Placental Separation And Complications

Separation Of Placenta

• After the delivery of the baby, the last step is to remove the placenta. In most cases, a gentle tug will bring the placenta out. But in some cases, a good amount of force is required. This application of force can sometimes cause complications in the mother. In this blog, we shall be reading about them. This is an important topic for competitive examinations like NEET-PG and FMGE.

Methods of Separation of the Placenta

• Controlled Cord Traction: it is also known as BRANDT & ANDREW’s Method. Here, gentle traction on the cord with one hand is done while the other is on the uterus for counter-traction.
• CREDES Method: this method is Obsolete now. Here, the uterus is Squeezed, and the cord is pulled out. This method is not performed these days as it may cause Causes RETAINED PLACENTAL BITS.

Signs of Placental Separation

• Permanent lengthening of the cord was observed.
• A fresh gush of bleeding is seen in cases of traumatic placental separation.
• The most specific sign of placental separation is the presence of a  Supra pubic bulge.

Retained Placenta

• It is defined as the separation of the placenta in the third stage of Labor that takes longer than 30 minutes.

Management of Retained Placenta

• The Retained placenta is managed by Manual Removal of the Placenta under General Anesthesia in the Operation theatre. 

Retained Placental Bits 

• Causes secondary PPH, that is, it presents after 24 hours of delivery up to 12 weeks. 
• Management is done by Curettage for evacuation of the uterus 
• Complications of curettage done for secondary PPH can result in  Asherman’s Syndrome

Modes Of Placental Separation

Central Separation/ Shultze Separation 

• The placenta folds on itself and comes out such that membranes come out first.
• This is the more common separation mode and is also seen in Controlled cord traction.

Marginal Separation / Duncan’s Separation 

• The placenta everts and comes out such that the cotyledons (outer surface) come first and membranes come out later.

Morbidly Adherent Placenta

• The main pathology in the morbidly adherent placenta is the absence of  Nitabuch’s fibrinoid layer, where Placental separation happens in normal placentation.

• Types of Morbidly Adherent Placenta:
  • PLACENTA ACCRETA: The placenta is stuck to the uterine wall but does not invade the  myometrium.
  • PLACENTA INCRETA: The placenta is adhered to the muscle layer but does not reach up to the serosa.
  • PLACENTA PERCRETA: The placenta invades the muscle layer and reaches up to the serosa.

Management of Morbidly Adherent Placenta

• Management usually involves Laparotomy, which includes a cesarean to deliver the baby, along with an obstetric hysterectomy.
• In cases of young age and where the uterus can be saved by separating as much placenta as possible at the time of cesarean section, the bleeding may be controlled by compression sutures or stepwise devascularization. Following this, post-opp Methotrexate or Actinomycin can be given to autolyze the placental tissue and prevent conversion to trophoblastic neoplasia.

Predisposing Conditions To A Morbidly Adherent Placenta

• Previous Cesarean Section
• Previous Curettage
• Placenta Previa (Low Lying Placenta) – The most common and most important
• Chronic Infections

Uterine Inversion

Pulling the cord without placental separation causes acute uterine inversion, which is defined as turning the inside out of the fundus into the uterine cavity following childbirth. 

• Inversion complications:
  • Neurogenic shock (pain)
  • Hemorrhagic shock- this is the most common cause of death in uterine inversion.

Classification of Uterine Inversion

1. First degree- the top of the uterus (fundus) has collapsed, but the uterus hasn’t come through the cervix.
2. Second degree - the uterus is inside-out and coming out through the cervix.
3. Third degree - the fundus of the uterus is coming out of the vagina.
4. Fourth degree - both the uterus and vagina protrude outside the introitus

Causes of Uterine Inversion

• Fundal Implantation of Placenta
• Uterine atony
• Morbidly adhered placenta
• Sudden cord traction

Management of Uterine Inversion

• Get IV Access
• Give rapid infusion of fluids, arrange Blood
• Try & Reposition as soon as possible
  • Manual Reposition: The part that came out last should be reposited first. This is the first-line management of acute uterine inversion.
  • Hydrostatic Reposition: Also called O’Sullivan’s method, this can be tried if manual repositioning fails. 
• For repositioning, first give a tocolytic such as Injection Terbutaline, which relaxes the uterus when repositioning is done by filling fluid in the uterus and keeping one hand in the vagina so that water does not come out (hydrostatic) or manually. Following repositioning, oxytocics such as Inj Oxytocin or Inj  Methylergometrine are given.
• Surgical Methods of uterine repositioning
  • Huntington’s Method → Atraumatic clamps
  • Haultian Method → Resection of the constricting Bands

Also Read: Mullerian Agenesis: Clinical Presentation and Treatment

Download the PrepLadder app now to access high-yield content with 24-hr Free Trial. Explore premium study resources like Video Lectures, digital notes, QBank, and Mock Tests for a seamless exam preparation. Time to begin your NEET PG coaching online with PrepLadder.