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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 LabourPurpose:

Retained placenta is a potentially life-threatening condition because of the associated risk ofhaemorrhage, 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 thirdstate of labour:

o Active management of third stage of labour: the placenta is not delivered within 30 minutes ofbirth of the infant

o Physiological management of third stage of labour: the placenta is not delivered within 60minutes of the birth of the infant

Causes/Predisposing Factors

Morbid adherence of the placentao Placenta acretao Placenta incretao Placenta percreata

Uterine abnormality Constriction ring Umbilical cord accident/snapped cord Second trimester induction of labour Intrauterine infection Prematurity Full bladder
http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0496-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0484-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0484-001http://pssbpr-trim02/PandP/showdoc.aspx?recnum=P2010/0496-001


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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 oflabour)

Consider:o Emptying the bladdero Breastfeeding or nipple stimulationo Change of position - encourage an upright positiono 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 intra-operatively.

For women with allergy to penicillin an appropriate alternative should be given.Complications of Retained Placenta

Shock Postpartum haemorrhage Puerperal sepsis Subinvolution HysterectomyComplications of MROP

Perforation of the uterus Retained products Infection Uterine inversionAttachments:

1 Clinical notes2 ReferencesPerformance Indicators: Evaluation of compliance with guideline to be achieved through medical recordaudit


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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 Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)

Date: January, 2010


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APPENDIX 1

Placental cord drainage

Placental cord drainage involves clamping and cutting the umbilical cord after the birth of the baby butimmediately afterwards, unclamping the maternal side of the cord and allowing the blood to drainfreely. 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 benefitform the use of placental cord drainage in terms of reducing the length of third stage. In one clinicaltrial the incidence of retained placenta at 30 minutes was reduced (Soltani H, Dickinson R & SymondsI, 2005).

Antibiotics

No randomised controlled trials that have determined whether prophylactic antibiotics reduce theincidence of endometritis. The World Health Organisation has recently suggested a single dose ofampicillin 2g IV and metronidazole 500mg IV for manual removal of placenta. The bases for thisrecommendation are that the antibiotics recommended cover aerobic and anaerobic flora commonlyseen in the genital tract; they are widely available, are inexpensive and safe; and are used only at thetime 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 ofretained placenta. Further research into umbilical vein injection is recommended before this practiseis introduced (Carroli G & Bergel E, 2001).

APPENDIX 2

REFERENCES

Carroli G, Bergel E. Umbilical vein injection for management of retained placenta. CochraneDatabase 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 ofretained 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 RetainedPlacenta,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 partof the management of the third stage of labour. Cochrane Database of Systemic Reviews 2005, Issue4. Art. No.: CD004665. DOI: 10.1002/14651858.CD004665.pub2. Online:http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004665/frame.html
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001337/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001337/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001337/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004904/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004904/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004904/frame.htmlhttp://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/alpha/index.htm#rhttp://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/alpha/index.htm#rhttp://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/alpha/index.htm#rhttp://www.thewomens.org.au/RetainedPlacentaManagementofhttp://www.thewomens.org.au/RetainedPlacentaManagementofhttp://www.thewomens.org.au/RetainedPlacentaManagementofhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004665/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004665/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004665/frame.htmlhttp://www.thewomens.org.au/RetainedPlacentaManagementofhttp://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/alpha/index.htm#rhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004904/frame.htmlhttp://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001337/frame.html

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