Retained placenta and manual removal: causes, treatment and recovery

After your baby is born, your body no longer needs the placenta. Tommy's explains that it normally comes away from the womb and leaves your body through the vagina, which is the third stage of labour. If you have a caesarean section, your medical team removes it after the baby is born. For vaginal births there are two approaches: active management, where oxytocin is injected into your thigh to make the womb contract and help the placenta come away more quickly, and physiological management, where you deliver the placenta without medication. Tommy's says you are less likely to bleed heavily or need a blood transfusion with active management.

A retained placenta is when some or all of the placenta and membranes stay in the womb. The NHS describes it in similar terms: part of the placenta or membranes can remain in the womb, and if untreated it can cause life-threatening bleeding. Tommy's says it needs to be removed to prevent complications such as heavy bleeding.

Your doctor or midwife diagnoses a retained placenta if all or part of it remains in the womb after 30 minutes of your baby's birth if you have had active management, or after 1 hour if you have had physiological management. Tommy's says around 1 to 3 in every 100 women who have a vaginal delivery have a retained placenta.

The NHS notes that retained placenta is one of the complications that can affect the placenta, alongside low-lying placenta, placenta praevia and placental abruption, and that these complications are not common.

Tommy's lists three main causes. The womb may not contract enough to force the placenta away from the wall. The placenta may attach too deeply into the wall of the womb, called placenta accreta. Or the placenta may become trapped behind the cervix as it starts to close after the baby is born.

Some things may increase the risk, according to Tommy's: having had a retained placenta before, giving birth prematurely, previous surgery on the womb such as a dilation and curettage, a previous termination of pregnancy, one or more miscarriages, having given birth more than 5 times before, or a differently shaped womb. Retained placenta may be more likely with a family history on both the maternal and paternal sides. If you had retained placenta in a previous pregnancy, you have a higher risk of it happening again, and Tommy's advises talking to your midwife about any concerns for your next pregnancy.

Your doctor or midwife will advise different ways to encourage the womb to contract and the placenta to come away. Tommy's lists asking you to breastfeed your baby to release more of your body's own oxytocin, asking you to change position, for example to sitting or squatting, helping you empty your bladder, massaging the top of your womb through your tummy and giving you an injection of oxytocin. The womb can become tired after a long labour and contractions can become less effective after the baby is born, which is why oxytocin helps.

The NHS adds that breastfeeding your baby as soon as possible after the birth can help your womb contract and push the placenta out, and that if these methods do not work a doctor may need to remove the placenta by hand, for which you will be given an anaesthetic.

If the other steps do not work, Tommy's says your midwife or doctor will talk to you about removing the placenta by hand. You will have a cannula put into a vein so medication can be given this way. You will be offered a vaginal examination to see whether the placenta needs to be taken out manually, and because this can be painful you will be offered pain relief. Tell the midwife or doctor if you are still in pain, as they can stop and give you more medication.

The procedure is done in an operating theatre and a doctor will talk to you about the type of anaesthetic that would be best for you. Your birth partner and newborn may be able to come with you to theatre if you want them to, and your baby can stay with your birth partner if you prefer or there is a medical reason. Once the anaesthetic is working and with your permission, the doctor puts their fingers through the vagina and cervix into the womb to detach the placenta and remove it. You may be given antibiotics to reduce the risk of infection.

Even after the placenta has been removed, Tommy's says there is a risk that small fragments of tissue or membrane may be left behind, sometimes called retained products of conception. It is normal to feel some discomfort, cramping and bleeding after delivery. Contact your doctor or midwife if you pass large blood clots from your vagina or soak a maternity pad within an hour, have vaginal discharge that smells bad, have a high temperature or have tenderness or pain where your womb is in the lower tummy. These can be signs of retained products of conception, which are diagnosed by ultrasound, and you may be admitted to hospital for treatment.

Tommy's says always to contact your doctor, midwife or health visitor if you are worried about any symptoms after having a baby. If bleeding is very heavy or you feel faint or unwell, treat it as an emergency and call 999.

A retained placenta is dealt with by the team looking after you at the time of the birth, whether in a hospital labour ward, a midwifery unit or at home with a transfer to hospital. Manual removal needs an operating theatre and anaesthetic, so it takes place in a hospital in both NHS and private settings. Ask your team afterwards to explain what happened and note it in your records, because it can be relevant in a future pregnancy.