Why placenta must be out 15 minutes after delivery, say gynaecologists

Leading obstetricians and gynaecologists have given reasons why the placenta must be out 15 minutes after vaginal delivery.

The maternal health experts explained that women who were unable to deliver the placenta, also known as afterbirth, 15 to 30 minutes after vaginal delivery, were at risk of bleeding and possible death if there were no urgent medical interventions.

The physicians noted that the condition called retained placenta was one of the causes of postpartum haemorrhage, which was the most common cause of maternal mortality in Nigeria and Africa.

According to the World Health Organisation, bleeding after delivery is the leading cause of MMR in low-income countries and the primary cause of about one-quarter of all maternal deaths globally.

PUNCH Healthwise reports that Nigeria has  512 maternal mortality per 100,000 live births.

In October, the World Bank reported that Nigeria’s MMR was among the highest in the world and represented 20 per cent of the global burden.

In exclusive interviews with PUNCH Healthwise, the gynaecologists further stated that women who had undergone fibroid removal surgery, dilation and evacuation and previous caesarean sections, were at risk of retained placenta.

The obstetricians emphasised that retained placenta was preventable through the active management of the third stage of labour, which is the delivery of the placenta.

According to the Mayo Clinic, a placenta is an organ formed in the uterus during pregnancy and connects to a developing baby through the umbilical cord to provide oxygen and nutrients.

In a vaginal delivery, after the baby is born, the placenta is expelled by the uterus five to 30 minutes after.

A delay in the normal contraction and delivery of the placenta leads to a retained placenta.

Speaking with PUNCH Healthwise, a Professor of Obstetrics and Gynaecology in the Faculty of Clinical Science at the Bayelsa Medical University, Bayelsa State, Uchenna Onwudiegwu, stated that in a vaginal birth, the placenta was pushed out by the uterus between five to eight minutes after birth.

He added that once the placenta was not out between 15 to 30 minutes of child delivery, it became a retained placenta.

The gynaecologist asserted that retained placenta was one of the causes of postpartum haemorrhage, which was the most common cause of death amongst women in Nigeria and Africa.

The researcher on Reproductive Health said, “Usually when women deliver, there are two ways. We wait for the placenta, which in physiology we call contraction and retraction, that will take place. It is a natural phenomenon that without interference the uterus will know that there is still something inside.

“The afterbirth, that’s what we call the placenta, will come out, when there is a powerful contraction and reduction in the size of the womb. This will separate the placenta, and the placenta will now slide down from the womb into the birth canal with some bleeding and then will come out. We call it passive delivery.”

Continuing, he said, “In these modern days, what we do is that, once the baby is delivered, we give an injection to the woman, into her muscle, what is called oxytocin, maybe 10 international units. When we give it, within one minute and 60 seconds, the uterus, the womb, will now contract and retract powerfully, not the natural mechanism.

“So, that will help to expel, separate the placenta, and the midwife or the doctor will now use her hand, and then hold the uterus with one hand, and then with the other one will pull a cord attached to the placenta in the womb, and pull it out. So, in that case, once the woman delivers, she is given that injection. You don’t wait for the uterus to contract by itself.”

Onwudiegwu noted that this active management of the third stage of labour, the delivery of the placenta, minimised the risk of postpartum haemorrhage (bleeding after delivery) and death.

The obstetrician noted that a retained placenta indicated an anomaly and needed urgent intervention to prevent blood loss which could lead to haemorrhagic shock and death.

He added, “We do what we call manual removal of the placenta. In this case, the doctor gets blood available, prepares the woman and the theatre, puts on gloves that will reach his elbow, puts the woman with minor anaesthesia, and then puts his hand deep into the birth canal and uses his hand to separate the placenta from the womb and bring it out. It is not what everybody can do because it requires technique and experience.”

The don noted that manual removal of the placenta was a traumatic procedure in which the uterus could be damaged and exposed the woman to infection and delayed recovery.

Onwudiegwu added that if the infection was not properly treated, it could lead to secondary infertility.

He further stated that women who have had previous operations on the uterus such as myomectomy (fibroid removal), caesarean sections and dilation and curettage procedures, were at risk of retained placenta.

The obstetrician noted that retained placenta could be prevented by active management of the third stage of labour.

On his part, an Obstetrician Gynaecologist at the University College Hospital, Ibadan, Oyo State, Chris Aimakhu, stated that a retained placenta prevented the uterus from contracting, leading to bleeding after delivery.

He noted that to prevent this, an injection called oxytocin was given after the delivery of the baby to ensure the placenta was completely expelled if not done naturally.

“The most disastrous effect is haemorrhage after delivery because once the placenta is retained, whether partially or wholly, and the uterus does not contract, that means the placenta has not separated from the uterus, so this can cause bleeding.”

“That’s why when we deliver the placenta, we must look at it under running water and make sure it is complete. We look at the membrane and the lobes, to make sure that nothing is missing because even the little bit that is left there, maybe just some retained parts, can cause secondary postpartum haemorrhage,” the don said.

The Second Vice President of the Society of Gynaecology and Obstetrics of Nigeria further said, “Apart from haemorrhage, you can have an infection because the placenta tissue there is dead tissue. Some of it may have been expelled into the uterus and couldn’t come out. Some may be at the point of the cervix and some may even be outside in the vagina. So, all those things can still cause infection, because blood and placenta tissue are a good focus for infection.”

Aimakhu noted that other conditions include continuous and unexplainable pain, infection of the inner lining of the womb, endometrium, fever after delivery, long-term effects of ectopic pregnancy and infertility.

The obstetrician stated that after the placenta was not delivered after 30 minutes and several doses of oxytocin, the doctor or skilled attendant could put their hand into the birth canal to locate and pull out the placenta.

However, if the placenta was still inside the uterus, the don said that manual removal of the placenta under anaesthesia was conducted.

Aimakhu asserted that retained placenta was mostly caused by unsupervised delivery and lack of proper management of the third stage of labour.

He added that multiple pregnancies, fibroid in the uterus, and a woman with fast and persistent labour could have retained placenta.

Previous caesarean section and fibroid surgery, the gynaecologist stated could cause retained placenta.

He urged pregnant women to attend antenatal care clinics regularly to ensure previous cases of retained placenta were identified and adequately prepared for.