Giving birth is a miracle of nature. It is loaded with many uncertainties, which can develop at any stage of the process. One such problem is the retention of placenta, which may occur, in the third stage of labour when the placenta and membranes are supposed to be delivered.
UNDERSTANDING THIRD STAGE OF LABOUR…
The third stage of labour refers to the period following the completed delivery of the newborn until the completed delivery of the placenta and its attached membranes. This stage involves one actively delivering the placenta and its membranes by actively pushing it out. It usually takes 10 to 20 minutes but may take up to an hour by natural effort. This process can however be speeded up by giving an injection (syntoncin) in the thigh. The injection helps the uterus to contract, separate the placenta, assist in placenta delivery and reduce the risk of heavy bleeding. This treatment shortens placenta delivery to within five to ten minutes.
HOW RETAINED PLACENTA OCCURS…
A retained placenta occurs when all or part of the placenta or membranes remain inside the uterus after childbirth. The delivery of the tissues should ideally be completely delivered within one hour of baby birth. For some women, however, the placenta does not deliver naturally and must be physically removed.
There are different reasons for the placenta to be retained for longer than is normal:
Uteriny atony. The uterus stops contracting or doesn’t contract enough to aid the placenta to separate.
Trapped placenta. The placenta detaches from the uterus but becomes trapped behind the cervix. This usually occurs when the umbilical cord is cut or snaps off, or when the cervix closes too early before the placenta is delivered.
Placenta accrete. An area of the placenta remains attached because it is deeply embedded in the uterine wall. This prevents detachment.
Succenturiate placenta. A small piece of the placenta, which is connected to the main part of the placenta with blood vessels, is left inside the uterus.
Among the reasons a placenta is retained include:
Full bladder. This alone may cause placental retention and it is advisable to empty bladder before delivery.
Associated problems. If the uterus is not well contracted, blood vessels in the uterus are therefore not well closed and the woman continues to bleed after delivery.
Late placenta delivery. Delivery of the placenta after more than 30 minutes when the baby has been born increases the risk of excessive bleeding, a condition known as post partum haemorrhage (PPH).
Small-retained pieces of placental tissue may not be detected immediately. This may cause heavy bleeding after 24 hours (secondary PPH). Such an occurrence may even take place six weeks after delivery.
Infection. This is also a known complication of retained placenta. After removal of the placenta, the mother should be put on antibiotics.
Once placenta is retained, there are high chances of it happening again in following pregnancies. Retained placenta is more common in premature births. This should, therefore, be closely evaluated after premature delivery. Due to the cord snapping or the cervix closing up too quickly, managed or natural third stage labour may be offered in the next delivery.
Treatment of retained placenta depends on the cause. Breastfeeding and nipple rubbing causes the uterus to contract. This helps the placenta to separate and therefore be expelled.
Changing to a more upright position, from a sitting or lying position helps the placenta to separate due to the force of gravity. Injection of oxytocin and controlled cord traction prevents retention of the placenta. This is active management in placental delivery.
Manual removal of the placenta under anaesthesia can be done in theatre. The bladder must be emptied first before this is done. Manual removal can involve a doctor placing their hand inside the uterus and gently removing the placenta from the uterine wall. When the placenta is separated, the doctor can then take hold of the placenta, remove it from the uterus through the vagina. Emptying the bladder can effectively assist in the removal of the placenta.
In case of prolonged heavy bleeding, pelvic ultrasound scan can be done to study the uterine cavity. If there are any retained parts, evacuation can be done in hospital followed by antibiotics. In cases where the placenta has deeply grown into the uterus, removal is only possible by hysterectomy. A hysterectomy is the surgical removal of the uterus. A woman who undergoes a hysterectomy will be unable to carry any future pregnancies.
A retained placenta is a potential life-threatening situation. After the placenta is delivered, the contraction of the uterus causes the blood vessels within it to constrict. If the placenta is retained, the uterus is unable to perform this function. If the blood vessels are not closed off, they continue to bleed, which could cause loss of a large amount of blood and possibly require blood transfusions.
A retained placenta, specifically in instances where placental debris is left within the uterus, can cause severe infection and fertility issues. Labour and delivery professionals are trained and aware of the signs and symptoms of retained placenta and know how to treat them accordingly. Incidences of retained placenta are actually quite few.