The retained placenta

The incidence and importance of retained placenta (RP) varies greatly around the world. In less developed countries, it affects about 0.1% of deliveries but has up to 10% case fatality rate. In more developed countries, it is more common (about 3% of vaginal deliveries) but very rarely associated with mortality. There are three main types of retained placenta following the vagina delivery: placenta adherens (when there is failed contraction of the myometrium behind the placenta), trapped placenta (a detached placenta trapped behind a closed cervix) and partial accreta (when there is a small area of accreta preventing detachment). All can be treated by manual removal of placenta, which should be carried out at 30-60 minutes postpartum. Medical management is also an option for placenta adherens and trapped placenta. The need for manual removal can be reduced by 20% by the use of intraumbilical oxytocin (30 i.u. in 30 mL saline). A trapped placenta may respond to glyceryl trinitrate (500 mcg sublingually) or gentle, persistent, controlled cord traction.     

Reoccurrence of retained placenta at a subsequent delivery: an observational study

Objective: To test the generalizability of previously reported increased risk of reoccurrence of retained placenta in yet another setting.

Methods: In this observational retrospective study we longitudinally followed women who had a vaginal delivery complicated by a partial or complete retained placenta at Edith Wolfson Medical Center between 1 January 2009 and 31 December 2012. The study group included parturient women who had a partial or complete retained placenta after a vaginal delivery (n?=?90). The control group included parturient women who did not have a partial or complete retained placenta after a vaginal delivery from the same time period using the same inclusion criteria (n?=?90).

Results: Retained partial or complete placenta at a previous delivery was found to be an independent risk factor for retained partial or complete placenta in a subsequent delivery (adjusted OR 9.8, 95%CI 1.2 to 80.6, p?=?0.032) and for retained partial or complete placenta and/or postpartum hemorrhage in a subsequent delivery (adjusted OR 14.1, 95% CI 1.7 to 111.9, p?=?0.012), after controlling for gestational age and induction of labor at previous delivery.

Conclusion: Retained partial or complete placenta at an index delivery increases the risk of reoccurrence of retained partial or complete placenta in a subsequent delivery.     

Policies for manual removal of placenta at vaginal delivery: variations in timing within Europe

The length of the third stage of labour is a potential modifiable risk factor for postpartum haemorrhage at vaginal delivery, but there is no definitive evidence that early intervention to remove the placenta manually will prevent postpartum haemorrhage. We report a wide variation between countries in Europe in policies about the timing of manual removal of placenta. Two groups of countries with clearly divergent policies were identified. A randomised controlled trial is needed to provide definitive evidence on the risks and benefits of manual removal of placenta at different timings after vaginal delivery.     

Different routes and forms of uterotonics for treatment of retained placenta: a randomized clinical trial*

Objectives: To compare between three different uterotonics (oxytocin, carbetocin and misoprostol) given via three different routes (intraumbilical, intravenous and sublingual, respectively) in reducing the need for manual removal of placenta (MROP).

Methods: A randomized trial for cases with retained placenta 30?min following vaginal delivery. They received intraumbilical oxytocin, intravenous carbetocin or sublingual misoprostol. Main outcome measures were delivery of the placenta within 30?min following drug administration, and need for MROP. Secondary outcome measures were injection to placental delivery time, post-delivery hemoglobin, need for blood transfusion or additional uterotonics.

Results: The overall success rate was 66.7% (64/96), 71.3% (67/94) and 63.7% (58/91) for oxytocin, carbetocin and misoprostol groups, respectively (p?>?0.05). When time needed to achieve placental delivery considered, a significant difference was observed with the shortest time for carbetocin (16.61?±?3.76?min), then oxytocin (18.28?±?3.34?min) and lastly misoprostol (23.00?±?3.38?min) (p?<0.001). Again, carbetocin group needed less additional uterotonics to achieve adequate uterine contractions (p?<0.001).

Conclusions: Although we aimed to exploit the advantage of certain drug over another, all seemed to have close efficacy but it would be important that further research should highlight availability, cost, ease of administration and storage requirements to determine which agent would best be used in this clinical scenario.     

Intravenous nitroglycerin for controlled cord traction in the management of retained placenta

Objective

To determine the effect of 200 μg of intravenous nitroglycerin in the release of retained placenta by controlled cord traction.

Methods

In this randomized controlled study, 40 women with a placenta retained for 30 minutes received intravenously 200 μg of nitroglycerin or a normal saline solution before umbilical cord traction was initiated. The rates of successful removal of the retained placenta in the study (n = 20) and control (n = 20) groups were compared, as were blood pressure, pulse rate, blood loss, and adverse effects.

Results

The placenta was released in only 15% and 20% of the participants in the study and control group, respectively. The remainder of the participants required general anesthesia and manual removal of the retained placenta regardless of group assignation. Blood pressure fell in significantly more women in the study group, but there were no differences in estimated blood loss or minor adverse effects.

Conclusion

Intravenously administered nitroglycerin did not facilitate the release of retained placenta by umbilical cord traction. However, cord traction may be performed longer than 30 minutes to attempt releasing the placenta before operative manual removal is initiated.     

A randomized controlled trial on the value of misoprostol for the treatment of retained placenta in a low-resource setting

Objective

To evaluate the efficacy and safety of misoprostol among patients with retained placenta in a low-resource setting.

Methods

A prospective, multicenter, randomized, double-blind, placebo-controlled trial was carried out in Tanzania between April 2008 and November 2011. It included patients who delivered at a gestational age of 28 weeks or more and had blood loss of 750 mL or less at 30 minutes after delivery. Sublingual misoprostol (800 μg) was compared with placebo as the primary treatment. Power analysis showed that 117 patients would be required to observe a reduction of 40% in the incidence of manual removal of the placenta (MRP; P = 0.05, 80% power), the primary outcome. The secondary outcomes were blood loss and number of blood transfusions.

Results

Interim analysis after recruitment of 95 patients showed that incidence of MRP, total blood loss, and incidence of blood transfusions were similar in the misoprostol (MRP, 40%; blood loss, 803 mL; blood transfusion, 15%) and placebo (MRP, 33%, blood loss 787 mL, blood transfusion, 23%) groups. The trial was stopped because continuation would not alter the interim conclusion that misoprostol was ineffective.

Conclusion

Treatment with misoprostol was found to have no clinically significant beneficial effect among women with retained placenta.Clinical Trial Registration: Current Controlled Trials ISRCTN16104753     

Afterpains: A Comparison Between Active and Expectant Management of the Third Stage of Labor

Abstract: Background: Management of the third stage of labor, the period following the birth of the infant until delivery of the placenta, is crucial. Active management using synthetic oxytocin has been advocated to decrease blood loss. It has been suggested, but not studied, that oxytocin may increase afterpains. The aim of this study was to compare women’s experience of pain intensity when the third stage of labor was managed actively and expectantly and their experience of afterpains. Methods: A single‐blind, randomized, controlled trial was performed at two delivery units in Sweden in a population of healthy women with normal, singleton pregnancies, gestational age of 34 to 43 weeks, cephalic presentation, and expected vaginal delivery. Women (n = 1,802) were randomly allocated to either active management or expectant management of the third stage of labor. Afterpains were assessed by Visual Analog Scale (VAS) and the Pain‐o‐Meter (POM‐WDS) 2 hours after delivery of the placenta and the day after childbirth. Results: At 2 hours after childbirth, women in the actively managed group had lower VAS pain scores than expectantly managed women (p = 0.014). Afterpains were scored as more intense the day after, compared with 2 hours after, childbirth in both groups. Multiparas scored more intense afterpains, compared with primiparas, irrespective of management (p < 0.001). Conclusions: Active management of the third stage of labor does not provoke more intense afterpains than expectant management. (BIRTH 38:4 December 2011)     

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study

Objective: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH).

Methods: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ² tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000?cc), retained placenta over 30?min and manual removal of the placenta.

Results: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p?=?0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR?=?0.69 (95% CI 0.50–0.97; p?=?0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta.

Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.     

Foley尿管水囊联合缩宫素用于足月妊娠促宫颈成熟的有效性、安全性和对产程的影响#br#

Objective?To explore the application effectiveness and safety of Foley catheter water bag combined with oxytocin in promoting cervical ripening and its influences on stages of labor in full-term pregnancy. Methods?A total of 102 full-term pregnant women with induced labor indications in Obstetrics Department of our hospital were enrolled between June 2017 and January 2021. According to different treatment methods by their willingness, they were divided into control group (51 cases, oxytocin) and combination group (51 cases, Foley balloon combined with oxytocin). Before induced labor and after intervention, cervical ripening effects in both groups were observed. The effect of cervical ripening before labor induction and after intervention in the two groups was observed, and the labor process and maternal and infant outcomes were compared between the two groups. Results?After intervention, Bishop scores were significantly higher than those before induced labor in both groups, which were significantly higher in combination group than control group (P<0.05). The first stage of labor and total stage of labor in combination group were significantly shorter than those in control group (P<0.05). The successful rate of labor induction and vaginal delivery in the combined group were higher than those in the control group, and the rates of postpartum hemorrhage and soft birth canal tearing were lower than those in the control group (P<0.05). The neonatal Apgar score in combination group was higher than that in control group (P<0.05). Conclusion?Foley catheter water bag combined with oxytocin can effectively and safely promote cervical ripening and shorten stages of labor in full-term pregnant women.     

Clinicians' guide to the use of oxytocin for labor induction and augmentation

Oxytocin is commonly used in obstetrics for labor induction and augmentation. Careful assessment of the individual clinical situation based on indications and contraindications is essential to enhancing safe and effective use. Counseling the woman and her partner regarding potential risks and benefits before use is necessary to promote informed consent. At least 39 weeks of gestation is required for elective labor induction. Recent research has shown that deferring elective induction until cervical readiness has been achieved without the use of pharmacologic agents can be beneficial in reducing the risk of cesarean birth associated with elective induction. A conservative physiologic oxytocin protocol for labor induction and augmentation is recommended to minimize the risk of side effects. Although treatment of excessive uterine activity related to oxytocin has not been studied prospectively, several interventions such as maternal repositioning, an intravenous fluid bolus, and discontinuation of the oxytocin infusion are beneficial in returning uterine activity to normal, based on retrospective review of oxytocin-induced tachysystole. Perinatal quality measures from the National Quality Forum and the Joint Commission can be useful in monitoring care related to induction of labor. These include elective births before 39 weeks of pregnancy and cesarean births for low-risk, first-birth mothers.     

Previous history of surgically induced abortion and complications of the third stage of labour in subsequent normal vaginal deliveries

Objective. To estimate the risk of complications of the third stage of labour needing manual revision of uterine cavity or curettage in deliveries following one or multiple induced abortions in nulliparous women who had singleton live births in Estonia in 1994–2002.

Methods. Registry study using the data from the Estonian medical birth registry: 32,652 women had not had any abortions, 7333 women had had one and 2383 women had had two or more surgically induced abortions before their first delivery. Multiple logistic regression analysis was performed to estimate crude odds ratios (OR), adjusted ORs and their 95% confidence intervals, with women having had no abortions as the reference group. Adjustment was made for maternal age, sex and weight of infant, labour induction/augmentation.

Results. In the single abortion group, the crude OR was 1.25 (95% confidence intervals (CI) 1.12–1.40), the adjusted OR was 1.23 (95% CI 1.10–1.38); in the multiple abortion group the crude OR was 1.28 (95% CI 1.06–1.53), the adjusted OR was 1.24 (95% CI 1.03–1.49).

Conclusions. Our findings suggest a positive association between one or more first trimester abortion(s) and the risk of complications in the third stage of labour in subsequent singleton delivery.     

低置胎盘的分娩方式探讨

目的:探讨低置胎盘的合理分娩方式。方法:选取2012年1月1日至2014年4月30日在我院分娩的单胎头位低置胎盘产妇650例。按是否试产将患者分为试产组和选择性剖宫产组;按分娩前最后一次超声胎盘下缘距离宫颈内口的距离将患者分为低置胎盘1组(下缘距内口≥0mm但20mm)、低置胎盘2组(下缘距内口≥20mm但40mm)和低置胎盘3组(下缘距内口≥40mm但70mm)。分析患者的阴道试产成功率、试产失败原因、产后出血量及分娩期并发症。结果:(1)试产组的试产总成功率为82.64%,低置胎盘1、2、3组的阴道试产成功率分别为62.5%、82.61%和84.65%,其中因产前出血而改行剖宫产的风险分别为31.25%、8.7%和1.49%;(2)低置胎盘1组患者中阴道试产和选择性剖宫产的产后出血量无显著差异[(590.94±382.79)ml vs(465.68±367.83)ml];低置胎盘2组和3组中阴道试产的产后出血量明显少于剖宫产组[(267.17±104.47)ml vs(388.10±205.61)ml,P0.0001]及[(293.00±263.731)ml vs(348.59±98.68)ml,P0.0001]。结论:胎盘下缘距宫颈内口≥20mm不应作为孕妇选择性剖宫产的手术指征。     

Length of the third stage of labor at term pregnancies is shorter if placenta is located at fundus: prospective study

AIM: To investigate how the location of the placenta at term pregnancies affects the duration of the third stage of labor and to discuss the possible mechanisms affecting the duration of the third stage. We believe that this is the first prospective study comparing the duration of the third stage of labor according to placental location. METHODS: The placental implantation was determined as anterior (n = 78), posterior (n = 59), or fundal (n = 64) by ultrasound, in 201 women with singleton pregnancies. After delivery of the newborn, oxytocin infusion was routinely given. Duration of the third stage of labor was compared by anova. P < 0.05 was determined as significant. RESULTS: The duration of the third stage of labor was 10.36 +/- 5.94 min, 10.44 +/- 5.35 min, and 8.12 +/- 4.25 min with placentas located anteriorly, posteriorly, and fundal, respectively. The length of the third stage was significantly shorter in the fundal placenta group. CONCLUSION: In this study, the length of the third stage of labor was approximately 2 min shorter with placentas located at the fundus compared to the other two groups. The mechanism responsible for shorter duration may be the bipolar separation of fundal placentas in contrast to usual unipolar down-up separation of anterior or posterior placentas. Another contributing factor may be the use of oxytocin infusion for the management of the third stage, however this should be investigated by further studies by using real time ultrasonography.     

The clinical research into the application of multifunctional airbag abdominal pressure belt in midwifery and in the prevention of postpartum hemorrhage

Objective: Explore the effect of the multifunctional airbag abdominal pressure belt on midwifery and on the prevention of postpartum hemorrhage.

Methods: Select 363 natural delivery cases of hospitalized primiparae and divide them randomly into two groups. In the observation group, 182 primiparae used the multifunctional airbag abdominal pressure belt during the second and third stages of labor, whereas the control group of 181 did not use the belt. Delivery outcomes of the primiparae and their fetus were then observed.

Results: The average duration for the second stage of labor, from head emergence to delivery, placenta delivery and postpartum hemorrhage were all shorter in the observation group (p?p?>?0.05). No statistical difference was found in primipara signs and no fetal heart rate change of the primiparae under different internal pressures of the belt during the second stage of labor in the observation group (p?>?0.05).

Conclusion: By closely monitoring and appropriately adjusting the internal pressure of the belt, the multifunctional airbag abdominal pressure belt can speed up the second and third stages of labor, prevent postpartum hemorrhage and promote natural delivery.