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Retained placenta is defined as placenta undelivered at 1-2 hours postpartum with no excessive bleeding in a homebirth situation (30 minutes in a medical facility). The average length of time for a normal placental delivery in a homebirth when the newborn is breastfeeding upon birthing ranges from 15 minutes to about 45 minutes.
Encourage natural delivery of placenta with complimentary therapies, including herbs, squatting, emptying bladder, walking, remaining in upright position, etc.
An easy way to encourage the placenta to separate is to breastfeed your baby, as nipple stimulation releases hormones that help your uterus to contract. Your midwife might use reflexology, aromatherapy oils such as jasmine massaged into the abdomen around the top of the uterus, or acupuncture to help the placenta to separate.
HELPFUL HERBS
Herbs like Myrrh, or Raspberry Leaf may also be effective. Angelica Root Tincture (50 drops) and Blue Cohosh Tincture (20 drops) every 2 to 5 minutes may be helpful. Homemade tinctures are usually best and more potent.
MoonDragon's Health Therapy: Herbal Tinctures Index
One suggestion would be to try some Cayenne Tincture. Wait 30 minutes. If the placenta has not been expelled, then give some Lobelia Tincture. After 30 minutes, try Cayenne again. Often this will do the trick. It's best to use your own fresh homemade tincture. Store bought Lobelia Tincture is usually weak and worthless. Do not be afraid to take quite a dose. The reason herbs do not work for most people is that they do not take enough of them. The most that is going to happen with these herbs if you take too much is that you will vomit. No other bad side effects are going to happen.
A tea made with Angelica, Black Cohosh and Blue Cohosh, Ginger, Raspberry, and lots of honey.
HERBAL PRODUCTS
Herbal Remedies: Myrrh Gum (Commiphora Myrrha) Powder, 4 oz. Bulk
Herbal Remedies: Myrrh Gum Supplement Tincture, 2 fl. oz.
Herbal Remedies: Raspberry Leaf, Organic, Caffeine Free, Kosher, Traditional Medicinals, 16 Tea Bags
Pour one cup of boiling water over 1 or 2 teaspoons of dried Red Raspberry leaf, steep for 10 minutes, and then sweeten to taste. Drink 2 to 3 cups daily while pregnant.
Herbal Remedies: Red Raspberry Tincture Supplement, 100% Organic, 2 fl. oz.
Herbal Remedies: Angelica Root Tincture, 2 fl. oz.
Herbal Remedies: Blue Cohosh Tincture (Caulophyllum Thalictroides), 100% Organic, 2 fl. oz.
Herbal Remedies: Blue Cohosh Powder, 4 oz. Bulk
Herbal Remedies: Cayenne Supplement Tincture, 2 fl. oz.
Herbal Remedies: Lobelia Extract Tincture, Herbal Remedies USA, 2 fl oz.
Herbal Remedies: Multiflora Honey, 100% Pure New Zealand Honey, 1.1 lb.
Herbal Remedies: Manuka Honey, Bio-Active 10+, 500 grams
HELPFUL HOMEOPATHIC REMEDIES
The homeopathic remedies below aid contraction of the womb and expulsion of the placenta.
Specific remedies to be given every 5 minutes for up to 10 doses:
PULSATILLA 30C
Intermittent bleeding, retention of urine, lower abdomen hot, red, sore, and painful to the touch, especially if woman is of a mild, tearful disposition.
Herbal Remedies: Pulsatilla Homeopathic Clikpak, 30C, 84 Pellets
SECALE 30C
Bearing down sensation continues, pains strong and continuous but ineffectual, muscles of uterus no longer able to contract, woman throws bedclothes off and craves fresh air.
Homeopathic Laboratories: Secal Cor. (Spurred Rye, Ergot of Rye)
BELLADONNA 30C
Vagina feels dry and hot, profuse bleeding, woman red in face, moaning, very distressed, and sensitive to slightest jarring.
Herbal Remedies: Belladonna Homeopathic Clikpak, 30C, 84 Pellets
PLATINUM 30C
Vulva and vagina extremely sensitive, severe cramping pains in abdomen, constant ooze of dark blood.
Herbal Remedies: Platinum Ionic Mineral Supplement, Fully Absorbable, 50 +/- ppm, 16 fl. oz.
Homeopathic Laboratories: Platinum Met.
Homeopathic Laboratories: Platinum Mur.
Despite all effort, however, the placenta fails to come away either partially or completely in about 3 percent of births. This can happen even when drugs have been given to bring it away. Sometimes the placenta attaches to the uterine wall more deeply than usual, and it's more common if it happened at a preceding birth or you have had a cesarean section previously as there is scar tissue in the uterus. High Doses of vitamin E has been associated with retained placenta problems. From the 7th month of pregnancy until delivery, the mother should taper her vitamin E intake down to 400 IU per day.
Note: If there is bleeding, there is some or total placental separation. Heavy blood loss indicates that a considerable portion of the placenta is already separated (lots of uterine blood vessels exposed) so if manual removal is required, it should not be too difficult. Sometimes the placenta is fully separated but has lodged just inside the cervix, in which case it is easily grasped and removed. But if it is still attached, you must remove it.
If stimulation, herbs, and other techniques used for initiating contractions for placental separation are unsuccessful, perform manual removal.
EMERGENCY MANUAL REMOVAL OF A RETAINED PLACENTA IN NON-HOSPITAL SETTING
A retained placenta stops the uterus from contracting effectively to prevent excess bleeding so it has to be removed manually. This is usually a straightforward procedure performed in a medical facility in a surgical room under general anesthetic, although it might be done under epidural if one is already in place.
If the procedure must be done outside of a medical facility (such as a homebirth situation) anesthetic will not be available to the mother. Manual removal of a placenta may be painful for the mother and may not always be successful. Sterile technique is an absolute must if manual removal is performed since infection often is an issue that may occur with this procedure. Thus it should only be performed in dire necessity.
The procedure is relatively simple. The midwife should put on fresh, elbow-length sterile gloves, pour some antiseptic over her gloved hand and insert her hand through the os, using her other hand at the fundus to prevent the uterus from being forced upwards.
The midwife slips her hand between the edge of the placenta or separated portion (if the placenta has partially separated) and the uterus, then pry the rest of the placenta away, using her hand like a spatula and working her way across the entire surface.
Once the placenta is removed, quickly go over the uterine wall to remove any fragments, then grasp the placenta and bring it down and through the os.
The midwife should give methergine and/or pitocin, if she has this available, as soon as the placenta is out, and vigorous uterine massage should be started at once.
Assess the mother's blood loss and vital signs. If her blood pressure is low, she looks pale, feels cold and clammy, or her pulse is thready or erratic, give oxygen and transport at once to the nearest medical facility, treating the mother for shock.
If she is stable, push fluids, keep her warm and quiet, and continue to assess vital signs.
The placenta should be examined carefully to be sure it is complete. If there is any question, take the mother to the hospital immediately for a consultation (she may need a D&C). Bring the placenta in case evaluation by a pathologist is suggested.
If unsuccessful, consult client's health care provider and prepare for immediate transport. If sections of the placenta cannot be removed manually and the mother continues to bleed, methergine can be given as a last resort (if this is available). This will cause very strong contractions and may close the cervix, but the priority is to save the mother's life at this point and minimize blood loss during transport, particularly if she has lost more than 3 cups of blood and transport time is more than 20 minutes.
Watchful wait if parents decline transport. It will be very important to be very watchful for placental separation, bleeding, and maternal vital signs. Keep the mother focused on the here and now and keep her interacting with the midwife, her partner, and her baby during this time.
MEDICAL MANAGEMENT OF RETAINED PLACENTA
NORMAL PLACENTA DELIVERY
After delivery of the baby, the placenta normally detaches from the inside of the uterus and is expelled, often with additional pushing efforts by the mother. Normally this occurs within a few minutes of delivery of the baby, but may take as long as an hour.
The four signs of placental separation are:
- Apparent lengthening of the visible portion of the umbilical cord.
- Increased bleeding from the vagina.
- Change in shape of the uterus from flat (discoid) to round (globular).
- The placenta being expelled from the vagina.
MANUAL REMOVAL OF PLACENTA IN MEDICAL SETTING
Commonly, after about 30 minutes of waiting or if there is increased bleeding without evidence of placental separation, a manual removal of the placenta is undertaken. Anesthesia (regional or general) is typically used for this as manual removal can cause considerable abdominal cramping. Sometimes, IV narcotic analgesia will prove helpful in relieving this discomfort
Review for indications.
Review general care principles and start an IV infusion.
Provide emotional support and encouragement. Give pethidine and diazepam IV slowly (do not mix in the same syringe) or use ketamine.
Give a single dose of prophylactic antibiotics:
- Ampicillin 2 g IV PLUS metronidazole 500 mg IV.
OR
- Cefazolin 1 g IV PLUS metronidazole 500 mg IV.
Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor.
Wearing high-level disinfected gloves, insert a hand into the vagina and up into the uterine cavity.
Introducing one hand into the vagina along cord.
Let go of the cord and move the hand up over the abdomen in order to support the fundus of the uterus and to provide counter-traction during removal to prevent inversion of the uterus. Note: If uterine inversion occurs, reposition the uterus.
Move the fingers of the hand laterally until the edge of the placenta is located. If the cord has been detached previously, insert a hand into the uterine cavity. Explore the entire cavity until a line of cleavage is identified between the placenta and the uterine wall.
Supporting the fundus while detaching the placenta.
Detach the placenta from the implantation site by keeping the fingers tightly together and using the edge of the hand to gradually make a space between the placenta and the uterine wall. Insert the side of your hand in between the placenta and the uterus. You may need to push through the placental membranes to accomplish this.
Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall. Separate the placenta from the uterus with a sweeping motion.
If the placenta does not separate from the uterine surface by gentle lateral movement of the fingertips at the line of cleavage, suspect placenta accreta and proceed to laparotomy and possible subtotal hysterectomy.
After the placenta is mostly separated and has been swept off the uterus, curl your palm and fingers around the bulk of the placenta and exert a gentle downward and outward traction. You may need to release the placenta and then re-grab it. Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it.
With the other hand, continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn. Continue to grasp the placenta as you remove it from the uterine cavity. Then pull the placenta through the cervix. Most placentas can be easily and uneventfully removed in this way. A few prove to be problems.
Withdrawing the hand from the uterus.
Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed.
Give oxytocin 20 units in 1 liter IV fluids (normal saline or Ringer's lactate) at 60 drops per minute.
Have an assistant massage the fundus of the uterus to encourage a tonic uterine contraction.
If there is continued heavy bleeding, give ergometrine 0.2 mg IM or prostaglandins.
Examine the uterine surface of the placenta to ensure that it is complete. If any placental lobe or tissue is missing, explore the uterine cavity to remove it.
Examine the woman carefully and repair any tears to the cervix or vagina, or repair episiotomy.
RETAINED PLACENTA PROBLEMS
If the placenta is retained due to a constriction ring or if hours or days have passed since delivery, it may not be possible to get the entire hand into the uterus. Extract the placenta in fragments using two fingers, ovum forceps or a wide curette.
PLACENTA ACCRETA & PERCRETA
When you manually remove the placenta, be prepared to deal with an abnormally adherent placenta (placenta accreta or placenta percreta). These abnormal attachments may be partial or complete.
If partial and focal, the attachments can be manually broken and the placenta removed. It may be necessary to curette the placental bed to reduce bleeding. Recovery is usually satisfactory, although more than the usual amount of post partum bleeding will be noted.
If extensive or complete, you probably will not be able to remove the placenta in other than handfuls of fragments. Bleeding from this problem will be considerable, and the patient will likely end up with multiple blood transfusions while you prepare her for a life-saving, post partum uterine artery ligation or hysterectomy. If surgery is not immediately available, consider tight uterine and/or vaginal packing to slow the bleeding until surgery is available.
POST-PROCEDURE CARE
Observe the woman closely until the effect of IV sedation has worn off.
Monitor the vital signs (pulse, blood pressure, respiration) every 30 minutes for the next 6 hours or until stable.
Palpate the uterine fundus to ensure that the uterus remains contracted.
Check for excessive lochia.
Continue infusion of IV fluids.
Transfuse as necessary.
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HELPFUL PRODUCTS & FURTHER EDUCATION
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Prescription for Nutritional Healing: The A-To-Z Guide To Supplements
-- by Phyllis A. Balch, James F. Balch - 4th Edition
Prescription for Herbal Healing: The A-To-Z Reference To Common Disorders
-- by Phyllis A. Balch
The Complete Guide to Natural Healing
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