Retained Placenta

Written by : Dr.M.D.Mazumdar, MD

The placenta is said to be retained when it is not expelled from the uterus even 30 minutes after the delivery of the baby.

Normally the placenta is expelled in three stage - it first separates from the uterine muscle, then it descends into the lower segment of the uterus and vagina and then it is expelled outside. Problems can occur at any of these stages.

Causes of Retained Placenta:

  • Placenta separated but not expelled: The placenta may separate completely from the uterine muscle but may still be retained within the uterus. There are three causes for this retention:

    • Failure of the woman to push out the placenta due to exhaustion or prolonged labour.
    • Closure of the cervix preventing the placenta from being expelled.
    • A constriction ring in the uterus can hold up the placenta.

  • Simple Adherent Placenta:The placenta may fail to separate completely from the uterine muscle due to lack of contraction of the uterine muscles. This condition, called 'uterine atonicity' occurs in cases where the uterine muscles have become lax, either due to repeated pregnancy, prolonged labor or overdistension of the uterus during pregnancy, as in twin pregnancy. Simple Adherent Placenta is the commonest cause for retention of placenta.

  • Morbid adhesion of the placenta: Morbid adhesion of the placenta can occur when the placenta is implanted deeply into the uterine muscles and thus fails to separate. The placenta can burrow upto different depths in the uterine muscle. In simple cases, it is just attached firmly to muscle and can be stripped off by hand. In severe morbid adhesion, the placenta can burrow through the full thickness of the muscle. In this case, the uterus may be need to be removed ('hysterectomy') to control the bleeding. There are three types of morbid adhesion of the placenta:

    • Placent Accreta: In this condition, the placenta penetrates deep into the uterine endometrium and reaches the muscles but does not penetrate into the muscles.

    • Placent Increta: Here, the placenta attaches even deeper into the uterine wall and penetrates into the uterine muscle.

    • Placent Percreta: In this condition, the placenta not only penetrates through the full thickness of the uterine muscles but also attaches to another organ such as the bladder or the rectum. Placenta percreta is very rare.

    Morbid Adhesion of Placenta
    Morbid Adhesion of Placenta

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    Risks of Retained Placenta

    Management / Treatment of Retained Placenta

    Treatment will depend on the cause of the retention of the placenta. If bleeding is present, active treatment is done to control the blood loss and support the general condition of the patient.

    • Controlled Cord Traction

      If the placenta is separated but not expelled, then controlled cord traction should be carried out. In this method, the uterus is held in place or pushed up gently through the abdominal wall by the left hand. The cut umbilical cord hanging from the vagina is held in the right hand and pulled steadily and slowly to pull out the placenta.

      Controlled Cord Traction

    • Manual removal of the placenta

      The placenta may need to be removed manually if controlled cord traction fails.

      The patient is put under general anesthesia in the operation theatre. Under all aseptic conditions, the sterile gloved hand of the doctor is inserted into the uterus. The placenta is stripped from the uterine muscle gently and brought out.

      Manual Removal of Placenta

    • Hysterectomy: If the placenta is too deeply embedded into the uterine musculature (called placenta accrete), a hysterectomy to remove the uterus may be indicated.

    Also Read-

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