– Placenta not yet expelled 30 to 45 minutes after delivery.
– Haemorrhage prior to spontaneous expulsion of the placenta.
Figure 9.1 - Manual removal of placenta
– Cup the fundus with one hand and hold it down.
– Advance the other hand, fully pronated, directly to the fundus and locate the cleavage plane between the uterine wall and the placenta with the fingertips. This hand is inserted all the way up to the forearm in the genital tract.
– Once the cleavage plane has been located, use the side of the pronated hand like a spoon to detach the placenta and bring it out.
– Immediately reinsert the hand to perform uterine exploration.
On very rare occasions, it is impossible to remove the placenta manually because there is no cleavage plane between the placenta and the uterine wall (placenta accreta). In this event, refer for hysterectomy.