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Before we delve into what we mean by a retained placenta, let’s take a moment to step back and briefly discuss what happens after the birth of your baby. You might think, now you have your baby in your arms, that the work is done. In fact, though, there is another vital stage that needs to be completed before your birth is technically over.
What is the third stage of labor?
Once your baby is born, your body goes through one final stage of labor to birth your placenta. Now that your baby has arrived the job of the placenta is complete. It’s no longer needed to support your baby, so your body will naturally expel it.
The stage between giving birth to your baby and the birth of your placenta and membranes is known as the third stage of labor.
For many women, little, if any, intervention is needed; however, in some cases (about 1-3% of births) retained placenta occurs.
Related reading: Third Stage Of Labour – Important Things You Need To Know.
How does your body birth the placenta?
After a vaginal birth, the placenta remains attached to the uterine lining. As it’s no longer needed, the placenta detaches from the uterine wall, to be expelled. This process is aided by the uterus, which continues to contract, due to the high levels of oxytocin in your system after birth. You might feel this happening; you might experience what feel like strong period pains.
This is a positive sign that your body is doing everything it needs to do at this stage. As the uterus shrinks in size, the placenta is pushed off the wall and will fall down into the vagina (birth canal) ready to be expelled.
In a physiological third stage of labor, the placenta is birthed by mom, by giving a few pushes; it can be helped by changing positions or taking advantage of gravity.
A physiological third stage can also be referred to as ‘expectant management’.
Related reading: The Third Stage Of Labor | Benefits Of A Natural Third Stage.
Active versus expectant management
Some people will opt to have an active management of the third stage. Active management means that a synthetic oxytocin injection (or drip) is given, after the birth, to help the placenta separate. The synthetic oxytocin works by making the uterus contract more strongly and often faster than the body would do naturally, as in physiological management.
Once the placenta has separated, your doctor or midwife will gentle guide the placenta out, using controlled cord traction. This means they’ll gently pull on the umbilical cord to guide the placenta out of the birth canal.
This option could be recommended to you if you have increased risk factors for retained placenta or bleeding, or to manage excessive bleeding after birth.
What happens if I have a cesarean birth?
If your baby is born by cesarean, your doctor will remove your placenta after the cord is clamped and cut. The delivery of the placenta will happen through the cut in your abdomen.
It’s possible to have a retained placenta after a cesarean birth but it’s less common. If the reason for the cesarean is placenta attachment abnormalities, it can make it difficult for the placenta to be removed cleanly. Small pieces of the placenta or membranes can remain inside the uterus, causing a partially retained placenta.
To find out more about cesarean birth read our article C-Section Birth – What Happens In A Cesarean?
What is retained placenta?
Retained placenta, or trapped placenta, occurs when the placenta is not expelled within one hour of the vaginal birth of your baby. Retained placenta can also occur when only some of the placenta tissue is expelled, or part of it was not removed during a c-section.
This might be noticed when doctors examine the placenta and find a tear, or notice that the placenta is not complete. In rare cases, the retained placenta can go unnoticed until other symptoms arise.
Another cause of retained placenta is a trapped placenta. This can occur when some or all of the placental tissue remains stuck or trapped in or behind the cervix as the cervix begins to close after birth.
3 signs of placental separation
After your baby’s birth, your midwife or doctor will look for signs that your placenta has detached from the uterus.
1. Blood loss
The most obvious sign to look for is blood loss. As the blood vessels that have supplied the placenta in pregnancy now begin to close off, as the placenta peels away, it’s normal to have what’s known as a separation bleed. This can be around 100-200 mls of blood loss. For healthy women, this amount of blood loss should not cause a problem.
2. Cord lengthening
Your care team will see whether the length of cord hanging outside of the body has lengthened. Once the placenta falls down into the birth canal the cord will appear to lengthen. This can give a good indication that the placenta has separated.
3. Uterine contractions
It’s normal to still feel some contractions or cramps after your baby is born. They will not be as intense as those you’ve just experienced but they are helping your body to complete this stage.
You can read more about the third stage of labor and what to look out for by reading our article Placental Expulsion | 3 Signs Of Placenta Separation.
What are the most common causes of retained placenta?
There isn’t always a known cause for each case of retained placenta.
Here are some risk factors for retained placenta:
- Previous cesarean birth
- Previous retained placenta
- Preterm birth
- Induction or augmentation of labor
- Uterine abnormalities
- Uterine atony (failure of the uterus to contract properly)
- Placental abnormalities or an adherent placenta (placenta accreta)
- Grand parity, which means having more than 5 previous births
- IVF conception
- Stillbirth
- Prolonged labor.
If you have one or more of these risk factors for retained placenta, remember it’s simply a risk and not a guarantee of complications. Your medical team will most likely discuss a managed vs physiological third stage with you and you can think about benefits and risks for each.
Related reading: Placenta Accreta | Symptoms, Bleeding And Treatment.
Retained placenta and medical interventions
World famous obstetrician and researcher, Doctor Michel Odent, believes the increase in interventions and the interruption of immediate mother-baby bonding can be linked to complications such as retained placenta. Routine interruptions to normal physiological birth are not without risks. Sometimes we need interventions in those situations where the benefit outweighs the risk. When it is not medically indicated, we need to assess the risk of interrupting a natural process.
Learn more about augmentation of labour by reading our article Augmentation Labor | What You Need To Know.
Retained placenta – symptoms and signs
In the case of a fully retained placenta, where the entire placenta is not expelled and remains in place, the diagnosis is easy. As you near an hour after vaginal birth and the placenta is nowhere to be seen, you’ll be diagnosed with retained placenta. This is also known as a prolonged third stage.
In cases where fragments of the placenta remain inside, it might take time – sometimes days or weeks – to notice. Some signs and symptoms are:
- Postpartum hemorrhage after the birth of the placenta or delayed postpartum hemorrhage (24 hours or more after birth)
- Passing clots or experiencing heavy bleeding
- Foul smelling discharge
- Fever or feeling unwell
- Painful cramping and contracting, or a tender abdomen
- Examination of the placenta shows possible tears or missing pieces
- Delay in milk production.
In cases of missed retained placenta, the typical postpartum ailments and concerns can mask the symptoms.
Can retained placenta affect milk supply?
Many new mothers are concerned about low milk supply or a delay in milk production. For most, infant led feeding is all that’s necessary to begin adequate milk production. In the case of retained placenta, there is a noticeable delay in milk supply, regardless of any other potential causes being ruled out.
Renee Kam, IBCLC, (International Board Certified Lactation Consultant) says: ‘The detachment of the placenta is the cause of hormonal changes that signal for a mother’s milk to ‘come in’. If any of the placental tissue gets left behind in the uterus, this signal is interrupted and a mother’s milk doesn’t come in properly’.
Related reading: How To Increase Milk Supply | Fast! 9 Best Things To Do.
How is retained placenta treated?
Sometimes, a number of simple techniques can be used to try to expel the placenta if changing positions and gravity hasn’t helped:
- Breastfeeding and/or skin to skin. Oxytocin, which is the hormone needed to contract the uterus during labor, is released during skin to skin and breastfeeding. This hormone is also required to birth your placenta. Simply holding your baby skin to skin, or initiating breastfeeding, can sometimes be enough for the uterus to contract enough to expel your placenta
- Empty the bladder. Getting up to empty your bladder is important. A full bladder can prevent the uterus from shrinking down in size and pushing the placenta off the wall. If the uterus is unable to do this you have an increased risk of heavy bleeding. If you are unable to empty your bladder, your care provider might suggest using a urinary catheter to help you
- Synthetic oxytocin. If you have a natural (physiological) third stage, and reach an hour after giving birth without the placenta expelling, your caregiver will likely want to give you an injection of synthetic oxytocin, to encourage the uterus to contract and reduce heavy bleeding. The contractions should help with placental expulsion. Your provider might try to pull the umbilical cord gently, to remove the placenta if it appears to have detached but is not yet expelled. If the synthetic oxytocin doesn’t work, or if there are concerns about severe bleeding, your medical team might try another medication or an intravenous oxytocin drip to help.
- Manual extraction (removal). Some doctors opt for a manual removal of placenta (MROP), where they will use their hands and manually remove the placenta or pieces of the placenta that remain inside
- Suction curettage. If none of the above options works, then further surgical intervention might be recommended. A curettage is an emergency surgery, usually performed when there is severe blood loss. This procedure will remove any placenta remaining inside. Both manual placenta removal and curettage are done with local or general anaesthesia so that you are comfortable
- Hysterectomy. In extremely rare cases, if bleeding cannot be controlled, or if the placenta is embedded so deeply into the wall of the uterus that it cannot be safely removed, sometimes the safest option is to remove the placenta and the entire uterus. This would be done as a last resort to save someone’s life and it would be done under a general anaesthetic.
If you are discharged and the retained placenta goes unnoticed, you might be readmitted for care. If there’s concern aboutf infection, your re-admittance would include a procedure to remove the retained placenta pieces, as well as antibiotic IV medication.
Some providers will do an outpatient or day procedure to remove the retained placenta, and will send you home with oral antibiotics to prevent or treat any signs of infection.
How serious is retained placenta?
For many women, a retained placenta after a vaginal birth can be managed in a straightforward way; however, the risks associated with placental retention can be very serious.
If retained placenta is left untreated, women are susceptible to infection and massive hemorrhage, which, in rare cases, can be life threatening.
Life threatening blood loss can lead to damage to major organs and might require numerous blood transfusions, iron infusions or treatment for anaemia.
This rare complication can also have a significant impact on future pregnancies.
Related reading: Iron Rich Foods For Pregnancy | 9 Things To Eat.
Can retained placenta be prevented?
Birth can be unpredictable, so it can be hard to reduce the risk of rare complications. If you had a retained placenta with a previous birth, or you are known to have placenta accreta in your current pregnancy, you have a higher chance of having a retained placenta. Your provider will probably make some suggestions, antenatally, for you to consider.
When birth is low-risk, the less interference with medical interventions, the lower the risk of complications. Keeping mama and baby together skin to skin and undisturbed can lower the risk of, or prevent, retained placenta. Avoiding unnecessary synthetic oxytocin inductions and augmentations might also reduce the risk, as well as avoid a c-section and a subsequent uterine scar. Too much synthetic oxytocin can cause uterine atony, which is when the uterus stops contracting or isn’t contracting effectively.
If there are complications, even despite allowing physiological birth, we are fortunate to have access to medical technology. Retained placenta is often easily treated. Choosing a healthcare provider that you really trust is invaluable when complications arise. When you trust your midwife or doctor, you can rest assured they will be there to help you have a positive birth and help resolve unexpected complications.
Related reading: Who Cares? Maternity Care Options For Australian Women.
