Manual Removal of the Placenta

After the birth, the placenta usually delivers within half an hour. Sometimes though, the placenta is delayed or a piece of placenta is left behind in the uterus. Even a small piece can prevent the uterus from contracting and the vessels will continue to bleed. This video will show how to remove a placenta with your hand.

If the placenta is not delivered in 30 minutes and the woman is not bleeding, ask her to try to urinate, give her a second dose of oxytocin, continue controlled cord traction, and encourage her to bear down. Do NOT repeat misoprostol. If the placenta remains inside the uterus after one hour, OR if the placenta has missing pieces OR the woman is bleeding heavily -- remove the placenta or pieces with your hand. Do not delay!

Here the cord breaks. You wait one hour, since the woman is not bleeding, but the placenta fails to come. Tell the woman you will now need to remove her placenta with your hand and why. Ask for her consent. Be sure she has an IV and her bladder is empty. Then give her diazepam 10 milligrams IV – if she is not in shock. Also give her a single dose of antibiotics to prevent infection, either 2 grams of ampicillin IV or 1 gram of cefazolin IV. Then, wash your hands, and put on long, sterile gloves up to your elbows.

With your thumb in your palm and fingers together, carefully insert your flattened hand. Move it gently into the vagina, forward through the cervix and into the uterus. If the cord is present, pull it gently until it is taut and then follow it into the uterus. Now move your hand to the top of the abdomen to support the uterus and keep it in place during removal. The back of your hand will be against the uterine wall. Feel for an edge of the placenta. Then with your fingers tightly together, sweep your hand back and forth to gently separate the placenta from the uterine wall a little at a time. Proceed slowly until the placenta is completely detached. Then hold the placenta in your hand and BRING pull your hand out, gently twisting your wrist back and forth as you come down the birth canal. Hold the placenta in both hands and twist it to bring all the membranes together. Then check if the uterus is well contracted and massage it if it is soft.

If the placenta cannot be easily separated from the uterine wall, do not force it! The placenta could be abnormally attached and the woman may need surgery. Refer her to higher level care right away.

Examine the placenta for completeness. Give oxytocin 20 units in 1 liter of IV fluids at 60 drops per minute. Teach the woman to monitor her uterus and call you if it becomes soft or she feels her bleeding has increased. Monitor her pulse, blood pressure, uterine tone and vaginal bleeding every 15 minutes for two hours, and then every 30 minutes for the next 6 hours or until she’s stable.

Remember, enter the uterus with a flattened hand, thumb in palm and fingers together. Find the edge of the placenta then sweep your fingers back and forth to gently detach it. Remove the whole placenta once it is separated.