Clinical guideline for the diagnosis and

Document Title
management of retained placenta

Type of document Clinical

This guideline gives guidance to all hospital

and community based midwives, Obstetricians
Brief summary of contents and obstetric anaesthetists in the diagnosis
and management of a retained placenta

Executive Director responsible for Executive Director of Nursing, Midwifery and

Clinical Guideline: AHPs
Directorate / Department responsible Maternity risk manager, Maternity services,
(author/owner): obs and gynae directorate

Contact details: 01872 252270

Date original version written: October 2007

Date revised: October 2009 and December 2011

This document replaces (exact title of Management of retained placenta
previous version):
Approval route (names of Maternity guidelines group, labour ward forum,
committees)/consultation: Obs and gynae directorate meeting

Divisional Manager confirming approval

{File copy signed}
processes
Name and Post Title of additional
signatories
Equality Impact Assessment appended
Approval must not be given if the EIS is Yes
not attached
Signature of Executive Director giving
{File copy signed}
approval
Publication Location (refer to Policy on
Internet & Intranet  Intranet Only
Policies – Approvals and Ratification):
Document Library Folder/Sub Folder Midwifery and obstetrics

Date of final approval: 12th December 2011

Date guideline becomes live: 12th December 2011

Date due for revision: 1st December 2014

Links to key external standards CNST 3.7,
Related Documents: Management of massive obstetric
 haemorrhage

Suggested Keywords: Placenta, 3rd stage of labour, PPH

Training Need Identified? No.

This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

This version supersedes any previous versions of this document.

All or part of this document can be released under the Freedom of Information Act
2000

This document is to be retained for 10 years from the date of expiry.

Clinical Guideline Template

Version No: 2.1
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 Women’s and children’s division
Maternity services

Clinical guideline for the diagnosis and management of retained placenta

1. Aim/Purpose of this Guideline

This guideline gives guidance to all hospital and community based midwives,
Obstetricians and obstetric anaesthetists in the diagnosis and management of a
retained placenta

2. The Guidance
The placenta is considered retained if it remains undelivered after 30 minutes of
actively managed third stage and 60 minutes of physiological third stage.¹
On diagnosis of retained placenta care must be transferred to a consultant unit and
to obstetric care.

Retention may be caused by

 Full bladder
 Uterine abnormality
 Abnormal placental insertion²

A retained placenta will not necessarily be immediately accompanied by

haemorrhage but a haemorrhage can occur at any point. This may be concealed
therefore it is essential to monitor the women closely, using a MEOWS chart, to
identify early deterioration in her condition. This must be commenced at the point of
diagnosing retained placenta.
N.B. If PPH occurs at any point refer to PPH guideline

If in a community setting, prepare for transfer as soon as retained placenta is

diagnosed -call 999

Management:
 Regular maternal observations initially every 15 minutes on a MEOWS chart (be
guided by MEOWS score/level of bleeding).
 Simple measures may be effective – ensure bladder empty
- nipple stimulation/breast feed
- further controlled cord traction
 Ensure good IV access (bleeding is always a potential problem)
 Take blood for FBC and group and save, cross match if necessary
 Inform obstetrician of retained placenta and any concerns about maternal
condition.
 Do NOT use IV oxytocin infusion
 Intra-umbilical vein injection of 20ml saline + 20IU oxytocin1., 2. If delivered in
the community setting this should not be undertaken until the patient is on
delivery suite. If a twin delivery this should only be attempted under instruction
from the obstetrician.

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 If placenta still retained after further 20 minutes
 Obtain consent for manual removal
 Inform anaesthetist/ODA/theatre team
 Transfer patient to theatre and ensure adequate anaesthesia
 Perform manual removal
 Antibiotics IVI at time of procedure, and orally thereafter. 3.4

A retained placenta in a patient with a previous caesarean section must be treated

with great care; the likelihood of a placenta acreta is increased. During manual
removal if there is any suggestion that the placenta is not separating call a
consultant for further advice.

Reference: 1. Intrapartum care (CG55) NICE June 2008

2. Manorama Purwar. Injection into umbilical vein for management
of retained placenta: RHL review – WHO Library
3. RCH antibiotic policy, Jan 2009
4. Chongsomchai, C. in Cochrane database – Review published
2006

3. Monitoring compliance and effectiveness

Element to be The number of retained placenta will be recorded on the maternity
monitored services monitoring dashboard on a monthly basis
Lead Maternity risk management team.

Tool The following points should be audited

 In the absence of active bleeding, the placenta was retained
greater than 60 minutes following physiological
management.
 Regular maternal observations were undertaken on a
MEOWS chart
 IV access was ensured
 IV oxytocin infusion was not used

Trends should also be excluded, such as:

 Person conducting the delivery
 Type of management of the third stage.

Frequency If the red flag alert is breached on the maternity dashboard, an audit of
retained placenta for the month in question will be allocated to a junior
doctor/midwife by the risk management midwife
Reporting The results will be reviewed at the maternity risk management
arrangements forum.
Acting on Any deficiencies are identified and action plan will be developed
recommendations and monitored by the maternity risk management forum
and Lead(s)
Change in Results and lessons learnt will be distributed through the maternity
practice and risk management newsletter and presented at the perinatal audit
lessons to be meeting
shared
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4. Equality and Diversity
4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.

4.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 1.

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Appendix 1.Initial Equality Impact Assessment Screening Form
Name of service, strategy, guideline, policy or project (hereafter referred to as policy)
to be assessed:
Clinical guideline for the diagnosis and management of retained placenta
Directorate and service area: Is this a new or existing Procedure?
Maternity services, Obs and gynae
directorate Existing

Name of individual completing Telephone:

assessment:
Jan Clarkson 01872 252270
Maternity risk manager
1. Procedure Aim* This guideline gives guidance to all hospital and
community based midwives, Obstetricians and
obstetric anaesthetists in the diagnosis and
management of a retained placenta

2. Procedure Objectives* To ensure safe, effective and evidence based diagnosis

and management of a retained placenta
3. Procedure – intended To ensure safe, effective and evidence based diagnosis
Outcomes* and management of a retained placenta

4. How will you measure By compliance monitoring

the outcome?

5. Who is intended to Pregnant woman

benefit from the
Procedure?

6a. Is consultation No
required with the
workforce, equality
groups etc. around this
procedure?

b. If yes, have these

groups been consulted?

c. Please list any groups

who have been consulted
about this procedure.

*Please see Glossary

7. The Impact

Please complete the following table using ticks. You should refer to the EIA guidance
notes for areas of possible impact and also the Glossary if needed.
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  Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the ‘Positive impact’ box.
 Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the ‘Negative impact’ box.
 Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the ‘No impact’ box.

Equality Positive Negative No Reasons for decision

Group Impact Impact Impact
Age Y All pregnant woman

Disability Y All pregnant woman

Faith and Y All pregnant woman

Belief

Gender Y All pregnant woman

Race Y All pregnant woman

Sexual Y All pregnant woman

Orientation

You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 A negative impact and
 No consultation (this excludes any policies which have been identified as not
requiring consultation).

8. If there is no evidence that Full statement of commitment to policy of

the policy promotes equality, equal opportunities is included in the
equal opportunities or improved guideline
relations - could it be adapted
so that it does? How?

Please sign and date this form.

Keep one copy and send a copy to the Human Resources Team,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department,
Lamorna House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
They will arrange for a summary of the results to be published on the Trust’s web site.

Signed: Jan Clarkson

Date: 2nd December 2011

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