MANUAL REMOVAL OF THE PLACENTA Definition Manoeuvre performed by inserting a hand through the vagina into the uterine

cavity after delivery, in order to separate the placenta from the uterine wall and extract it. Indications 1) Active haemorrhage before the placenta is expelled, in excess of 500ml. It is important to be aware of the widespread tendency to underestimate the blood loss at delivery, often by as much as 50%. 2) When the placenta is not expelled after 30 minutes from the delivery of the foetus. Delays of over 30 minutes are associated with increased risk of postpartum haemorrhage. Technique 1) The removal of the placenta should be done under aseptic precautions and should be followed by an inspection of the birth canal using retractors, under good lighting. These requirements, combined with the need for adequate analgesia, are only satisfied in the operating theatre. 2) Analgesia. If the patient has already an epidural catheter, the analgesia may need to be topped up. Otherwise, a spinal or general anaesthesia would be indicated. 3) Attention to resuscitation. Should the patient bleed heavily, energic resuscitation measures, described in the chapter on post-partum bleeding, need to be instituted, while she is readied for theatre. 4) Consent. Informed consent is required as for any intervention. 5) Positioning the patient. The patient should be in lithotomy position. 6) Scrubbing, dressing and draining the bladder. The skin of the perineum, thighs, buttocks and lower abdomen is cleaned with antiseptics. The patient is draped in sterile surgical towels. The surgeon is scrubbed, gowned and gloved. General precautions in the presence of bodily fluids should be observed: together with the above protection attire, the surgeon should wear goggles, an waterproof apron and waterproof theatre shoes/boots. To facilitate the manoeuvre, the bladder should be emptied by Foley catheter. This would also enable the monitoring of urinary output during resuscitation. 7) The manoeuvre. The operator grasps and steadies the fundus of the uterus, through the abdominal wall, with the non-dominant hand. For ease of insertion in the birth canal, the fingers of the dominant hand are extended and their tips are brought together in the shape of a cone (the accoucheurs hand). The hand is then inserted in the vagina, with the tips of the fingers towards the sacrum. Once inside the vagina, the hand is turned in supination to bring the fingers in the direction of the cervix. While the uterine fundus is held steady, the hand is inserted into the uterus and, by tearing through the membranes, the operator would start to separate the placenta from the uterine wall. The placenta is then completely freed by using the cubital margin of the palm like a wedge that opens the cleavage space. During the manoeuvre, the fingers are kept together, parallel this time, and the back of the palm is in constant contact with the uterine wall. When the organ is completely free, it is grasped by the operating hand and pulled out through the cervix and vagina. A manual control of the uterine cavity is then done, to evacuate possible remaining cotyledons and

membranes. This is followed by an inspection of the vagina and cervix with right-angled retractors; any bleeding lacerations should be sutured. Accidents and incidents 1) Cervical retraction. Sometimes the cervix is spastic, forming a ring that prevents the insertion of the hand in the uterus. This is usually transitory and in a minute or two will disappear. If it persists for longer, any oxytocin drips should be stopped. As the half-life of oxytocin in the blood is only 3 minutes, the uterus should relax soon afterwards. Alternatively, the inhalatory anaesthetic rate could be increased, which results in uterine relaxation. 2) Placenta accreta. If no cleavage between the placenta and the decidua can be initiated, consider the possibility of placenta accreta. Stop performing the manoeuvre as it may produce intractable bleeding. Hysterectomy would be the usual solution in such cases. Sometimes, however, only a few cotyledons are adhering morbidly, and it is difficult to remove them by hand. An instrumental evacuation of the adherent tissue with a large blunt Bumm curette, together with continued uteroconstrictive medication, will usually control the bleeding. Postoperative care If indicated, the resuscitation for post-partum bleeding should continue. Remember to check the Rh status of the mother and baby, as the manual extraction might increase the likelihood of iso-immunization. Administer anti-Rh immunoglobulins in case of Rh incompatibility. If the manoeuvre was executed under aseptic circumstances, antibiotics are not necessary.