Within five to 30 minutes of delivery, the placenta usually follows the same path that that baby just took out of the body. In about one out of every 100 to 200 deliveries, the placenta is "retained" in the uterus and doesn't deliver-even after 30 to 45 minutes. A retained placenta is often accompanied by heavy bleeding.

Sometimes, the placenta actually separates from the uterus but is engulfed by the cervix and cannot leave the body. In this situation, the doctor can easily remove the placenta by gently grasping it and pulling it out of the lower part of the uterus.

Manual Removal of the Placenta

If the placenta does not spontaneously separate from the uterine wall, the placenta must be removed manually. This may be done in the delivery room or the operating room. To accomplish manual removal of the placenta, the physician places a hand inside the uterus and gently separates the placenta from the wall of the uterus. She will then gently withdraw the placenta from the uterus. Because manual removal may be uncomfortable, pain medication-narcotics, spinal or epidural anesthetic, or general anesthetic-may be necessary. Medications such as oxytocin (Pitocin) and methylergonovine (Methergine) are often given to help the uterus contract and to prevent bleeding before and/or after removal of the placenta. Antibiotics are often given to reduce the risk of uterine infection. The uterus is also massaged to help it contract. In a case of significant blood loss, a blood transfusion may be performed.

Occasionally, a retained placenta is difficult to remove, and can only come out in fragments. In this case, a curette may be used to scrape the inside of the uterus and remove any retained fragments. This process is necessary in order to prevent bleeding and infection in the uterus.

Very rarely, the placenta will not separate, or the adherent fragments cannot be removed completely. This may indicate placenta accreta-a placenta that has grown into the uterine wall-a relatively common condition in women who have had a previous cesarean delivery. Significant bleeding is common, and often requires an emergency hysterectomy. Blood transfusions are also common in these cases.