Retained Placenta

How the placenta normally delivers

After the baby is born, the uterus continues to contract. These contractions shear the placenta off the uterine wall and push it out, usually within 5 to 30 minutes. This is the third stage of labor. Contraction of the uterus also clamps the blood vessels where the placenta was attached, which controls bleeding.

Active management (an oxytocin injection after birth plus controlled cord traction) shortens the third stage and reduces bleeding, and is recommended by WHO.

Types of retained placenta

Risk factors

• previous retained placenta
• previous cesarean birth or other uterine surgery (major risk for accreta)
• placenta previa with a previous cesarean
• preterm birth, especially before 26 weeks
• stillbirth
• prolonged labor or labor induction
• IVF pregnancy
• uterine abnormalities and fibroids
• older maternal age and multiple previous births

Symptoms

At birth

• the placenta does not deliver within 30 to 60 minutes
• heavy bleeding

Days to weeks later (retained fragments)

• heavy or prolonged bleeding, or bleeding that restarts
• passing large clots or tissue
• cramping and abdominal pain
• fever and chills
• foul-smelling discharge
• delayed return of milk supply in some

Diagnosis

• At delivery: time since birth and examination of the delivered placenta for missing pieces.
• Later: pelvic ultrasound to look for tissue in the uterus, blood count, and tests for infection.

Treatment

Immediately after birth

• emptying the bladder, which helps the uterus contract
• oxytocin and other uterotonic medicines
• breastfeeding or nipple stimulation, which releases natural oxytocin
• controlled cord traction by the clinician

Manual removal of the placenta

If the placenta does not deliver, it is removed manually in the delivery room or operating room under spinal or general anesthesia. The clinician places a hand inside the uterus to separate and remove the placenta. A single dose of antibiotics is given to prevent infection.

Retained fragments

• medicine (misoprostol) to help expel tissue in some cases
• suction or hysteroscopic removal
• antibiotics for infection

Placenta accreta

Accreta often requires a planned cesarean hysterectomy at a specialist center, with blood available. In selected cases, the placenta is left in place to be reabsorbed, with close monitoring.

Complications

• postpartum hemorrhage and need for blood transfusion
• hemorrhagic shock
• infection of the uterus (endometritis) and sepsis
• uterine perforation or scarring (Asherman syndrome) from procedures
• hysterectomy in severe cases
• higher risk of retained placenta in future pregnancies

Frequently asked questions

How long can a placenta stay in after birth?

The placenta usually delivers within 30 minutes of birth. If it has not come out within 30 minutes with active management, or about 60 minutes with physiological management, it is considered retained and usually needs to be removed manually.

What are the signs of retained placenta after birth?

Signs of retained fragments include heavy or prolonged bleeding, bleeding that gets heavier again, large clots, cramping, fever and foul-smelling discharge, usually in the days or weeks after birth. These need prompt medical assessment.

Is retained placenta dangerous?

It can be. It is a major cause of severe bleeding after childbirth and can lead to infection. With prompt recognition and treatment, most women recover fully. Emergency care is needed for heavy bleeding or signs of infection.

Will I have a retained placenta again?

Having one retained placenta increases the risk in future births, but most women do not have it again. Your care team will plan for the third stage of labor and be ready to manage bleeding in your next delivery.