Manual removal of placenta (MRP)

· Failure to deliver the placenta within 30 minutes after delivery of the fetus

· Management :

- monitor vital sign

-observe if there is sign of placental separation

-continue massage uterus

-if still no sign of separation , call MO

-insert large bore IV access (16-18 gauge)

-take blood and send for FBC & GXM

-do catheterization

- attempt control cord traction, if still failed, take verbal consent for MRP

· Preparation:

1. Give IV antibiotic Flagyl 500mg stat and 400mg TDS + Ampicillin 1 gm stat and 500mg QID for 1 day

2. Ensure adequate analgesia ( GA, epidural ,spinal)

3. If patient already on epidural, procedure can be carried out in LR

· Procedure:

1. Put patient in lithotomy position

2. Clean and drape

3. Scrub and wear MRP gloves

4. Put left hand on abdomen to encourage uterus to contract

5. Re-attempt CCT

6. If failed, the left hand should remain on abdomen

7. Insert right hand into uterine cavity by following direction of umbilical cord

8. If present of constriction ring at lower uterine segment, slowly dilate cervical ring until hand able pass to fundus ( forcefully dilate lead to vasovagal attack)

9. Plane of cleavage is identified

10. Assess degree of adherence and site of attachment of placenta

11. By moving fingers from side to side, this plane of cleavage is extended until whole placenta free from wall of uterus

12. Placenta is then removed

13. Re-explore cavity to make sure cavity is empty

14. Abandoned procedure if there is placenta accrete

15. Give IM syntometrine / IV pitocin to promote uterine contraction

16. Check placenta for completeness

17. Continuous iv pitocin 30units in 500mls NS at rate 125mls/hr infusion for 4-6 hours after procedure to maintain uterine contraction

· Complication

-post partum hemorrhage

-infection

-if placenta accrete --> risk of hysterectomy

source: workshop

hanisah A115275