Recallab › Question bank › Obstetrics › #50182
Retained placenta
Thirty minutes after a normal delivery the placenta is undelivered. During controlled cord traction the cord snaps at the level of the introitus. The uterus is well contracted, bleeding is minimal and the woman is haemodynamically stable. What is the most appropriate next step?
- A. Repeat controlled cord traction on the remaining stump
- correctB. Manual removal of the placenta under anaesthesia
- C. Give a further dose of oxytocin and wait another hour
- D. Proceed directly to hysterectomy
Explanation
Key fact
A retained placenta beyond 30 minutes is removed manually, under anaesthesia. A snapped cord removes the only conservative option.
Manual removal under anaesthesia. With no cord to traction and the placenta still in situ, the hand is the only way to deliver it.
Why
The third stage is prolonged beyond 30 minutes.
Controlled cord traction has failed and the cord has gone.
A retained placenta prevents the uterus contracting fully and will bleed eventually.
Anaesthesia is needed - the cervix must relax and the procedure is painful.
Give antibiotic cover and a uterotonic after the placenta is out.
Thirty minutes, and a snapped cord removes the only conservative option
Why not the others
- A. Repeat controlled cord traction on the remaining stump — is futile once the cord has separated, and risks inverting the uterus.
- C. Give a further dose of oxytocin and wait another hour — delays the inevitable and risks torrential haemorrhage. Uterotonics do not deliver an adherent placenta.
- D. Proceed directly to hysterectomy — is a last resort, and only if manual removal reveals a morbidly adherent placenta with uncontrolled bleeding.
Remember
Never pull on a cord without guarding the uterus. Uncontrolled traction causes cord rupture and, worse, acute uterine inversion.
Go deeper
If the plane of cleavage cannot be found at manual removal, suspect placenta accreta - stop, call for help and prepare for haemorrhage rather than persisting.
Bleeding before the placenta separates should raise partial separation; bleeding after suggests atony or trauma.
Active management of the third stage - a uterotonic within one minute, controlled cord traction and uterine massage - reduces retained placenta and postpartum haemorrhage.
DC Dutta's Textbook of Obstetrics, 11th ed. (Jaypee, 2026); Williams Obstetrics, 26th ed. (McGraw Hill, 2022).