Retained placenta and manual removal

The baby is twenty-five minutes old and pink. The cord is still hanging there and the midwife has tried two rounds of controlled cord traction. Nobody is panicking, and that calm is the danger — retained placenta is one of the few obstetric emergencies that announces itself quietly, then converts to a two-litre haemorrhage moment placenta half separates. Decide now, while the room is still calm, what your threshold and your destination are.^[1][12]

Overview and definition

Retained placenta is defined by time, and the clock you use depends on how you ran the third stage. ^[1]

• 30 minutes after birth if the third stage was actively managed — prophylactic uterotonic, cord clamping and controlled cord traction.^[1][10]
• 60 minutes after birth if the third stage was physiological — no uterotonic, maternal effort and gravity; follow your local protocol for the exact physiological-third-stage threshold.^[1]
• Immediately, whatever the clock says, if she is bleeding. A woman haemorrhaging with an undelivered placenta is not a retained placenta waiting for a threshold; she is a postpartum haemorrhage with tissue as the cause.^[1][15]

Incidence runs at roughly 1 to 6% of births, and it matters far out of proportion to that number because it is a leading tissue cause of postpartum haemorrhage and, in low-resource settings, of maternal death.^[4][15]

References18ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
2. [2]Weeks AD, Alia G, Vernon G, et al. Umbilical vein oxytocin for the treatment of retained placenta (Release Study): a double-blind, randomised controlled trial Lancet, 2010.PMID 20004013
3. [3]Weeks A, Mirembe F, Alfirevic Z The Release Trial: a randomised controlled trial of umbilical vein oxytocin versus placebo for the treatment of retained placenta BJOG, 2005.PMID 16167963
4. [4]Kumar N, Jahanfar S, Haas DM, et al. Umbilical vein injection for management of retained placenta Cochrane Database Syst Rev, 2021.PMID 33705565
5. [5]Sothornwit J, Ngamjarus C, Pattanittum P, et al. Uterotonics for management of retained placenta Cochrane Database Syst Rev, 2024.PMID 39465684
6. [6]Denison FC, Carruthers KF, Hudson J, et al. Nitroglycerin for treatment of retained placenta: A randomised, placebo-controlled, multicentre, double-blind trial in the UK PLoS Med, 2019.PMID 31887169
7. [7]Abdel-Aleem H, Abdel-Aleem MA, Shaaban OM Nitroglycerin for management of retained placenta Cochrane Database Syst Rev, 2015.PMID 26558329
8. [8]Kongwattanakul K, Pattanittum P, Jongjakapun A, et al. Prophylactic antibiotics for manual removal of retained placenta in vaginal birth Cochrane Database Syst Rev, 2024.PMID 39474979
9. [9]Safrai M, Kabiri D, Haj-Yahya R, et al. The effect of prophylactic antibiotic treatment for manual removal of the placenta on frequency of postpartum endometritis Int J Gynaecol Obstet, 2017.PMID 28677204
10. [10]Hofmeyr GJ, Mshweshwe NT, Gülmezoglu AM Controlled cord traction for the third stage of labour Cochrane Database Syst Rev, 2015.PMID 25631379
11. [11]Urner F, Zimmermann R, Krafft A Manual removal of the placenta after vaginal delivery: an unsolved problem in obstetrics J Pregnancy, 2014.PMID 24812585
12. [12]Kanerva J, Svensson M, Hagman A, et al. Management of women with retained placenta and the risk of postpartum haemorrhage: A retrospective cohort study from a Swedish single centre Eur J Obstet Gynecol Reprod Biol, 2026.PMID 41166790
13. [13]Granfors M, Sandström A, Stephansson O, et al. Placental location and risk of retained placenta in women with a previous cesarean section: A population-based cohort study Acta Obstet Gynecol Scand, 2020.PMID 32575148
14. [14]Patrick HS, Mitra A, Rosen T, et al. Pharmacologic intervention for the management of retained placenta: a systematic review and meta-analysis of randomized trials Am J Obstet Gynecol, 2020.PMID 32592695
15. [15]Yunas I, Islam MA, Sindhu KN, et al. Causes of and risk factors for postpartum haemorrhage: a systematic review and meta-analysis Lancet, 2025.PMID 40188841
16. [16]Shimizu F, Arakaki T, Takita H, et al. Association Between Third-Stage Duration and Postpartum Hemorrhage in Women With Retained Placenta J Obstet Gynaecol Res, 2026.PMID 42209248
17. [17]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
18. [18]Kallianidis AF, Rijntjes D, van den Akker T, et al. Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis Obstet Gynecol, 2023.PMID 36701608