What is a placenta retention?Placenta retention is when either the entire placenta (spinal cakes or afterbirth) or parts thereof or the third-stage amniotic sac remains in the uterus. In the third stage, you reject the placenta and the amniotic sac. They are treated for placental retention if the third stage (postpartum period) lasts longer than usual, or there are signs that the placenta or the amniotic sac has not completely detached from the uterus - but this is very rare.
What is meant by the postnatal period?This refers to the period between the birth of the baby and the delivery of the afterbirth. The postpartum or placental period lasts between a few minutes and one hour (NCCWCH 2007: 178). It can be natural (physiologic placental period) or accelerated via an injection in the thigh or arm vein (active conduction of the placental period). Injected is the hormone oxytocin, which ensures a faster elimination of the placenta and thus reduces the risk of heavy bleeding (NCCWCH 2007: 178). These bleedings can occasionally become life-threatening for the woman. When the afterbirth period is actively managed, it usually takes five to ten minutes (Dombrowski et al 1995, Magann et al 2005).
You will be treated for placental retention if the placenta has not been completely excreted:
- within an hour of your baby's birth, if you have a natural third stage - this is approximately 13 percent of the cases (NCCWCH 2008: 246)
- within half an hour after your baby's birth, if you have a controlled third stage (NCCWCH 2008: 246) - this happens in less than 5 percent of cases (Prendiville et al 2000)
How and why does placental retention occur?There are three main reasons for placental retention:
- uterine atony - this means the uterus stops contracting or does not contract enough to allow the placenta to detach from the uterine wall.
- Trapped Placenta - the placenta separates from the uterine wall. It does not pass through the now narrowed cervix
- Placenta accreta - a part of the placenta has not resolved because it is deeply embedded in the uterine wall (Weeks 2008)
When the placenta has released and is ready to escape, it slides gently through the vagina. If the placenta has not completely loosened, if the umbilical cord is very thin or if your midwife pulls too hard, the umbilical cord may tear and the placenta will remain in the uterus. If this happens, you can help to clear the placenta by squeezing the placenta out with a contraction as instructed by the midwife. But occasionally the cervix has narrowed so much that the placenta can not go through.
There is sometimes a placenta retention because a small piece of placenta remains in the uterus. It is connected to the main placenta via blood vessels. Your midwife will carefully examine the placenta and the amniotic sac after breast-feeding for completeness, and if it discovers a blood vessel that ends in nothingness, this could be an alarm sign that some of the placenta has been left behind Occasionally, part of the placenta also grows with a tumor or scar from a previous caesarean section (Lindsay 2004: 995).
Sometimes a full bladder can hinder the afterbirth, so your midwife will probably place a catheter, Lindsay 2004: 995.
What problems does a placenta retention entail?
Normally, when the placenta leaves the womb, all the blood vessels in it are normally closed, if the placenta only partially peels off , the uterus can not shrink properly, so the blood vessels continue to bleed If the placenta is not excreted 30 minutes after delivery of your baby, the risk of profuse bleeding increases many fold (Magann et al 2005). Severe bleeding in the first 24 hours after delivery is called primary postpartum hemorrhage (PPH).If small parts of the placenta or amniotic sac remain behind and are not detected immediately, it can lead to severe bleeding and infection later. They are known as secondary PPH and occur in less than one percent of births (Hoveyda and MacKenzie 2001).
How is PPH handled? Breastfeeding your baby or massaging the nipples can cause uterine contractions, indirectly helping to flush out the placenta (Prendeville et al 2000). Emptying your bladder or changing your position can also help. If you are sitting or lying, try to get upright because gravity can help (Harris 2004: 512, Prendeville et al 2000).
If you choose a controlled third stage, you will be injected with the hormone oxytocin, which causes your uterus to contract. Your midwife then carefully pulls on the umbilical cord to remove the placenta.
If all these attempts fail, the placenta must be surgically removed. You may be given regional anesthesia, such as epidural or spinal anesthesia, or you may ask for general anesthesia, if you prefer (NCCWCH 2007: 248). You also get antibiotics to prevent infection.Before the placenta is surgically removed, your midwife places a catheter to empty the bladder. They receive intravenous (IV) antibiotics to prevent infection (Lindsay 2004: 996). After this procedure, you may need more medication that is given intravenously to allow the uterus to contract (Lindsay 2004: 995-6).
If you have persistent heavy bleeding for days or weeks after giving birth, you will probably be sent for an ultrasound exam to see if there are any parts of the placenta or amniotic sac in your uterus. If the finding is positive, you will be referred to a hospital where the remains will be removed under anesthesia. This procedure is called curettage (scraping). Also with this treatment additional antibiotics are prescribed.
I had a placentary retention on my first delivery. Can I do something to prevent this?
If you have had a placenta retention in childbirth in the past, you have a higher risk of getting it again (Tandberg et al : 33-6). If the cause was a caesarean scar or a placenta accreta, you can not do much to prevent a new placenta retention.
Placenta retention is especially common in premature delivery, possibly because the placenta was created to Staying in the uterus for 40 weeks, so if you have a premature baby again, there may be placental complications again (Dombrowski et al 1995).
However, if you have had a placenta retention because the umbilical cord is torn or because of the If the cervix is already too closed, you should discuss with your midwife whether you should go through a natural third stage with your next baby, and if the placenta can be expelled naturally, avoid the possibility that the cervix closes too quickly and the placenta is included.Sources
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Hatfield JL, Brumsted JR, Cooper BC. 2006. Conservative treatment of placenta accrete. J Minim Invasive Gynecol 13 (6): 510-3.
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Magann EF, Evans S, Chauhan SP, et al. 2005. The length of the third stage of labor and the risk of postpartum hemorrhage. Obstetrics and Gynecology 105 (2): 290-3.
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