Retained placenta and manual removal — structured SAQ (15 marks)

(a) Definition and the bleeding override (2 marks)

• Definition (1 mark): a placenta is retained at 30 minutes after active management (prophylactic uterotonic, cord clamping, controlled cord traction) or 60 minutes after physiological management.^[1][10]
• The override (1 mark): this woman is bleeding (600 mL and rising), so the threshold is irrelevant — she is managed as a postpartum haemorrhage with tissue as the cause, now. Bleeding overrides the clock entirely.^[1]

(b) Immediate management priorities (5 marks)

One mark per point, maximum five. ^[1]

• Call for help and declare the emergency — consultant obstetrician, anaesthetist, midwifery coordinator; allocate roles and a scribe; activate the massive haemorrhage protocol if loss is major or continuing.^[1]
• Two large-bore cannulae and bloods — full blood count, coagulation with fibrinogen, group and hold or crossmatch depending on loss.^[1]
• Uterotonics — oxytocin 10 IU IM or 5 IU slow IV, with an infusion (40 IU in 500 mL crystalloid at 125 mL/h), because partial separation is accompanied by atony.^[1]
• Tranexamic acid 1 g IV over 10 minutes, as early as possible and within 3 hours of birth; a second 1 g dose if bleeding continues after 30 minutes.^[17]
• Catheterise, warm, quantify loss, and transfer to theatre for manual removal — empty the bladder (a named step in RANZCOG C-Obs 43), keep a running tally, and do not wait.^[1]

(c) Medical options — name the trials and results (5 marks)

• Umbilical vein oxytocin — the Release trial (Lancet 2010; 577 women): 50 IU oxytocin in saline versus placebo via umbilical vein catheter. Need for manual removal 61.3% versus 62.1% (RR 0.98, 95% CI 0.87–1.12). No clinically significant effect.^[2]
• Updated Cochrane review (24 trials): oxytocin solution may slightly reduce manual removal versus expectant management (RR 0.73) and versus saline (RR 0.82), but on low-certainty evidence. Cheap and reasonable in a stable woman; not a substitute for theatre.^[4]
• Nitroglycerin — the GOT-IT trial (PLoS Med 2019; 1107 women): sublingual nitroglycerin 800 micrograms versus placebo. Manual removal at 15 minutes 93.3% versus 92.0% (OR 1.01, p = 0.393), with more palpitations (9.8% versus 4.0%). Should not be used.^[6]
• Systemic uterotonics — Cochrane 2024: sulprostone or misoprostol versus placebo made little to no difference (RR 0.82, 95% CI 0.54–1.27). No medical agent is a reliable substitute for theatre.
• Honest conclusion (1 mark): every medical shortcut has failed its trial; the answer for a retained placenta that does not deliver is theatre with proper anaesthesia.^[1][2][6]

(d) Manual removal technique and the step that matters most (3 marks)

• Preparation (1 mark): consent, theatre with regional or general anaesthesia, catheterise, lithotomy, uterotonics ready.^[1][8]
• Technique (1 mark): one hand follows the cord through the cervix in a cone, the other steadies the fundus externally; find the placental edge, develop the cleavage plane with the ulnar border of the hand in a sweeping motion, deliver the placenta whole, check it is complete, and give a uterotonic.^[1]
• The step that matters most (1 mark): if there is no plane, the cord avulses, or bleeding becomes torrential — stop, leave the placenta in situ, and call the most senior obstetrician and anaesthetist. Accreta discovered mid-procedure becomes survivable when the operator stops.^[18][1]