When planning the birth, lots of emphasis is placed on the first and second stages of labor. Essentially these are stage one - where you go through early labor, active labor, and the transitional stage and then stage two - where your baby appears.
Less attention is paid to stage three of labor, the delivery of the placenta, also known as the afterbirth. This delivery is often taken for granted and considered to be a done deal but it does not always go smoothly, and some mothers experience a retained placenta. This is when the placenta is not expelled from the body within the expected time limit.
This time varies according to whether your third stage is actively managed or natural. An actively managed third stage involves oxytocin being administered via intramuscular injection which encourages the uterus to contract and push out the placenta. Controlled cord traction may also be used, as well as fundal massage. Delivery under these circumstances is expected within 30 mins. A natural third stage usually means leaving the body to expel the placenta when it is ready and is generally supposed to take up to an hour.
15When It Won't Let Go
Placenta adherens is the name given to the condition when the placenta remains loosely attached to the wall of the uterus. It’s kind of like those times your toddler really wants to go with grandma and grandpa to the store to buy candy but hangs onto your leg a little because they aren’t quite ready to let go yet.
Although placenta adherens is something that, of course, needs to be dealt with, it is the most common form of retained placenta and also the easiest, generally speaking, with which to deal.
The most frequent treatment to deal with placenta adherens is either a shot of oxytocin or the gentle massage of the uterus, through the abdominal wall, to encourage nature to take its course. This massage technique is often the first step when time has passed during an unmanaged third stage of labor.
14A Controversial Tug Of War
Controlled Cord Traction is, however, not just pulling on the umbilical cord. While a particular level of pressure is applied to the cord, the doctor or midwife applies counter pressure to the mom’s belly. This can be very uncomfortable for the mother, although not actually painful.
The application of the controlled cord traction technique requires precise training and should be attempted by unqualified medical personnel.
Beginning controlled cord traction too soon, while any of the placentae is still attached to the uterine wall, could potentially result in significant maternal hemorrhage.
This technique has become a matter of much research over the last few years with some studies concluding that the potential benefits of controlled cord traction are far outweighed by the potential risks. It was also suggested that in cultures where controlled cord traction was not used, there was no significantly higher risk to the mother.
Happening in around 1 in 2000 births, a uterine inversion occurs when the placenta exits the body before it has properly detached from the wall of the uterus. The placenta pulls on the inside surface of the womb and turns the uterus inside out. In some cases, the uterus is visible only at the cervix, but in more extreme cases, the uterus can be visible outside of the cervix.
Causes or contributory factors include; a weakness of the uterus which can be congenital and undetected until this point, a speedy delivery, or a short umbilical cord.
On rare occasions, a health care practitioner who is untrained or unskilled in using cord traction may contribute to a uterine inversion. This happens when too much pressure is applied to the cord, and the placenta is pulled before being allowed to fully separate.
An incomplete separation of the placenta or retained fragments of the placenta can contribute to a condition known as atony of the uterus. The main symptom of atony of the uterus is a uterus that remains relaxed and without tension after giving birth.
Under normal circumstances the uterine muscles contract during labor which in turn squeezes the blood vessels and reduces blood flow to the uterine muscles. This increases the body's ability to cause clotting in the area and prevent massive blood loss after the birth.
Atony of the uterus is one of the most common causes of postpartum hemorrhage. A postpartum hemorrhage is defined as loss of more than one pint of blood after the delivery of the placenta.
The first step in treating atony of the uterus is to massage the womb to stimulate contractions. If this does not work, oxytocin is injected to induce contractions.
11In Too Deep
Around one in 2,500 moms-to-be may experience placenta accreta, placenta increta or placenta percreta. These are all similar kinds of conditions but with different levels of severity and differing treatments.
Placenta accreta is name given to the condition when the placenta attaches too deep in the uterine wall but does not go any further than the wall itself. This form of the condition accounts for approximately 75% of cases.
It is unknown exactly what causes this set of conditions, but they are found at a higher rate in women who have placenta previa and in moms who have had a previous cesarean delivery. The greater the number of C-Sections a woman has had, the higher her chance of having placenta accreta. In fact, multiple cesareans have occurred in 60% of women who have had placenta previa.
The second level, placenta increta is a more severe form of the condition where the placenta has taken root so deeply into the womb it has actually penetrated the uterine wall. This accounts for approximately 15 % of cases and obviously presents a significantly higher danger to both mom and baby.
With any form of these conditions, the baby is at increased risk of premature delivery and all of the health risks that subsequently poses. For the mother, the primary threat is the problem of getting the placenta to separate after the birth.
With placenta accreta, this risk is raised, but with the more severe placenta increta, the mother is at a high danger of suffering significant blood loss during the manual attempts to detach the deeply embedded placenta from the uterine wall while avoiding any damage to the uterus itself.
9Clinging To The Organs
The most severe form of the conditions is Placenta percreta. This occurs when the placenta has not only penetrated the uterine wall, but it has also attached itself to surrounding organs. Accounting for around 5% of cases in placenta percreta, the tiny little roots of the placenta that keep it firmly affixed to your womb, spread so deeply they go through the wall of your uterus and cling to other structures such as the bladder or the bowel.
Nothing can be done to prevent this happening, but if it is diagnosed in your pregnancy, your doctor can discuss the surgical options with you. Most frequently the only way to treat this is to perform a hysterectomy after the birth, but if you want more children, there may be alternatives available.
When you become pregnant, the placenta starts to pump out the hormones estrogen and progesterone. These hormones prevent your body from continuing on its regular menstrual cycle and also stops you from producing milk before you need it.
When the placenta is delivered this hormone drops and triggers a rise in another hormone prolactin, which is responsible for producing breast milk.
If any of your placenta is retained and is not immediately diagnosed, your body will not begin to pump out prolactin, and this will make breastfeeding enormously difficult.
As soon as your retained placenta is treated, you will start to produce milk so swift treatment will help you exclusively breastfeed if that is your wish. If the condition goes undiagnosed and treatment is delayed, you may have to feed your baby some formula to ensure their continued good health.
7Caught In A Trap
On some occasions, the placenta can successfully detach from the wall of the uterus, but it becomes trapped behind your cervix which has closed before the placenta can be delivered.
The risk of this happening is increased if you have managed the third stage of labor and the oxytocin injection is either given too soon, causing the cervix to close quickly or sometimes your body might just react quickly to the injection. If this has been the case for you, consider having a natural third stage if you should have another bay, to reduce the risk of a repeat performance.
Another risk is the prolonged use of synthetic oxytocin during an induction or in an attempt to speed up a slow labor. Any extra oxytocin in your system elevates your risk of the cervix closing before the placenta is expelled.
When your medical professionals are happy that the placenta has detached, but your body is failing to deliver it, they may attempt a manual removal of the afterbirth. This might be done in the delivery room, or you may be taken to an operating theatre for the procedure.
To begin with, a catheter will be inserted to empty your bladder, and you will be given intravenous antibiotics to prevent any possible infection following the procedure.
Once the drugs have started flowing, you’ll be given an epidural or spinal anesthetic to keep you as comfortable as possible during the process itself. Once it has taken effect, your doctor will reach inside your uterus, yes you read that right, reach inside your uterus, and remove the placenta. Following this you will be given further drugs intravenously, to have your uterus contract.
5The Uncommon, Drastic Measure
On rare occasions, the retained placenta might be so deeply attached to either the uterus or the surrounding organs, that surgery is needed to remove the placenta and stem the blood loss. When this occurs, the only option to save the mother's life may be hysterectomy.
This is not a common occurrence, and not one that you should be worried will just suddenly happen to you. The chances of experiencing a retained placenta are quite small. Of those cases, only a tiny proportion involve the placenta growing beyond the uterine wall, and of those cases, very few will require a hysterectomy.
In the unlikely event, you find yourself facing the decision on whether or not to have a hysterectomy in these circumstances, be aware that this decision is not taken lightly by the medical team. It is not the easy option, and they would only recommend major surgery of this kind if they thought it was essential.
If you are happy to have no further children, then it may be an easy decision for you. If not, it can be traumatic to feel you are giving up any chance of further pregnancy. If this is the case, ensure you access follow-up counseling as this decision on top of postpartum hormonal changes and caring for a new baby may put you at higher risk for postpartum depression.
4Small Sneaky Pieces
On some occasions, the placenta can pass inspection because it is complete and none of it has been retained. However, very rarely, a woman's placenta can develop normally but have an additional blood vessel that connects to another piece of placenta, separate from the main. This is called a succenturiate lobe and when the placenta is delivered the lobe and its blood vessel can be left behind. There can be one or more of these little attached “mini placentas, ” and if they have not been identified before the birth, your medical team might have no reason to suspect one.
Apart from the risk of retaining this piece of placenta, there is no real problem with a succenturiate lobe unless the blood vessels become trapped between the baby's presenting part and the cervix. This can result in the blood vessel rupturing and is a serious medical emergency.
3Symptoms At Home
When the placenta is delivered, your healthcare professional will carefully examine it to make sure the entire placenta is there. It the placenta looks incomplete, your doctor or midwife will likely order an ultrasound to ensure no pieces of the placenta have been left behind.
However, on occasion, even a detailed examination of the placenta appears to show everything as normal, and a new mom may be discharged from the hospital with what are known as “retained products of conception (rpoc).”
If you pass a clot sometime after the birth calls your hospital or midwife to let them know what has happened. They might want to examine you to ensure there are no more rpoc.
However, not everyone who has a small piece of retained placenta will pass it naturally. If you have any of the following symptoms they may be a sign you have rpoc, and you should see your doctor as soon as possible.
- Heavy bleeding
- Tummy cramps
- Smelly discharge
- A lack of breastmilk
- Continued intermittent bleeding
2Getting The Little Bits
Once you have shown signs of having some retained products of conception you will probably be sent for an ultrasound to give your doctor an idea of how big the piece(s) is and where it is located in your uterus.
The standard treatment is for a D&C (dilation and curettage) to be performed. This operation is usually performed under general anesthetic, but you are allowed to go home the same day. Once you are asleep, the doctor will place your legs in stirrups and use a special instrument to gently open your cervix. This is the dilation stage. After this, a surgical instrument called a curette is inserted and used to remove the pieces of retained placenta. The curette used to do this can either be one that cuts out the pieces or one that sucks them out.
After the procedure, you will be monitored for an hour or two, and then you can go home. It is not painful, and most women feel fine afterward. You will just be advised to take it easy for a week or so.
1How Likely Is It To Happen?
Rates of retained placenta were examined in a research project that looked at 146 women who experienced a retained placenta compared to 300 women who delivered virginally and did not suffer from this complication. Researchers considered factors such as maternal age, duration of labor, medical history and antenatal abnormalities and chose women who were giving birth under similar conditions.
The study showed that the most significant risk factor for suffering from a retained placenta was experiencing a retained placenta after a previous birth. This was closely followed by having previous uterine surgery, including a cesarean section.
After history, premature delivery was found to be a risk factor, and it is thought that this is because the placenta is designed to be in place for 40 weeks and is ‘unwilling’ to detach before then.
The final risks, in descending order, were found to be, a mother over 35 years of age, a placenta that weighs less than 1.3 pounds, pethadine use in labor, induction and finally if it is the fifth or higher birth for the mother. If you have a number of these risk factors, your healthcare team should be especially alert to the possibility of a retained placenta.
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