Manual removal of placenta

• 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 uterus (Fig P-42).

Figure P-42

 Introducing one hand into the vagina along cord

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• 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 (Fig P-43).

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.

Figure P43

  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.

• Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall.

• 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. 

• Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it (Fig P-44).

• 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continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn. 

Figure P-44

 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 L 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 (Table S-8).

• 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. 

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.

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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