Ultrasound-guided instrumental removal of the retained placenta after vaginal delivery

Abstract

The standard treatment for retained placenta is manual extraction, in which a hand is introduced inside the uterus to cleave a plane between the placenta and the uterine wall. For women without an epidural, the procedure is extremely uncomfortable and may require additional measures such as intravenous narcotics or regional anesthesia. Although ultrasound-guided instrumental removal of the placenta is standard practice as part of second-trimester abortion by dilation and evacuation and may be done at many institutions, especially after failed manual extraction, it has not yet been described in the literature as a technique following vaginal birth. Our experience with this technique is that it causes less discomfort to the patient than a traditional manual extraction, because the instrument entering the uterus is much narrower than a hand. With the patient in dorsal lithotomy, we locate the cervix and stabilize it either with fingers or a ring forceps on the anterior lip. We introduce Bierer ovum forceps into the uterus under direct ultrasound guidance. The Bierer forceps are preferred because of their long length, large head, and serrated teeth that allow for a firm, secure grip on the placenta. We grasp the placental tissue with the forceps and apply slow, gentle traction in short strokes, regrasping increasingly more distal areas of placenta as necessary to tease out the placenta. After 1-2 minutes, the placenta separates and can be pulled out of the uterus, usually intact. Our experience suggests that this technique is a well-tolerated option for women without an epidural who have a retained placenta. Further study is needed to quantify the amount of discomfort and anesthesia that can be avoided with this technique, as well as whether there is any change in the frequency of infectious complications or the necessity of postremoval curettage.

Keywords: Bierer forceps; retained placenta; ultrasound guidance.

Figure 1

Ultrasound image of the retained placenta in situ This ultrasound image shows a retained placenta before it was removed.

Figure 2

Bierer forceps, the instrument of choice for placental removal This is a photo of the Bierer forceps, the instrument used for placental removal.

Figure 3

Ultrasound image of Bierer forceps grasping the retained placenta with uterus, forceps and cervix identified. This ultrasound image shows the forceps grasping the placenta in preparation to bring it out.

Figure 4

Ultrasound image of placenta being brought out with Bierer forceps In this image, the placenta has been loosened from its attachment to the uterine wall and is being slowly pulled out with the forceps/

Figure 5

Ultrasound image of empty uterus after instrumental removal of the previously retained placenta. This image shows the empty uterus after successful instrumental removal. Video Clip: Ultrasound cine clip of Bierer forceps removing a retained placenta. This video clip shows how the Bierer forceps are used to grasp and then slowly detach the placenta from the uterine wall and then bring it out of the uterus.