Manual removal of the placenta: Evaluation of some risk factors and management outcome in a tertiary maternity unit. A case controlled study


Objective: Lack of consensus on when to diagnose and manage retained placenta in the absence of hemorrhage in the 3rd stage of labor, has often subjected Manual removal of placenta (MROP) to the discretion of the accoucher. This study aimed to appraise the practice of manual removal of placenta in a tertiary institution in Nigeria with a view to evaluating risk factors for the procedure and advance probable guidelines to enhance standardization of diagnosis of retained placenta. Design: Case controlled study. Setting: Tertiary maternity center in South west Nigeria. Participants: Data from the hospital records of 92 parturients who had MROP from January to December 2009 were compared with 91 immediate next parturients without MROP matched for age and parity. Variables such as the past obstetric and gynecological history, status of accoucher, gestational age at delivery, duration of 3rd stage, estimated blood loss, quantum of blood transfused and length of hospitalization were extracted and subjected to statistical analysis using the SPSS package. Results: There were 4613 deliveries of which 92 parturients had MROP, an incidence of 1.99%. The mean duration of 3rd stage in the study group was 35.6 ± 18.8 minutes compared to 21.6 ± 6.28 minutes in the control. Doctors were the accoucher in 96.8% of cases while midwives took the deliveries in 84.4% in the control group. Previous scarring of the pregnant uterus such as dilatation and curettage and caesarean section predisposed to MROP compared to the control group (P < 0.032) and (P < 0.024) respectively but there was no significant difference between the two groups with respect to previous myomectomy. Conclusion: There is a need to establish standard guidelines in the management of the 3rd stage of labor with definite criteria for diagnosis of retained placenta to reduce the probable risk of unnecessary MROP.

Share and Cite:

Akinola, O. , Fabamwo, A. , Tayo, A. , Bande, A. , Rabiu, K. and Oshodi, A. (2013) Manual removal of the placenta: Evaluation of some risk factors and management outcome in a tertiary maternity unit. A case controlled study. Open Journal of Obstetrics and Gynecology, 3, 279-284. doi: 10.4236/ojog.2013.32052.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] WHO (2009) World Health Organization guidelines for the management of postpartum hemorrhage and retained placenta. World Health Organization, Geneva. Accessed 30/11/2012
[2] Deneux-Tharaux, C., Macfarlane, A., Winter, C., Zhang, W.H., Alexander, S., Bouvier-Colle, M.H. and Euphrates Group (2009) Policies for manual removal of placenta at vaginal delivery: Variations in timing within Europe. BJOG, 116, 119-24. doi:10.1111/j.1471-0528.2008.01996.x
[3] National Collaborating Centre for Women’s and Children’s Health (NCCWCH) (2007) Intrapartum care, care of healthy women and their babies. NICE Clinical Guidelines.
[4] Weeks, A.D., (2008) The retained placenta. Best Practice & Research Clinical Obstetrics and Gynaecology, 22, 1103-1117. doi:10.1016/j.bpobgyn.2008.07.005
[5] Obajimi, G.O., Roberts, A.O., Aimakhu, C.O., Bello, F.A. and Olayemi, O. (2009) An appraisal of retained placentae in Ibadan: A five year review. Annals of Ibadan Postgraduate Medicine, 7, 21-25.
[6] Etuk, S.J. and Asuquo, E.E. (1997) Maternal mortality following post-partum hemorrhages in calabar a 6-year review. West African Journal of Medicine, 16, 165-169.
[7] Eifediyi, R.A., Eigbefoh, J.O., Isabu, P.A., Omorogbe, F.I., Ukponmwan, O.G. and Momoh, M. (2011) Retained placenta: Still a cause of maternal morbidity and mortality in a Nigerian semi-urban population. Sudan Journal of Medical Sciences, 6, 33-38
[8] Soltan, M.H. and Khashoggi, T. (1997) Retained placenta and associated Risk Factors. Journal of Obstetrics and Gynaecology, 17, 245-247. doi:10.1080/01443619750113159
[9] Daftary, S.N. and Nanawati, M.S. (1996) Management of postpartum hemorrhage. In: Buckshee, K., Patwardhan, V.B. and Soonawala, R.P., Eds., Principles and Practice of Obstetrics and Gynecology for Postgraduates. FOGSI Publication, Jaypee Brothers Medical Publishers, New Delhi.
[10] Kamani, A.A., McMorland, G.H. and Wadsworth, L.D., (1988) Utilization of red blood cell transfusion in an obstetric setting. American Journal of Obstetrics & Gynecology, 159, 1177-1181.
[11] International Confederation of Midwives, International Federation of Gynecology and Obstetrics (2004) Joint statement: Management of the third stage of labour to prevent post-partum hemorrhage. Journal of Midwifery & Women’s Health, 41, 76-77.
[12] World Health Organization (2003) Managing complications in pregnancy and childbirth. World Health Organization, Geneva. Accessed 30 Nov 2012.
[13] Winter, C., Macfarlane, A., Deneux-Tharaux, C., Zhang, W.H., Alexander, S., Brocklehurst, P., et al. (2007) Variations in policies for managing of postpartum hemorrhage in Europe. BJOG, 114, 845-854.
[14] Titiz, H., Wallace, A. and Voaklander, D.C., (2001) Manual removal of the placenta—A case control study. Australian and New Zealand Journal of Obstetrics, 41, 41- 44. doi:10.1111/j.1479-828X.2001.tb01292.x
[15] Prendiville, W.J., Elbourne, D. and McDonald, S. (2009) Active versus expectant Management of the third stage of labor. Cochrane Database of Systematic Reviews, 8, CD- 000007.
[16] Ng, P.S., Chan, A.S.M., Sin, W.K., Tang, L.C.H., Cheung, K.B. and Yeun, P.M. (2001) A Multicenter randomized controlled trial of oral misoprostol in the management of the third stage of labor. Human Reproduction, 16, 31-35. doi:10.1093/humrep/16.1.31
[17] Pigingas, A., Hofmeyr, G.J. and Sesel, K.R., (1993) Umbilical Vessel Oxytocin Administration for retained placenta: In-vitro study of various infusion techniques. American Journal of Obstetrics & Gynecology, 168, 793- 795.
[18] Lim, P.S., Singh, S., Lee, A. and Muhammad Yassin, M.A. (2011) Umbilical vein oxytocin in the management of retained placenta: An alternative to manual removal of placenta? Archives of Gynecology and Obstetrics, 284, 1073-1079. doi:10.1007/s00404-010-1785-6
[19] Thomas, W.O. (1993) Manual of removal of placenta. American Journal of Obstetrics & Gynecology, 86, 600- 606.
[20] Setubai, A., Clode, N., Bruno-Palva, J.L., Roncon, I. and Graca, L.M. (1999) Vesico uterine fistula after manual removal of placenta in a woman with previous cesarean section. The European Journal of Obstetrics & Gynecology and Reproductive Biology, 84, 75-76. doi:10.1016/S0301-2115(98)00305-4
[21] Oshodi, Y.A., Akinola, O.I., Fabamwo, A.O., Oludara, B., Akinola, R.A. and Adebayo, S.K. (2012) Ruptured uterus and bowel injury from manual removal of placenta: A case report. Nigerian Postgraduate Medical Journal, 19, 181-183.
[22] Leduc, D., Senikas, V., Lalonde, A.B., Ballerman, C., Biringer, A., et al., Clinical Practice Obstetrics Committee; Society of Obstetricians and Gynecologists of Canada (2009) Active management of the third stage of labor: Prevention and treatment of postpartum hemorrhage. Journal of Obstetrics and Gynaecology Canada, 31, 980- 993.
[23] Owolabi, A.T., Dare, F.O., Fasuba, O.B. Ogunlola, I.O., Kuti, O. and Bisiriyu, L.A. (2008) Risk factors for retained placenta in Southwestern Nigeria. Singapore Medical Journal, 49, 532-537.

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.