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Summary Table

Feature	Detail
Risk Factors	Prior retained placenta, preterm delivery (<34 weeks), prolonged use of oxytocin during labor, grand multiparity, prior uterine surgery (cesarean, curettage), placenta previa, accessory (succenturiate) placental lobe, maternal age >35
Etiology	Failure of the placenta to separate from the uterine wall or failure of expulsion after separation, within 30 minutes of delivery (up to 60 minutes with active management)
Patient Presentation	Third stage of labor exceeds 30 minutes; continued vaginal bleeding after delivery of the infant; uterus is boggy and fails to contract firmly
Classic Physical Exam	Boggy, enlarged uterus that remains above the umbilicus; continuous or intermittent vaginal bleeding; the placenta is either absent or only partially delivered with visible missing cotyledons or membranes on inspection
Key Diagnostic Results	Clinical diagnosis based on inspection of the delivered placenta (missing cotyledons/membranes); ultrasound confirms retained tissue within the uterine cavity
Management	Controlled cord traction + uterine massage first; if this fails, manual removal of the placenta under regional or general anesthesia; if tissue remains adherent, curettage; if placenta accreta is encountered, hysterectomy may be required
Keywords	"Prolonged third stage," "missing cotyledon," "boggy uterus," "postpartum hemorrhage," "placenta fails to deliver," "30 minutes after delivery"

1. Pathophysiology

The third stage of labor begins after delivery of the infant and ends with delivery of the placenta. Normal placental separation occurs through a process of retroplacental clot formation at the decidua basalis. Uterine contractions compress the spiral arteries and create a plane of cleavage between the placenta and the uterine wall. Once this plane develops, the placenta shears off and is expelled by continued uterine contractions.

Retained placenta occurs when this process fails. There are three distinct mechanisms, each with different underlying pathology:

Placenta adherens is the most common type. The placenta has separated incompletely or not at all because the uterus fails to generate adequate retraction and contraction behind the placenta. The myometrium in the lower segment or at the placental site is hypotonic, so the retroplacental clot does not form effectively, and the mechanical shearing force is insufficient. This is functionally a problem of uterine atony localized to the placental bed.

Trapped placenta occurs when the placenta has fully separated from the uterine wall but cannot be expelled because the cervix closes or constricts before the placenta passes through. The detached placenta sits in the lower uterine segment or upper cervical canal. This variant is important because it produces a distinctive clinical picture: the cord may lengthen (a sign of separation), a gush of blood may occur (retroplacental clot escaping), yet the placenta does not appear at the introitus.

Placenta accreta spectrum represents the most dangerous mechanism. Here, the placenta has invaded beyond the normal decidual plane into the myometrium (accreta), through the myometrium (increta), or through the serosa to adjacent organs (percreta). Because there is no decidual cleavage plane, the placenta cannot separate. Attempting manual removal in this setting risks catastrophic hemorrhage or uterine perforation. The pathophysiology traces back to prior endometrial damage (from cesarean sections, curettage, or endometritis) that destroyed the decidua basalis, allowing trophoblastic invasion directly into the myometrium.

The clinical consequence of all three mechanisms is the same: the uterus cannot fully contract, the spiral arteries at the placental site remain open, and the patient develops postpartum hemorrhage. The connection between pathophysiology and presentation is direct: an undelivered or partially delivered placenta physically prevents the myometrium from clamping down on its own blood supply.

2. Classification and Clinical Manifestation

Type	Mechanism	Clinical Features	Frequency
Placenta adherens	Inadequate myometrial contraction behind the placenta; no separation occurs	Cord does not lengthen, no gush of blood, no signs of placental separation; uterus is soft and boggy; steady bleeding	Most common (~75% of cases)
Trapped placenta	Placenta has separated but cervix constricts before expulsion	Signs of separation are present (cord lengthening, blood gush, uterus becomes globular and firm), but the placenta does not deliver; may feel the placenta trapped in the lower segment on exam	Less common
Placenta accreta spectrum	Abnormal trophoblastic invasion beyond the decidua into the myometrium or beyond	Placenta is firmly adherent; attempted manual removal reveals tissue that cannot be dissected from the uterine wall; often associated with prior cesarean scar and/or placenta previa	Least common but most dangerous

Signs of placental separation (important for distinguishing trapped from adherent placenta):

Sign	What It Indicates
Cord lengthening	Placenta has descended from the fundus toward the lower segment
Gush of vaginal blood	Retroplacental hematoma has been expelled
Uterus becomes globular and firm	Fundus contracts after the placenta separates
Uterus rises in the abdomen	The separated placenta in the lower segment pushes the fundus upward

If these signs are present but the placenta has not appeared, the diagnosis is a trapped placenta. If none of these signs occur within 30 minutes, the diagnosis is placenta adherens or accreta.

3. Diagnostic Workup

Test	Role	Key Finding
Inspection of the delivered placenta	Best initial assessment when placenta partially delivers	Missing cotyledon(s) on the maternal surface; ragged or incomplete membranes suggest retained fragments
Transabdominal or transvaginal ultrasound	Best initial imaging test	Echogenic mass within the uterine cavity consistent with retained placental tissue; helps distinguish blood clot from tissue
Clinical time threshold	Diagnostic criterion	Third stage exceeding 30 minutes (or 60 minutes if active management with oxytocin was used) defines retained placenta
CBC, coagulation panel, fibrinogen	Supportive	Assess blood loss severity and screen for early disseminated intravascular coagulation
Blood type, crossmatch	Preparation	Anticipate transfusion need

Retained placenta is primarily a clinical diagnosis. The clock starts at the moment the infant is delivered. If the placenta has not been expelled within 30 minutes despite active management (controlled cord traction, oxytocin, uterine massage), the diagnosis is made.

When the placenta delivers but appears incomplete, the next step is careful inspection of the maternal surface. A normal placenta has a complete set of cotyledons forming a smooth, uninterrupted maternal surface. A gap, defect, or area of absent tissue indicates that a fragment remains in the uterus. Similarly, ragged membranes trailing off the placental edge suggest retained membranes. This inspection is the most commonly tested "bedside diagnostic" in exam vignettes.

Ultrasound is the best initial imaging modality when there is clinical suspicion of retained products. It can identify echogenic tissue within the endometrial cavity and help differentiate retained placental tissue from simple blood clot. However, in the acute setting of ongoing postpartum hemorrhage, ultrasound should not delay manual exploration if the clinical picture is clear.

There is no role for MRI in the acute evaluation of retained placenta. MRI may be used in the elective setting if placenta accreta spectrum is suspected antenatally, but during active third-stage complications, the workup is clinical and ultrasound-based.

Laboratory studies (hemoglobin, hematocrit, platelet count, fibrinogen, PT/INR) are drawn not to diagnose retained placenta but to quantify blood loss and to screen for consumptive coagulopathy. A fibrinogen level falling below 200 mg/dL in the postpartum period is an early warning of DIC and should prompt aggressive factor replacement.

4. Management and Treatment

Clinical Scenario	Management
Third stage <30 min, no excess bleeding	Active management: oxytocin 10 IU IM or IV after delivery of the anterior shoulder, controlled cord traction with counter-pressure on the suprapubic uterus (Brandt-Andrews maneuver), uterine massage
Third stage 30 min, placenta undelivered	Attempt controlled cord traction one more time; if unsuccessful, proceed to manual removal of the placenta
Manual removal of placenta	Performed under regional (epidural/spinal) or general anesthesia; hand is introduced into the uterus, a cleavage plane is developed between the placenta and the uterine wall, and the placenta is peeled off in a sweeping motion
Incomplete removal or retained fragments	Uterine curettage with a large blunt curette (banjo curette) under ultrasound guidance to minimize perforation risk
Suspected placenta accreta (placenta does not separate with manual removal)	Stop manual dissection immediately to avoid provoking hemorrhage; consult for hysterectomy (cesarean hysterectomy if diagnosed intraoperatively); uterine artery embolization may be considered in select cases to preserve fertility
Ongoing hemorrhage during any step	Bimanual uterine compression, uterotonics (oxytocin infusion 20 to 40 IU in 1 L crystalloid; methylergonovine 0.2 mg IM; carboprost 250 mcg IM every 15 minutes, max 8 doses; misoprostol 800 to 1000 mcg rectally), transfusion as needed
Trapped placenta	Nitroglycerin 50 to 100 mcg IV to relax the cervix; if unsuccessful, general anesthesia with halogenated agents for uterine relaxation, then manual extraction

Active management of the third stage is the standard of care and reduces the incidence of retained placenta. The key components are: (1) oxytocin administration immediately after delivery of the infant, (2) controlled cord traction (not forceful pulling, which risks cord avulsion or uterine inversion), and (3) uterine massage after placental delivery.

If 30 minutes pass and the placenta has not delivered, the next best step is manual removal under anesthesia. This is the most tested management decision for retained placenta on licensing exams. The procedure involves passing a gloved hand through the cervix, identifying the lower placental edge, and gently sweeping the fingers between the placenta and the uterine wall in the plane of the decidua basalis. The other hand stabilizes the fundus abdominally to prevent uterine inversion.

A critical teaching point: if the operator's fingers cannot find a cleavage plane and the placenta seems inseparable from the myometrium, the immediate concern is placenta accreta. Continuing to force dissection in this situation risks tearing into the myometrium and causing uncontrollable hemorrhage. The correct response is to stop, call for surgical backup, and prepare for possible hysterectomy.

For trapped placenta, the cervix needs to be relaxed before extraction is possible. Nitroglycerin 50 to 100 mcg IV is the first-line agent for acute cervical relaxation. It acts within 60 to 90 seconds and has a short duration. If nitroglycerin fails, general anesthesia with a volatile halogenated agent (sevoflurane) provides both uterine and cervical relaxation, allowing manual extraction.

Uterotonic agents should be administered concurrently with manual removal to promote uterine contraction and limit hemorrhage:

Agent	Dose	Route	Contraindications
Oxytocin	10 to 40 IU in 1 L crystalloid	IV infusion	None (first-line agent)
Methylergonovine	0.2 mg	IM (not IV due to severe hypertension risk)	Hypertension, preeclampsia
Carboprost (15-methyl PGF2-alpha)	250 mcg every 15 min, max 8 doses	IM	Asthma
Misoprostol	800 to 1000 mcg	Rectal or sublingual	Fewest contraindications; useful when others are unavailable

Methylergonovine is contraindicated in hypertension because it causes vasoconstriction. Carboprost is contraindicated in asthma because prostaglandin F2-alpha induces bronchospasm. These two contraindications are tested repeatedly.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Uterine atony	Both present with postpartum hemorrhage and a boggy uterus	In atony, the placenta has already been delivered completely and the uterus simply fails to contract; in retained placenta, the placenta (or fragments) is still inside the uterus
Genital tract laceration	Postpartum hemorrhage with continued vaginal bleeding	The uterus is firm and well-contracted (ruling out both atony and retained placenta); bleeding is continuous and bright red; source is identified on inspection of the cervix, vagina, or perineum
Uterine inversion	Occurs during the third stage, with hemorrhage and hemodynamic instability	Palpation reveals a fundal dimple or absent fundus abdominally; a round mass may be visible at the introitus or in the vagina; severe vasovagal response with bradycardia and hypotension disproportionate to blood loss
Coagulopathy / DIC	Diffuse bleeding after delivery	Bleeding is from multiple sites (IV lines, gums, incision sites), not only vaginal; labs show low fibrinogen, elevated PT/INR, low platelets, elevated D-dimer
Placenta accreta spectrum	Placenta fails to deliver, mimics adherens type	Identified during attempted manual removal when no cleavage plane exists; often associated with prior cesarean scar and previa; requires surgical intervention rather than simple manual extraction

The classic vignette will ask you to differentiate the four T's of postpartum hemorrhage: Tone (atony), Tissue (retained placenta), Trauma (lacerations), and Thrombin (coagulopathy). The distinguishing feature for retained placenta is always that the uterus is not empty. The vignette will either state that the placenta has not delivered, that a cotyledon is missing on inspection, or that the uterus remains boggy despite oxytocin (because retained tissue prevents full contraction).

Uterine inversion is the highest-stakes distractor. It occurs when excessive cord traction is applied before placental separation, pulling the fundus through the cervix. The physical exam finding of a mass at the introitus with an absent uterine fundus on abdominal palpation is the discriminator. Management of inversion (manual replacement with Johnson maneuver, uterine relaxation) is the opposite of retained placenta management (uterine contraction, removal of tissue).

6. Traps and High-Yield Pearls

The most frequent trap involves the sequence of management steps. When a vignette describes a patient with a boggy uterus and continued bleeding after delivery, students often jump directly to uterotonics or surgical intervention. The correct first response depends on whether the placenta has been delivered. If the placenta is out and complete, the diagnosis is atony and uterotonics are appropriate. If the placenta is still in utero or inspection reveals a missing cotyledon, the tissue must be removed before uterotonics alone can be effective. A uterus with retained tissue will not respond adequately to oxytocin because the myometrial fibers cannot fully contract around the foreign material. This is the central logic test-writers exploit: recognizing that the treatment for postpartum hemorrhage depends entirely on identifying the cause.

A second common error is confusing the trapped placenta with placenta accreta. In a trapped placenta, signs of separation (cord lengthening, gush of blood, firm globular uterus) are present, indicating that the placenta has already detached from the wall. The problem is purely mechanical: the cervix has constricted. The treatment is cervical relaxation with nitroglycerin, not hysterectomy. In accreta, there are no signs of separation, the placenta is fused to the myometrium, and attempting forceful removal is dangerous.

Students also underestimate the importance of inspecting the placenta after every delivery. The exam will test this by describing a patient who has "delivered the placenta" but develops delayed postpartum hemorrhage hours later. The clue will be a statement buried in the stem: "the placenta appeared intact but membranes were ragged" or "no formal inspection was performed." Retained fragments, even small ones, serve as a nidus for hemorrhage and infection (endometritis).

The core competency being tested is the ability to systematically evaluate the cause of postpartum hemorrhage by working through the four T's in order, and to correctly sequence the management of retained placenta from conservative (cord traction, uterotonics) to procedural (manual removal) to surgical (curettage, hysterectomy) without skipping steps or choosing interventions that do not match the underlying mechanism.

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