"Saya sedang hamil anak kedua..baru 18 minggu.Sewaktu bersalin anak kedua 23 Mac 2008 lepas, Alhamdulillah segalanya berjalan dengan lancar. Namun, selepas itu saya menghadapi kesukaran dan ujian yang tidak terjangkau oleh akal fikiran saya..uri saya tidak dapat dikeluarkan dengan normal..uri saya telah melekat. 2 doktor telah berusaha mengeluarkan uri tersebut dan alhamdulillah berjaya. Namun, selepas itu pula saya mengalami tekanan darah yang tinggi. hampir 8 jam saya berada di labour room..sekarang nie, bila saya mengenangkan kejadian lepas, saya takut."
"Saya ada bertanya doktor ada kemungkinan tak lekat uri lagi untuk anak kedua ni, doktor pun tak dapat nak pastikan. Saya masih ingat doktor pelatih pegang tali pusat yang dipotong tu maacm gaya orang masukkan gear 1,2,3,4,5 dan reverse untuk cubaan keluarkan uri...sampai dia kepenatan...saya pula masa tu tidak rasa ngeri pula sebab sebelum ni tidak pernah ambil tahu pun tentang ini, bila dah siap semua barulah tahu akibat lekat uri ini boleh bleeding dan bawa maut."
"Uri lekat atau 'retained placenta' berlaku apabila selepas proses untuk mengeluarkan placenta(uri) secara 'control cord traction' (CCT) gagal dilakukan, dan samada tali pusat terputus semasa proses CCT atau placenta terkoyak dan sebahagian tertinggal di dalam rahim. Salah satu sebab keadaan uri lekat berlaku antaranya kerana rahim gagal mengecut dan kekurangan kalsium dalam badan. Selalunya jika kita pernah mengalami uri lekat, doktor akan merekodkan ianya sebagai 'bad obstetrical hystory'dengan ink merah.Maknanya kemungkinan untuk kejadian ini untukberulang itu ada. Dalam kes uri lekat, doktor terpaksa mengeluarkan uri dengan menggunakan tangan samada dibawah kesedaran pesakit ataupun tidak. Sesetengah hospital mereka akan berikan pesakit bius sebelum melakukan prosedur tersebut."
What is retained placenta?
Retained placenta means that all or part of the placenta or membranes are left behind in the uterus (womb) during the third stage of labour. The third stage is when you deliver the placenta and membranes. You'll be treated for a retained placenta if the third stage takes longer than usual or if there are signs that any of the placenta or membrane is still attached to the uterus.
A natural third stage, which involves you actively delivering the placenta by pushing it out, normally takes about 10 to 20 minutes but it can take up to an hour (NCCWCH 2007: 178). The third stage can be speeded up with an injection in your thigh, given just as your baby is being born. This is known as a managed third stage and usually takes about 5 to 10 minutes (Dombrowski et al 1995; Magann et al 2005). Managing the third stage reduces the risk of you experiencing heavy bleeding (NCCWCH 2007: 178).
You'll be treated for retained placenta if you have not completely delivered the placenta:
• within one hour of your baby's birth, if you have a natural third stage - this happens in about 13 per cent of cases (NCCWCH 2008: 246)
• within 30 minutes of your baby's birth, if you have a managed third stage (NCCWCH 2008: 246) - this happens in less than 5 per cent of cases (Prendiville et al 2000)
Why and how does a retained placenta happen?
There are three main causes of retained placenta:
• uterine atony - this means that the uterus stops contracting or doesn't contract enough for the placenta to separate from the wall of the uterus
• trapped placenta - the placenta comes away from the uterus successfully but becomes trapped behind a closed cervix
• placenta accreta - an area of the placenta remains attached because it is deeply embedded into the uterus wall
A trapped placenta can happen during a managed third stage if the cord snaps during "controlled cord traction". Your midwife gives you an injection and then waits for signs that the placenta has separated. Controlled cord traction is when she puts one hand on your tummy to keep your uterus steady whilst pulling gently on the cord with her other hand.
If the placenta has separated and is ready to come out, it will slide easily through the vagina. If it has not completely separated, if the cord is very thin or if your midwife pulls too hard, the cord may snap, leaving the placenta inside the uterus. If this happens you can usually help to deliver the placenta by pushing with a contraction when the midwife tells you to, but occasionally the cervix will have closed too much to let the placenta out.
Retained placenta may be due to a small piece of placenta, connected to the main part of the placenta by a blood vessel, being left behind in the uterus. This is called a succenturiate lobe. The midwife will examine the placenta and membranes carefully after delivery to ensure that they are complete. If she notices a vessel leading to nowhere, this should alert her to the possibility of part of the placenta being retained.
Sometimes a part of the placenta may adhere to a fibroid, or a scar from a previous caesarean section (Lindsay 2004: 995).
Sometimes a full bladder will prevent the placenta from being delivered, so your midwife may insert a catheter to drain your bladder Lindsay 2004: 995.
What are the problems associated with retained placenta?
Normally after the placenta is delivered, your uterus contracts down to close off all the blood vessels inside the uterus. If the placenta only partially separates, the uterus cannot contract properly, so the blood vessels inside will continue to bleed.
If the third stage is managed and delivery of the placenta takes longer than 30 minutes after the birth of your baby, your risk of heavy bleeding increases substantially (Magann et al 2005). Heavy bleeding in the first 24 hours after birth is known as primary postpartum haemorrhage (PPH).
If small fragments of placenta or membrane are retained and are not detected immediately, this may cause heavy bleeding and infection later on. This is known as secondary PPH and happens in just under 1 per cent of births (Hoveyda and MacKenzie 2001).
How is it treated?
If the third stage is taking a while, you could try breastfeeding your baby or rubbing your nipples, as this can cause the uterus to contract and may help to expel the placenta (Prendeville et al 2000). If you're sitting or lying down, try changing to a more upright position so that gravity can help (Harris 2004: 512; Prendeville et al 2000).
If you choose a managed third stage, you'll be given an injection of an oxytoxic drug to make your uterus contract and your midwife will use controlled cord traction to gently pull the uterus out.
If the placenta still can't be removed, it may need to be removed manually. You'll be given a regional anaesthetic such as a spinal or epidural, or you can ask for a general anaesthetic if you prefer.(NCCWCH 2007: 248).
Before the placenta is removed manually your midwife will insert a catheter in to empty your bladder and you'll be given intravenous (IV) antibiotics to prevent infection (Lindsay 2004: 996). After manual extraction, you may need more drugs which are given intravenously to help the uterus contract down (Lindsay 2004: 995-6).
If you have prolonged heavy bleeding in the days or weeks following the birth, you may be referred for an ultrasound scan to see if there are any fragments of placenta or membrane in your uterus. If so, you will be admitted to hospital for removal under anaesthetic - a procedure known as evacuation of retained products of conception (ERPOC), and treated with antibiotics.
I had a retained placenta with my first labour. Can I do anything to stop it happening again?
If you have already had a retained placenta in a previous birth, you have a higher risk of it happening again (Tandberg et al 1999: 33-6). There is not much you can do to prevent it happening again if it was due to the placenta adhering to an old caesarean scar, or placenta accreta.
Retained placenta is more common in premature births than those born full term, probably because the placenta was designed to stay put for 40 weeks, so if you have another premature labour, it may happen again (Dombrowski et al 1995).
However, if the retained placenta happened because the cord snapped or the cervix closed too quickly after having the oxytocic injection, you may wish to discuss with your midwife whether or not to have a natural third stage with your next baby. By allowing the placenta to deliver naturally, you avoid the possibility of the cervix closing too quickly and trapping the placenta.
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