WHO recommendations for the treatment of retained placenta

WHO recommendations for the treatment of retained placenta

Recommendation

  • If the placenta is not expelled spontaneously, the use of additional oxytocin (10 IU, IV/IM) in combination with controlled cord traction is recommended. 
  • The use of ergometrine for the management of a retained placenta is not recommended as this may cause tetanic uterine contractions which may delay the expulsion of the placenta. 
  • The use of prostaglandin E2 alpha (dinoprostone or sulprostone) in the management of retained placenta is not recommended.
  • A single dose of antibiotics (ampicillin or first-generation cephalosporin) is recommended if manual removal of the placenta is practised.

 

Weak recommendations, very-low-quality evidence

 

Publication date: September 2012

 

Remarks

  • The GDG found no empirical evidence to support recommending the use of uterotonics for the management of a retained placenta in the absence of haemorrhage. The above recommendation was reached by consensus.
  • The WHO guide, “Managing complications in pregnancy and childbirth” (WHO, 2007), states that if a placenta is not expelled within 30 minutes after the delivery of a baby, the woman should be diagnosed as having a retained placenta. Since there is no evidence for or against this definition, the delay used before this condition is diagnosed is left to the judgement of the clinician.
  • The same WHO guide also suggests that in the absence of haemorrhage, the woman should be observed for a further 30 minutes after the initial 30 minutes, before the manual removal of the placenta is attempted. The GDG noted that spontaneous expulsion of the placenta can still occur, even in the absence of bleeding. A conservative approach is therefore advised and the timing of the manual removal of the placenta as a definitive treatment is left to the judgement of the clinician.
  • The recommendation regarding the use of prostaglandin E2 is informed by a lack of evidence on this question and also by concerns related to adverse events, particularly cardiac events.
  • Direct evidence of the value of antibiotic prophylaxis after the manual removal of the placenta was not available. The GDG considered indirect evidence of the benefit of prophylactic antibiotics from studies of caesarean section and abortion, as well as observational studies of other intrauterine manipulations.
  • Current practice suggests that ampicillin or first-generation cephalosporins may be administered when the manual removal of the placenta is performed.
  • This question was identified as a research priority for settings in which prophylactic antibiotics are not routinely administered and those with low infectious morbidity.

 

 

Evidence Base and GRADE tables for these recommendations

 

WHO recommendations for the prevention and treatment of postpartum haemorrhage

 

Resources

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctor

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

VIDEO: Active management of the third stage of labour

VIDEO; Examination of the placenta

VIDEO: Umbilical vein injection for retained placenta: why and how?

 

This recommendation should be cited as:WHO Reproductive Health Library. WHO recommendation on the treatment of retained placenta (last revised 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.