Retained Placenta

Treat it as a hemorrhage case from the start - Retained placenta and abnormal placentation are a primary cause of postpartum hemorrhage. ACOG defines PPH as cumulative loss of 1,000 mL or more with signs of hypovolemia within 24 hours of birth, but more than 500 mL after a vaginal delivery is already abnormal — and estimated loss at delivery is routinely too low.

Find the cause by exam before you commit - A soft, boggy, enlarged fundus points to atony; a cherry-colored mass in the vagina is uterine inversion; brisk bleeding with a firm uterus points to a laceration. Manual exploration of the cavity or bedside ultrasound showing an echogenic endometrial stripe is what confirms retained tissue.

Access and blood first - Large-bore IV access, type and crossmatch, and early activation of the massive transfusion protocol. Labs lag the clinical picture, so don't hold transfusion pending a hemoglobin. In a postpartum patient, tachycardia and hypotension may be blunted — if they are present, assume more than 25% of blood volume is gone.

Anesthetic for manual extraction - Removal is manual or by dilation and curettage, and it belongs in a room with anesthesia support rather than at the bedside. An in-situ epidural can usually be extended to a surgical level; without one, weigh spinal against general anesthesia on how much she has already lost and how fast.

Relax the uterus, then reverse yourself - A halogenated inhaled anesthetic, nitroglycerin, terbutaline, or magnesium will relax the uterus enough for extraction or for replacing an inverted uterus. The moment the uterus is empty and back in position, stop relaxing it and give oxytocin plus additional uterotonics — the same volatile that helped you is now the reason she is bleeding.

Uterotonic sequence - Oxytocin is the agent of choice, with bimanual massage; ergot alkaloids and prostaglandins are the escalation when oxytocin isn't enough.

Know the next three moves - If uterotonics fail: intrauterine balloon tamponade with 250 to 500 mL of saline, uterine artery embolization if she is stable, then laparotomy for O'Leary uterine artery ligation or a B-Lynch compression suture, with hysterectomy as the definitive answer. Anticipate the conversion to general anesthesia rather than being caught by it.

Ultrasound signs of accreta spectrum - Prior cesarean plus a current previa is the highest-risk combination. Grayscale ultrasound findings are loss of the retroplacental sonolucent zone, vascular lacunae, myometrial thinning, and interruption of the bladder line. That patient is a planned peripartum hysterectomy, not a bedside manual extraction.

Tranexamic acid - In high-risk cesarean, prophylactic TXA reduced intraoperative and postoperative blood loss and the need for rescue uterotonics, at low-to-moderate quality of evidence. Thromboembolism is the standing concern.

Stay for the aftermath - Postpartum anemia is common and often not fully corrected by transfusion; a hemoglobin under 7 g/dL with symptoms is the usual transfusion trigger, and iron replacement follows. Sheehan syndrome is the late complication of severe loss.

A normal third stage separates the placenta along the decidua basalis and the fibrinoid Nitabuch layer — that plane is the cleavage line. Retained placenta is failure of all or part of it to deliver, either because the plane never formed (placenta accreta spectrum, where decidua basalis is partially or completely absent and villi adhere to or invade myometrium) or because an accessory lobe is left behind, as with succenturiate, bilobed, or multilobate placentas.

Hemostasis after delivery is mechanical: the myometrium contracts and compresses the placental bed, and the spiral arteries have no musculature of their own to do it for them. A uterus that still contains tissue cannot clamp down, so bleeding continues. Traction on the cord to hurry the placenta risks uterine inversion, and forcing an adherent placenta out can produce hemorrhage, shock, and inversion together.