MANUAL REMOVAL OF PLACENTA

1	Provide emotional support and encouragement. Sedation or anaesthesia may be required.
2	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.
3	Hold the umbilical cord with a clamp. Pull the cord gently until it is parallel to the floor.
4	Wearing sterile gloves, insert a hand into the vagina and up into the uterus along the cord.
5	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 (Figure 12.13). If uterine inversion occurs, reposition the uterus.
Figure 12.13
6	Move the fingers of the hand laterally until you locate the edge of the placenta.
7	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.
8	Detach the placenta from the implantation site by keeping your fingers tightly together and using the edge of your hand to gradually make a space between the placenta and the uterine wall.
9	Proceed slowly all around the placental bed until the whole placenta is detached from the uterine wall.
10	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.
11	Hold the placenta and slowly withdraw the hand from the uterus, bringing the placenta with it (Figure 12.14). 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continue to provide counter-traction to the fundus by pushing it in the opposite direction of the hand that is being withdrawn.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 12.14
12	Palpate the inside of the uterine cavity to ensure that all placental tissue has been removed.
13	Give oxytocin 20 units in 1 L IV fluids (normal saline or Ringer’s lactate) at 60 drops per minute.
14	Have an assistant massage the fundus of the uterus to encourage a tonic uterine contraction.
15	If there is continued heavy bleeding, give ergometrine 0.2 mg IM or prostaglandins.
16	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.
17	Examine the woman carefully and repair any tears of 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