A 38-year-old grand multipara (G6P5) delivers vaginally. She receives 10 units oxytocin IM. After 30 minutes, the placenta has not delivered. Gentle cord traction fails. Bimanual examination reveals no uterine contractions. She has lost 600 mL so far. Which is the MOST appropriate next step according to current international guidelines?
- A Proceed immediately to manual removal of placenta under regional or general anaesthesia ✓
- B Administer ergometrine 0.5 mg IM and await further
- C Perform controlled cord traction with uterine counter-pressure (Brandt-Andrews technique) under IV access
- D Administer a second dose of 10 units oxytocin IV and re-attempt cord traction after 10 minutes
Explanation
Retained placenta is defined as failure of placental delivery within 30 minutes after vaginal birth (WHO/FIGO criterion). After failure of controlled cord traction and with no spontaneous delivery, manual removal under adequate anaesthesia (spinal or general) is indicated. Giving a second oxytocin dose or ergometrine may assist uterine tone but will not address mechanical retention due to adherence or anatomical problems and delays definitive management. IV access, resuscitation, and preparation for manual removal under anaesthesia are required. The 'trapped' placenta (cervical ring) requires only gentle manual extraction.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.