Within five to 10 minutes after delivery, the placenta follows the same path that that baby just took out of the body. In about 2% of deliveries, however, the placenta is ?retained? in the uterus and doesn't deliver-even after 30 to 45 minutes.

Manual Removal of the Placenta

If the placenta is not spontaneously expelled, it must be removed by hand, either in the delivery room or in the operating room. Removing the placenta can be painful, so you'll probably be given pain medication or anesthesia-narcotics, spinal or epidural anesthetic, or general anesthetic-before the procedure begins.

To remove the placenta, your doctor inserts one hand into your uterus. If the placenta has already separated, but the cervix has kept it from being expelled, your doctor can easily remove the placenta by pulling it out of the lower uterus. In other cases, your doctor must gently peel the placenta from the uterine wall before pulling it out. Occasionally, a retained placenta is difficult to remove, and can be removed only in fragments. In this case, an instrument called a curette may be used to scrape the inside of the uterus and remove any remaining fragments. Very rarely, the placenta (or fragments) do not separate from the uterine wall at all. This may indicate placenta accreta (a placenta that has grown into the uterine wall). Significant bleeding is common and an emergency hysterectomy is often required.

Whenever the placenta is removed by hand, there's a risk of heavy bleeding. To reduce the bleeding, medications-such as oxytocin (Pitocin) and methylergonovine (Methergine)-are often given before or after removal to help the uterus contract and close off the open blood vessels in the uterine wall. The uterus may also be massaged by hand to help it contract. If blood loss is significant, a transfusion may be needed.

Removing the placenta by hand also increases the risk of infection, since a foreign object is inserted in the uterus. Often, antibiotics are given to reduce this risk.

After the procedure, be sure to have a follow-up appointment with your doctor.