persentase pertolongan persalinan oleh tenaga kesehatan di Indonesia

menunjukkan kecenderungan peningkatan dari tahun 2005 sampai dengan tahun

2015. Namun demikian, terdapat penurunan dari 90,88% pada tahun 2013

menjadi 88,55% pada tahun 2015. Kebijakan Kementerian Kesehatan dalam

dekade terakhir menekankan agar setiap persalinan ditolong oleh tenaga

kesehatan dalam rangka menurunkan kematian ibu dan kematian bayi. Namun

demikian, meskipun persalinan ditolong oleh tenaga kesehatan tetapi tidak

dilaksanakan di fasilitas pelayanan kesehatan, dianggap menjadi salah satu

penyebab masih tingginya Angka Kematian Ibu. Oleh karena itu mulai tahun 2015,

penekanan persalinan yang aman adalah persalinan ditolong tenaga kesehatan di

fasilitas pelayanan kesehatan (Kemenkes RI, 2016).

Dalam memecahkan masalah AKI dan AKB, Jateng mengadakan progam 5NG

yaitu Jateng Gayeng Nginceng Wong Meteng selamatkan ibu dan anak yang

memiliki 4 fase yaitu fase pra hamil, fase kehamilan, fase persalinan dan fase

nifas. Outcome yang diharapkan dari program tersebut adalah ibu hamil,

masyarakat semakin peduli atas kesehatan dan keselamatan ibu dan anak dengan

mengerti, menyadar faktor resiko dan faktor tak langsung lainnya, meningkatnya

derajat kesehatan masyarakat dengan ditekannya angka kematian ibu dan bayi,

meningkatnya peserta KB aktif dan pelayanan kesehatan publik menjadi lebih baik

dan meningkat (Dinas Kesehatan Jateng, 2015).

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
4

Dari banyaknya strategi yang dicanangkan, penulis tertarik untuk melakukan

asuhan komprehensif selama masa kehamilan hingga perencanaan Keluarga

Berencana untuk mengetahui permasalahan atau komplikasi yang mungkin terjadi

pada ibu hamil, bersalin, nifas, BBL dan keluarga berencana dalam rangka

mendukung program 5NG yaitu untuk upaya penurunan AKI dan AKB di Jawa

Tengah khususnya di wilayah Puskesmas 1 Kembaran Kab.Banyumas, karena

masih terdapat adanya kematian ibu dan bayi yang cukup menjadi permasalahan

diwilayah Kab. Banyumas.

Berdasarkan latar belakang yang sudah di jelaskan, maka penulis mengambil

judul Asuhan Kebidanan Komprehensif Kehamilan, Persalinan, Bayi Baru Lahir

(BBL), Nifas, dan Perencanaan Keluarga Berencana (KB) pada Ny.S G2P1A0 Umur

28 Tahun Umur Kehamilan 23 Minggu 3 Hari Didesa Kembaran Wilayah Kerja

Puskesmas 1 Kembaran Kabupaten Banyumas yang bertujuan untuk memantau

keadaan ibu mulai dari hamil sampai dengan perencanaan KB. Asuhan

komprehensif tersebut diharapkan dapat membantu mendeteksi dini

kegawatdaruratan maternal dan neonatal yang mengarah pada menurunnya

angka kematian ibu dan kematian bayi.

B. Tujuan

1. Tujuan umum

Mahasiswa mampu melakukan asuhan kebidanan komprehensif sesuai

Standar Asuhan Kebidanan dengan pendampingan bidan desa pada ibu

hamil, bersalin, bayi baru lahir, masa nifas dan perencanaan KB dengan

pendekatan manajemen kebidanan menurut 7 langkah Varney dan

pendokumentasian SOAP.

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
5

2. Tujuan khusus

a. Mampu melakukan asuhan kehamilan pada ibu hamil TM II, TM III, dan

melakukan pengkajian data Subjektif, data Objektif, melakukan penentuan

diagnosa, menyusun rencana asuhan dan melakukan evaluasi.

b. Mampu melakukan asuhan pada ibu bersalin dan melakukan pengkajian

data Subjektif, data Objektif, melakukan penentuan diagnosa, menyusun

rencana asuhan dan melakukan evaluasi.

c. Mampu melakukan asuhan pada bayi baru lahir dan melakukan

pengkajian data Subjektif, data Objektif, melakukan penentuan diagnosa,

menyusun rencana asuhan dan melakukan evaluasi.

d. Mampu melakukan asuhan pada ibu nifas dan melakukan pengkajian

data Subjektif, data Objektif, melakukan penentuan diagnosa, menyusun

rencana asuhan dan melakukan evaluasi.

e. Mampu melakukan asuhan pada ibu dengan perencanaan KB dan

melakukan pengkajian data Subjektif, data Objektif, melakukan penentuan

diagnosa, menyusun rencana asuhan dan melakukan evaluasi.

C. Ruang lingkup

1. Sasaran

Pengambilan studi kasus ini pada Ny. S dimulai dari kehamilan Trimester II,

Persalinan, Bayi Baru Lahir (BBL), nifas dan perencanaan keluarga

berencana.

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
6

2. Tempat

Pengambilan kasus ini dilaksanakan di Puskesmas I Kembaran dengan

melakukan pendampingan klien di Desa Kembaran dari masa kehamilan

hingga perencanaan Keluarga Berencana.

3. Waktu

Pengambilan kasus dimulai pada bulan Desember 2016 dan penyusunan

proposal ini dimulai dari bulan Januari 2017 sampai bulan Februari 2017

dilanjutkan dengan penyusunan KTI sampai bulan Juli 2017.

D. Pengumpulan data

1. Sumber data berasal dari berbagai sumber tergantung dari tujuan yang ingin

dicapai dan setiap sumber mempunyai keuntungan dan kerugian. Data yang

dikumpulkan dapat berupa data primer maupun sekunder. Data primer

merupakan data yang didapat dari individu atau perseorangan, seperti hasil

wawancara, pengisian kuisioner dan lain-lain. Selanjutnya yang disebut data

sekunder adalah data primer yang telah diolah lebih lanjut, misalnya dalam

bentuk tabel. Sumber data sekunder antara lain Dinas Kesehatan, Biro

Statistik, Puskesmas (Isna, 2011;h.31).

2. Pemeriksaan fisik

Menurut Mochtar (2011;h.39), Pemeriksaan yang dilakukan penulis dalam

mengumpulkan data melalui pemeriksaan fisik antara lain :

a. Inspeksi

Inspeksi dapat dibagi menjadi inspeksi umum dan inspeksi lokal. Pada

inspeksi umum pemeriksa melihat perubahan yang terjadi secara umum,

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
7

sehingga dapat diperoleh kesan dan keadaan umum pasien. Pada

inspeksi lokal, dilihat perubahan-perubahan lokal sampai sekecil-kecilnya.

b. Palpasi

Palpasi adalah pemeriksaan dengan meraba, menggunakan telapak

tangan dan jari tangan.

c. Perkusi

Pemeriksaan dengan mengetuk bagian tubuh yang diperiksa.

d. Auskultasi

Pemeriksaan dengan menggunakan stetoskop. Dengan cara auskultasi

dapat didengar suara pernafasan, bising jantung, peristaltik usus, dan

aliran darah dalam pembuluh darah.

E. Sistematika penulisan

1. BAB I : PENDAHULUAN

Bab ini berisi latar belakang masalah, perumusan masalah, tujuan

penulisan ruang lingkup, manfaat penulisan, metode memperoleh

data, dan sistematika penulisan.

2. BAB II : TINJAUAN TEORI

Bab ini berisi tentang tinjauan teori yang berisi tentang Asuhan

Kebidanan Komprehensif Pada Kehamilan, Persalinan, Nifas, Bayi

Baru Lahir dan KB.

3. BAB III : TINJAUAN KASUS

Berisi tentang manajemen asuhan kebidanan komprehensif pada

ibu hamil, bersalin, nifas, bayi baru lahir dan keluarga berencana

dengan pendekatan manajement kebidanan 7 langkah Varney dan

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
8

pendokumentasian menggunakan metode SOAP (Subjektif,

Objektif, Analisa dan Penatalaksanaan).

4. BAB IV : PEMBAHASAN

Berisi tentang menjelaskan tentang kesenjangan antara teori dan

kasus yang penulis temukan dilapangan tentang asuhan kebidanan

secara komprehensif ibu hamil, bersalin, nifas, bayi baru lahir dan

keluarga berencana.

5. BAB V : PENUTUP

Berisi tentang kesimpulan dan saran. Kesimpulan adalah jawaban

dari tujuan dan merupakan inti dari kegiatan pembahasan asuhan

kebidanan secara komprehensif ibu hamil, bersalin, nifas, bayi baru

lahir dan keluarga berencana. Sedangkan saran merupakan

alternatif pemecahan masalah dan tanggapan dari kesimpulan.

Asuhan Kebidanan Komprehensif..., Dian Meiliana Dewi, Fakultas Ilmu Kesehatan UMP, 2017
See discussions, stats, and author profiles for this publication at:
https://www.researchgate.net/publication/262194050

Manual Removal of the Placenta after Vaginal


Delivery: An Unsolved Problem in Obstetrics

Article in Journal of pregnancy · April 2014


DOI: 10.1155/2014/274651 · Source: PubMed

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Hindawi Publishing Corporation
Journal of Pregnancy
Volume 2014, Article ID 274651, 5 pages
http://dx.doi.org/10.1155/2014/274651

Review Article
Manual Removal of the Placenta after Vaginal Delivery:
An Unsolved Problem in Obstetrics

Fiona Urner, Roland Zimmermann, and Alexander Krafft


Division of Obstetrics, Department of Obstetrics and Gynecology, University Hospital Zurich, 8091 Zurich, Switzerland

Correspondence should be addressed to Alexander Krafft; alexander.krafft@usz.ch

Received 16 August 2013; Revised 12 January 2014; Accepted 30 January 2014; Published 9 April 2014

Academic Editor: Antonio Farina

Copyright © 2014 Fiona Urner et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The third stage of labor is associated with considerable maternal morbidity and mortality. The major complication is postpartum
hemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. Whereas in the event of PPH due
to atony of the uterus there exist numerous treatment guidelines; for the management of retained placenta the general consensus
is more difficult to establish. Active management of the third stage of labour is generally accepted as standard of care as already
its duration is contributing to the risk of PPH. Despite scant evidence it is commonly advised that if the placenta has not been
expelled 30 minutes after delivery, manual removal of the placenta should be carried out under anaesthesia. Pathologic adhesion
of the placenta in the low risk situation usually is diagnosed at the time of delivery; therefore a pre- or intrapartum screening
opportunity for placenta accreta would be desirable. But diagnosis of abnormalities of placentation other than placenta previa
remains a challenge. Nevertheless the use of ultrasound and doppler sonography might be helpful in the third stage of labor. An
improvement might be the implementation of standardized operating procedures for retained placenta which could contribute to
a reduction of maternal morbidity.

1. Introduction aim was to attract the obstetricians’ attention to the potential


risk of retained placenta in the low risk setting where it occurs
The third stage of labor is still associated with considerable without prior warning and to present a possible flowchart for
maternal morbidity and mortality. The major complication the timing of treatment to reduce blood loss and therefore
is postpartum hemorrhage (PPH), which affects about 5% maternal morbidity.
of deliveries [1, 2]. Therefore it is the leading cause of
maternal morbidity and mortality worldwide [3]. In western
countries, such as the United Kingdom, it is the fifth most 2. The Time Factor
common reason for maternal death after thromboembolism,
preeclampsia/eclampsia, genital tract sepsis, and amniotic In general it can be said that already the duration of the
fluid embolism. It has a mortality rate of 0.39 : 100,000 [4]. third stage of labour is contributing to the risk of PPH as
Some ten years ago, an editorial titled “The retained the risk of major bleeding is believed to increase with time
placenta—new insights into an old problem” was raising elapsed after birth. Hence, active management of third stage
hopes that this problem is to be solved soon [5]. Unfortu- of labour using prophylactic oxytocics is accepted as standard
nately, it is still not. of care. Active management of the third stage of labour
Whereas in the event of PPH due to atony of the uterus involves administration of intravenous oxytocin, early cord
there exist numerous guidelines, recommendations, and clamping, transabdominal manual massage of the uterus, and
flowcharts for its management; in the treatment of retained controlled traction of the umbilical cord. Should this appear
placenta the general consensus is more difficult to establish. insufficient, the next step is usually manual removal of the
Retained placenta is an important cause of PPH and has an placenta (MROP). However, the timing of this manoeuver
incidence of 1 : 100 to 1 : 300 births [6, 7]. With this paper our is difficult as the risk of PPH from leaving the placenta in
2 Journal of Pregnancy

situ has to be weighed against the knowledge that manual precautions, it is almost impossible for the clinician to detect
removal can itself cause hemorrhage. It should also be borne or even distinguish between placenta accreta and increta
in mind that the placenta may be delivered spontaneously despite numerous attempts to do so with several imaging
up to 30 minutes or more after delivery of the child, without techniques.
major additional blood loss. The management questions that
thus need answering are When and how to detect increased
blood loss? When to call in support staff? When to contact the 4. Risk Factors
anesthesiologist? Observation of routine practice shows that
Weeks observed a considerable variation in the retained pla-
MROP is regularly deferred beyond the limits recommended.
centa rate between countries [7]. In less developed countries
In the absence of immediate evidence of increased vaginal
it is less common (about 0.1% of all deliveries) but has a
bleeding, management is often conservative and expectant,
high fatality rate. In more developed countries it affects about
open to several different options, and paying little attention
3% of all vaginal deliveries but is very rarely associated with
to the time elapsed since birth.
maternal death. It is suggested that interventions common
In a study of over 12,000 births, Combs and Laros found
in the most developed countries such as abortions, uterine
that the risk of hemorrhage increased after 30 minutes of
intervention, labour induction, and use of oxytocin could be
placental retention [8]. Similarly, Magann et al. found that
contributing to the increase in retained placenta rate with
the risk of hemorrhage increased with time. In their study,
increasing development.
the risk of PPH was already significantly increased at 10
Commonly named risk factors for disturbances in pla-
minutes and, using a receiving operator characteristic (ROC)
cental disruption, such as placenta accreta, are history of
curve, they demonstrated that the optimal cut-off time for
retained placenta, previous caesarean section, maternal age
the prediction of PPH was 18 minutes, with a sensitivity
over 35 years, preterm labour, induced labour, multiparity,
of 31% and a specificity of 90% [9]. However, delaying the
previous uterine injury or surgery, uterine malformations,
manual removal will lead to the spontaneous delivery of many
infection, and preeclampsia [1, 3, 6–8, 14–18]. It is believed
placentas.
that placenta accreta is becoming more common due to the
Despite scant evidence it is commonly advised that if
rising caesarean section rate and advancing maternal age,
the placenta has not been expelled 30 minutes after delivery
both independent risk factors for placenta accreta [2, 17].
despite active management, MROP should be carried out
History of caesarean section and placenta previa are
under anaesthesia. Clearly, in the published recommenda-
often of special interest as risk factors for placenta accreta.
tions the choice of timing for manual removal depends on
In a prospective observational cohort study of over 30,000
the facilities available and the local risks associated with
women who had caesarean delivery without labour, placenta
both PPH and MROP. Thus the 2007 intrapartum guide-
accreta was present in 0.24% of women undergoing their
lines produced for the UK government agency the National
first up to 6.74% of women undergoing their sixth or more
Institute for Health and Clinical Excellence (NICE) suggest
caesarean delivery. In women with placenta previa the risk
30 minutes, [10] whereas the WHO manual for childbirth
for placenta accreta was 3%, 11%, 40%, 61%, and 67% for
suggests 60 minutes [11]. Accordingly, a survey in Europe
first, second, third, fourth, fifth, and sixth or more caesarean
showed that time until manual removal of placenta in the
deliveries. With every additional caesarean delivery the risk
absence of bleeding varies widely between different countries,
for emergency hysterectomy was rising as well. Hysterectomy
from under 30 minutes (Spain and Hungary) to 60 minutes
was required in 0.65% for their first caesarean delivery and
and more (The Netherlands) [12].
increased up to 8.99% for their sixth or more caesarean
delivery [19].
In another study the incidence of placenta accreta in case
3. Difficulties with Definition of placenta previa was 5%. With a previous caesarean section,
the incidence increased to 10% [1].
There are different reasons for retained placenta and there
is a wide variety in the nomenclature for disturbances in
placental disruption. We believe the following classification 5. Avoiding Increased Blood Loss
is sound: placenta adherens is caused by failed contraction
of the retroplacental myometrium, incarcerated placenta is Some studies showed promising results by injecting oxytocin
caused by a closed or closing cervix, and placenta accreta is into the umbilical cord, as it increased the rate of spontaneous
caused by abnormal placental implantation [13]. A part of the expulsions of the placenta and fewer manual removals of
placenta or the entire placenta is abnormally adherent to the the placenta, but two Cochrane reviews, either investigating
uterine wall without underlying decidua basalis. In placenta umbilical cord injection of saline or oxytocin in the routine
increta the placental villi invade into the myometrium, while management of the third stage of labour [20] or for the
percreta placenta is classified as placental villi penetrating reduction of MROP [21], were not able to detect a significant
through the uterine serosa or the adjacent organs, usually the reduction in the need for MROP. Nevertheless, umbilical vein
bladder [14, 15]. As there is a fair probability for detecting injection of oxytocin solution is an inexpensive and simple
cases with percreta placenta before the onset of labour intervention that could be performed while placental delivery
due to ultrasound and/or magnetic resonance imaging and is awaited. However, high-quality randomized trials show
therefore operative delivery can be planned with all necessary that the use of oxytocin has little or no effect. The same review
Journal of Pregnancy 3

showed a statistically lower incidence in manual removal of microarray as potential tools for the diagnosis of abnormali-
placenta if prostaglandin solution was used. Unfortunately, ties of placental invasion [15, 26, 27].
there were only two small trials contributing to this meta- But so far there exists no diagnostic tool ready to use in
analysis [21]. daily routine for prenatal diagnosis of placenta accreta. The
Eller et al. published a study including 57 cases with sensitivity of theoretically possible test methods also depends
placenta accreta, where all women underwent hysterectomy. on the degree and extent of the abnormal placental invasion.
In 15 cases an attempt was made to remove the placenta In our experience prenatal diagnosis is almost impossible in
manually, but these entire women required immediate hys- the low risk population, where often the parturient is seen
terectomy for uncontrollable bleeding. The authors of this in the maternity hospital only for childbirth. We only can
study concluded that, in case of suspected placenta accreta, assume that these patients most probably have not undergone
scheduled caesarean hysterectomy without attempting pla- prenatal ultrasound examination with the very question of
cental removal is associated with a significantly reduced rate morbidly adherent placenta.
of early morbidity compared with cases in which placental Nevertheless, the use of colour Doppler sonography in
removal is attempted [22]. the third stage of labour has been promisingly introduced by
Krapp et al. [6, 28]. They examined the third stage of labour
using greyscale and colour Doppler ultrasound. In cases
6. Diagnosis with normal placental separation they found cessation of
blood flow between placenta and myometrium immediately
Diagnosis of placenta accreta is not based on universally after birth. Suggestive of placenta accreta was persistent
valid standard criteria but rather a diagnosis based on the blood flow from the myometrium deep into the placenta
obstetricians’ impression and subjective judgement. Some demonstrated by colour Doppler ultrasound. According to
authors use only clinical criteria for the diagnosis of placenta the authors this method allows a quicker diagnosis of placenta
accreta, while others use histopathological criteria, which accreta and maternal blood loss can be minimized by early
is not always possible for obvious reasons. Some authors manual removal. As an ultrasound machine should be easily
distinguish between total and partial placenta accreta, a available in a well-equipped delivery unit it is advisable
diagnosis even more difficult to make. As well for the term to use ultrasound in the third stage of labour complicated
placenta adherens there is no consensus regarding exact by retention of the placenta. With a gain of experience
criteria for the definition. This may also be contributing to in judging the separation of the placenta from the uterine
the highly variable incidence of placenta accreta, with rates muscle ultrasound imaging may develop into a useful tool in
reported in literature between 1 : 93,000 and 1 : 110 [16]. the management of pathologic third stage of labour.
Aside from patients with placenta previa and patients
with a high risk of morbidly adherent placenta due to
obstetrical history, the diagnosis of placenta accreta is usually 7. Treatment
made at the time of delivery. A prenatal screening for placenta
accreta, especially for woman with risk factors, would be Audureau et al. were able to show that the implementation
eligible. A prenatal diagnosis would allow a more planned of a multifaceted intervention scheme for the prevention and
approach and minimize maternal blood loss. In literature management of postpartum hemorrhage can be successful. In
greyscale ultrasonography, colour Doppler imaging, and such way the median delay for second-line pharmacological
magnetic resonance imaging (MRI) have been described as treatment was significantly shortened from 80 min before
alleged successful approaches to diagnose placenta accreta introduction to 32.5 min afterwards [29]. Comparable to a
antenatally [6, 15, 17, 18]. Esakoff and colleagues stated strict work flow as already developed and implemented in
that ultrasound examination is a good diagnostic test for most large delivery units for emergency caesarean section
accreta in women with placenta previa and found this in (target of decision delivery time < 20 min) a similar stan-
consistency with most other studies in the literature [23]. A dardized protocol for manual removal of placenta might be
recent meta-analysis involving 3707 pregnancies showed a useful. In Figure 1 we present a showcase flowchart for cases
sensitivity of 90.72% and a specificity of 96.94% of ultrasound with retained placenta with special emphasis on the time
for the antenatal detection of invasive placentation [24]. frame. We believe that already strict observation of time, use
There is a general consensus that sensitivity and specificity of of ultrasound for evaluation of the grade of placental detach-
ultrasound are superior to those of MRI (sensitivity 80–85%, ment, and early involvement of support staff (i.e., second
specificity 65–100%) [25], but often both imaging techniques midwife, anaesthesiologist) might contribute to a reduction
are used in conjunction in women at risk. This is particularly of maternal morbidity. Needless to say, the suggested time
true when the placenta is posterior and in obese women. frame is only applicable in the absence of increased vaginal
However, prenatal diagnosis of placenta accreta in absence of bleeding, and its efficacy has to be proven in a controlled
further abnormalities of placentation remains a challenge. trial. In case of an increased blood loss during third stage of
There are also few biochemical markers named which are labour ideally standardized operating procedures are already
thought to have a diagnostic potential, such as elevated levels implemented.
of maternal serum creatinine kinase, alpha fetoprotein, and In conclusion, retained placenta remains a problem of the
𝛽-human chorionic gonadotropin [18]. Others promisingly third stage of labour, which in the low risk setting usually is
described cell-free fetal DNA, placental mRNA, and DNA occurring without prior warning. In daily routine adherence
4 Journal of Pregnancy

Delivery

Active
Episiotomy, tear
management
repair
3rd stage

Obstetrician for example, ultrasound,


informed credé

Anaesthesiologist
informed

Anaesthesia
sufficient

Placenta
delivered

Figure 1: Flowchart for the treatment of retained placenta with special emphasis on the time frame.

to a strict protocol of active management of third stage of [4] R. Cantwell, T. Clutton-Brock, G. Cooper et al., “Saving moth-
labour may be helpful to minimize time interval between ers’ lives: reviewing maternal deaths to make motherhood safer:
birth and delivery of placenta and therefore minimize post- 2006–2008. The Eighth Report of the Confidential Enquiries
partum complications. Further work is needed to proof this into Maternal Deaths in the United Kingdom,” British Journal
concept. of Obstetrics and Gynaecology, vol. 118, pp. 1–203, 2011.
[5] A. D. Weeks and F. M. Mirembe, “The retained placenta—new
insights into an old problem,” European Journal of Obstetrics
Conflict of Interests Gynecology and Reproductive Biology, vol. 102, no. 2, pp. 109–
110, 2002.
The authors declare that there is no conflict of interests [6] M. Krapp, A. A. Baschat, M. Hankeln, and U. Gembruch, “Gray
regarding the publication of this paper. scale and color Doppler sonography in the third stage of labor
for early detection of failed placental separation,” Ultrasound in
Obstetrics and Gynecology, vol. 15, no. 2, pp. 138–142, 2000.
References [7] A. D. Weeks, “The retained placenta,” Best Practice & Research
Clinical Obstetrics & Gynaecology, vol. 22, pp. 1103–1117, 2008.
[1] F. J. Mercier and M. van de Velde, “Major obstetric hemorrhage,”
Anesthesiology Clinics, vol. 26, no. 1, pp. 53–66, 2008. [8] C. A. Combs and R. K. Laros Jr., “Prolonged third stage of labor:
morbidity and risk factors,” Obstetrics & Gynecology, vol. 77, no.
[2] A. Wise and V. Clark, “Strategies to manage major obstetric 6, pp. 863–867, 1991.
haemorrhage,” Current Opinion in Anaesthesiology, vol. 21, no. [9] E. F. Magann, S. Evans, S. P. Chauhan, G. Lanneau, A. D. Fisk,
3, pp. 281–287, 2008. and J. C. Morrison, “The length of the third stage of labor and
[3] ACOG Practice Bulletin, “Clinical Management Guidelines for the risk of postpartum hemorrhage,” Obstetrics & Gynecology,
Obstetrician-Gynecologists Number 76, October 2006: post- vol. 105, no. 2, pp. 290–293, 2005.
partum hemorrhage,” Obstetrics & Gynecology, vol. 108, pp. [10] “Intrapartum Care. Care for healthy women and their babies
1039–1047, 2006. during childbirth,” National Institute for Health and Clinical
Journal of Pregnancy 5

Excellence, 2007, http://www.nice.org.uk/nicemedia/live/11837/ pregnant women with placenta previa and invasive placenta,”
36280/36280.pdf. Reproductive Sciences, vol. 21, pp. 215–220, 2014.
[28] M. Krapp, R. Axt-Fliedner, C. Berg, A. Geipel, U. Germer,
[11] C. Ronsmans and W. J. Graham, “Maternal mortality: who, and U. Gembruch, “Clinical application of grey scale and
when, where, and why,” The Lancet, vol. 368, no. 9542, pp. 1189– colour Doppler sonography during abnormal third stage of
1200, 2006. labour: colour Doppler during abnormal third stage of labour,”
[12] C. Deneux-Tharaux, A. Macfarlane, C. Winter et al., “Policies Ultraschall in der Medizin, vol. 28, no. 1, pp. 63–66, 2007.
for manual removal of placenta at vaginal delivery: variations [29] E. Audureau, C. Deneux-Tharaux, P. Lefèvre et al., “Practices
in timing within Europe,” British Journal of Obstetrics and for prevention, diagnosis and management of postpartum
Gynaecology, vol. 116, no. 1, pp. 119–124, 2009. haemorrhage: impact of a regional multifaceted intervention,”
[13] A. D. Weeks, G. Alia, G. Vernon et al., “Umbilical vein oxytocin British Journal of Obstetrics and Gynaecology, vol. 116, no. 10, pp.
for the treatment of retained placenta (Release Study): a double- 1325–1333, 2009.
blind, randomised controlled trial,” The Lancet, vol. 375, no.
9709, pp. 141–147, 2010.
[14] T. Y. Khong, “The pathology of placenta accreta, a worldwide
epidemic,” Journal of Clinical Pathology, vol. 61, no. 12, pp. 1243–
1246, 2008.
[15] C. Mazouni, G. Gorincour, V. Juhan, and F. Bretelle, “Placenta
accreta: a review of current advances in prenatal diagnosis,”
Placenta, vol. 28, no. 7, pp. 599–603, 2007.
[16] G. Bencaiova, T. Burkhardt, and E. Beinder, “Abnormal pla-
cental invasion: experience at 1 center,” Journal of Reproductive
Medicine for the Obstetrician and Gynecologist, vol. 52, no. 8, pp.
709–714, 2007.
[17] C. H. Comstock, “Antenatal diagnosis of placenta accreta: a
review,” Ultrasound in Obstetrics and Gynecology, vol. 26, no. 1,
pp. 89–96, 2005.
[18] T. Rosen, “Placenta accreta and cesarean scar pregnancy:
overlooked costs of the rising cesarean section rate,” Clinics in
Perinatology, vol. 35, no. 3, pp. 519–529, 2008.
[19] R. M. Silver, M. B. Landon, D. J. Rouse et al., “Maternal
morbidity associated with multiple repeat cesarean deliveries,”
Obstetrics & Gynecology, vol. 107, no. 6, pp. 1226–1232, 2006.
[20] R. Mori, J. M. Nardin, N. Yamamoto, and G. Carroli, “Umbilical
vein injection for the routine management of third stage of
labour,” Cochrane Database of Systematic Reviews, vol. 3, Article
ID CD006176, 2012.
[21] J. M. Nardin, A. Weeks, and G. Carroli, “Umbilical vein injec-
tion for management of retained placenta,” Cochrane Database
of Systematic Reviews, vol. 5, Article ID CD001337, 2011.
[22] A. G. Eller, T. T. Porter, P. Soisson, and R. M. Silver, “Optimal
management strategies for placenta accreta,” British Journal of
Obstetrics and Gynaecology, vol. 116, no. 5, pp. 648–654, 2009.
[23] T. F. Esakoff, T. N. Sparks, A. J. Kaimal et al., “Diagnosis and
morbidity of placenta accreta,” Ultrasound in Obstetrics and
Gynecology, vol. 37, no. 3, pp. 324–327, 2011.
[24] F. D’Antonio, C. Iacovella, and A. Bhide, “Prenatal identification
of invasive placentation using ultrasound: systematic review
and meta-analysis,” Ultrasound in Obstetrics & Gynecology, vol.
42, pp. 509–517, 2013.
[25] E. M. Berkley and A. Z. Abuhamad, “Prenatal diagnosis of pla-
centa accreta: is sonography all we need?” Journal of Ultrasound
in Medicine, vol. 32, pp. 1345–1350, 2013.
[26] G. Simonazzi, A. Farina, A. Curti et al., “Higher circulating
mRNA levels of placental specific genes in a patient with
placenta accreta,” Prenatal Diagnosis, vol. 31, no. 8, pp. 827–829,
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[27] A. Kawashima, A. Sekizawa, W. Ventura, K. Koide, K. Hori,
and T. Okai, “Increased levels of cell-free human placental
lactogen mRNA at 28–32 gestational weeks in plasma of

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Patient information leaflet

Department of Maternity Services


Whiston Hospital, Warrington Road, Prescot L35 5DR

Manual Removal of the Placenta


(afterbirth)
What is the nature of the procedure?
Following the birth of your baby, the placenta (afterbirth) normally delivers with
ease. Sometimes the placenta gets stuck on the wall of the womb (retained
placenta), and does not deliver and in these circumstances you would usually require
a manual removal of the placenta under anaesthetic (either a general or regional
anaesthetic).

 The third stage is the time between the birth of the baby and delivery of the
placenta and membranes. It takes anything from about 30 minutes to one
hour, if it is allowed to happen naturally. This is known as a physiological
third stage
 It may be speeded up with an injection in your thigh given just as the baby is
being born (Actively Managed Third Stage)
 The injection used is an Oxytocic drug to speed up the delivery of the placenta,
as this reduces the risk of haemorrhage.
 A Managed Third Stage usually lasts between five and 10 minutes

Why and how does a retained placenta happen?


 A common reason is a snapped cord during 'controlled cord traction'. In other
words, the pulling of the cord.
 If you have a Managed Third Stage, the Oxytocic injection will cause your womb
to contract, shearing the placenta away from the uterine wall.
 The midwife will wait for signs that the placenta has separated, and will then put
one hand on your tummy to keep your womb steady whilst pulling gently on the
cord with her other hand.
 If the placenta has separated and is ready to come out, it will slide easily through
the vagina.
 If it has not completely separated, if the cord is very thin or if too much traction
is used, the cord may snap; leaving the placenta inside the womb.
 Breastfeeding your baby will cause the womb to contract and may help to expel
the placenta.
 A change in your position or emptying your bladder may also work.

Sometimes a piece of the placenta can be retained. It can be connected to the main
part of the placenta by a blood vessel. This is called a Succenturiate Lobe. The

1
midwife will examine the placenta and membranes carefully after delivery to ensure
that they are complete. If she notices an unattached blood vessel this will alert her
to the possibility that part of the placenta could be retained in your womb.
Sometimes a part of the placenta may stick to a fibroid, or a scar from a previous
caesarean section. A rare cause of a retained placenta is known as Placenta Accreta.
This happens very rarely, approximately 1 in 2500 births and is not discussed in this
leaflet.

Risks of the Procedure?


 Normally after the placenta is delivered, the empty womb contracts down to close
off all the blood vessels inside the womb.
 If the placenta only partially separates, the womb cannot contract properly, so
the blood vessels inside will continue to bleed.
 If the placenta is not delivered within about 40 minutes after delivery of the
baby, there is a tenfold increased risk of heavy bleeding.
 Heavy bleeding in the first 24 hours after birth is known as Primary
Postpartum Haemorrhage (PPH).
If all attempts to remove the placenta fail, a manual removal will be necessary. This
will be done under general anaesthetic. A spinal or epidural will be used so that the
obstetrician can safely and painlessly remove the placenta. You will also need a
course of antibiotics to prevent infection.

I had a retained placenta with my first labour.


I'm pregnant again - can I do anything to stop it happening
again?

If you have already had a retained placenta in a previous delivery, you are at greater
risk of it happening again. There is not much you can do to prevent it happening
again if it was due to the placenta sticking to an old Caesarean scar, or placenta
accreta.
Retained placenta is more common in premature births than at full term. So if you
have another preterm labour, it is possible it may happen again.
However, if the retained placenta happened because the cord snapped or the cervix
closed too quickly after having the Oxytocic injection, you may wish to discuss with
your midwife whether or not to have a physiological third stage with your next baby.
By allowing the placenta to deliver naturally, you avoid the possibility of the cervix
closing too quickly and trapping the placenta.

What do I look for?


If small fragments of placenta or membrane are retained and are not detected
immediately, this may cause:
 Heavy bleeding, and
 Infection later on

2
Heavy bleeding, which happens from 24 hours until six weeks after the birth is
known as Secondary PPH, and happens in about one per cent of deliveries.
You must inform your midwife or GP if you have any of the following:
 Heavy bleeding
 Pass blood clots
 Offensive (bad odour) vaginal discharge
 Flu like symptoms
 Abdominal (stomach) pains
If you have any heavy bleeding or pass blood clots, you must keeping any pads or
clots so they can see how much you have lost and see if there is any placenta tissue.
If you have prolonged heavy bleeding in the days or weeks following the birth, you
may be referred to the hospital to see if there are any retained products of
conception in your womb. If this is diagnosed then treatment may involve waiting to
see if your body breaks down the products, or a procedure known as Evacuation of
Retained Products of Conception (ERPC), which is like a D&C or ‘scrape’. This is
done under anaesthetic and treatment with antibiotics. These choices will be
discussed with you by the doctor.

If you have any questions please contact your community


midwife, GP or the Maternity Unit for advice

Useful Telephone Numbers:-


Community Office: 0151 430 1492 (office Hours)

Switchboard: 0151 426 1600 and ask for the Maternity Bleep holder

If you have been discharged from midwifery care and over 28


day postnatal then contact your GP

This leaflet is available in alternative languages/formats on request.

Creation Date – April 2005


Review Date – May 2018
Version 1: New format
Produced by: Department of Maternity Services