Midwifery Today Community

any ideas as to what to do when there is placenta retention?

I am a missionary midwife serving in Guatemala,I grew up here, my parents came from Pa. we continue to serve the Lord here and the people of Guatemala.

I have a good midwife friend who says that with a "sticky placenta" you can ask the mama to stand up and give a few good coughs to see if that will dislodge the placenta if it appears to be slow in coming.

I have a book entitled Where Women Have No Doctor: health guide for women by Burns et al.  It's put out by the Hesperian Foundation out of Berkley CA.  I was able to get mine for free and I bet you can, too.  They also put out A Guide for Midwives and several other publications which are helpful for people working in developing countries. (www.hesperian.org) Here's what that book says about retained placenta (p92-93):

"If the mother is too weak to deliver the placenta herself or if she is bleeding so heavily she becomes faint, you may need to help guide the placenta out.  Only do this if you believe the woman's life is in danger.  First look for signs that the placenta has separated.

1. Mark the cord by tying a clean string around it about a hand's width from the vagina.
2. Put one hando n teh mother's abdomen just about her pubic bone. Wait until her womb feels hard and push upward toward her head.
3. If the string you tied to the cord moves toward the mother, the placenta is probably still attached to the womb. Take the mother to the nearest hospital.  If the string ont eh cord does nto move, the placenta may be lying in the vagina and you can try to help guide it out.
4. With your other hand, hold the cut end of the cord (a dry cloth will help), and pull slowly and firmly.  Do not pull hard.  If you do not feel the placenta moving down, STOP.
5. When the placenta comes out, rub the top of the womb with one hand until it stays very hard. At the same time, push teh bottom of the womb upward with your other hand.
6. Give fluids either in teh vein (IV) or in the rectum [they reference a page # here for those instructions]

If the placenta does not come out and the mother continues to bleed, take her to a health center or hospital.

 I have had really good results with homeopathic secale for retained placenta.

Just remember to help prevent placental retention you want to keep the birth atmosphere the same during the Third Stage as throughout - the mother needs that buildup of hormones for her body to effectively birth the placenta.

I've also found angelica and dong quai tincture to be very useful in bringing down a sticky placenta.

how long are you waiting? sometimes all they need is a little more time. having the mother get up and then squat to pee can help as well

 majikfaerie, I thought Angelica & Don Quai were the same thing.

BTW, Jesus had a midwife, named Dorcas.

There is Angelica (A.atropurpurea) and Dong Quai (Angelica sinensis)   :)

I was taught that Dong quai, Angelica sinensis, is a perennial and therefore exerts more of a tonic action; while Angelica archangelica & other Angelica species are biennials which possess a sharper, more acute action.

Adrienne:

I was taught that Dong quai, Angelica sinensis, is a perennial and therefore exerts more of a tonic action; while Angelica archangelica & other Angelica species are biennials which possess a sharper, more acute action.

So which would be more appropriate...I'm assuming Angelica Archangelica etc due to it's acute action? Especially if there was bleeding, for example with a partial separation?

No one has mentioned manual extraction of placenta. Although this can be very uncomfortable for a woman without analgesics, it can prevent large blood loss when indicated.

Ideally this should be done with a sterile gloves and gown, to minimize infection. I am successful 95% of the time by simply placing 2 fingers in the vagina and apply downward pressure on the placenta/membranes just above the cord insertion, while applying gentle and slightly upward traction to the cord. I curl my fingers slightly downward to get some "traction" on the membranes. This also allows me to feel if the placenta is descending and helps to guide the amount of traction. If a tearing sensation is felt (the cord separating) then traction on the cord is reduced. 

If this is ineffective and the mother is bleeding heavily, then I will need to enter the uterine cavity with my hand, while applying fundal pressure for stabilization, and manually remove the placenta. Keep in mind, the cervix and vagina have just passed a baby's head which is much larger than a hand, so this is not as horrible as it might seem and can be life saving. I have only had to do this a few times in my career, as the above mentioned technique works well. That said too, this is not a procedure that is practiced and rehearsed in Med School, so a confident midwife should do just as well as a first time physician. 

Would recommend reviewing the literature and diagrams before attempting though, and then only if bleeding is severe and help is not imminent.

Hope this helps.

Great tip on the 2 finger, downward pressure with traction, Henry! 

I have had to do about 4 complete manual removals in my midwifery life and while uncomfortable for mama and midwife it can be a blessing to have the confidence to do this manuever.  I gained the confidence after a retained placenta that I transported for, after trying all other therapies to my knowledge.  The attending OB simply did a VERY brutal  manual removal while being condescending to my mama and me and I swore I would never put a woman through that if I could do it more humanely at home.

With the 2 fingers inside, I can usually get a "grip" on what feels like a band of membranes above the cord insertion site, which facilitates removal. If the cord feels like it wants to separate, I can guide 1 or 2 ring forceps (aka sponge stick, minus the sponge) inside the cervix and grasp the membranes and placenta to continue gentle traction. 

This can be done with very minimal discomfort on non-anesthetized patients, in my experience, and could save a trip to the hospital, or a blood transfusion.

Would this technique be advisable/doable in the original poster's case?  Is this something a novice could accomplish working on her own or with those with little-to-no experience?

The poster seemed to indicated that she was a midwife, so I assumed some level of training. The manual technique is really only applicable to those who have training such as a CPM/CNM, but its really not a big difference than a good bimanual exam in terms of technique. Therefore I would say that anyone who can perform a proper pelvic exam and understands the anatomy could perform this procedure.

Thanks, Henry.  I was just wondering as I couldn't really assess how much experience Anita had.  I wish we'd hear from hear from her again.