During the third stage of labour, a patient exhibits signs of placental separation, but the

placenta fails to deliver within 30 minutes despite active management. Which of the

following is the most appropriate next step in management?

1. A

   Administer tocolytics to relax the uterus

2. B

   Continue uterine massage and observe for another hour

3. C

   Manual removal of the placenta under appropriate anaesthesia

4. D

   Immediately initiate caesarean section

Appeared in: BTSC 3 August 2025

Explanation

• A retained placenta is diagnosed when it fails to deliver within 30 minutes of childbirth despite active management (uterotonics and controlled cord traction).
• This situation is an obstetric emergency due to the high risk of postpartum hemorrhage (PPH).
• Manual removal of the placenta under appropriate anesthesia is the definitive and standard procedure to resolve the retention and prevent life-threatening bleeding.
• The procedure involves the provider manually separating the placenta from the uterine wall and removing it.

Why Other Options Were Wrong

• Option A: Tocolytics cause uterine relaxation. This would prevent the uterus from contracting, which is essential to control bleeding at the placental site, thereby worsening the risk of hemorrhage.
• Option B: The standard 30-minute window for active management has already passed. Further waiting significantly increases the risk of severe postpartum hemorrhage and associated complications like shock and infection.
• Option D: A caesarean section is a surgical procedure to deliver a fetus from the uterus. It is irrelevant in this scenario, as the baby has already been born and the issue is the delivery of the placenta.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of Retained Placenta to guide bedside assessment, documentation, and the next nursing action.
• The nurse's role is critical in accurately timing the third stage of labor, recognizing the signs of placental retention, and promptly alerting the provider. The nurse must also prepare for intervention by ensuring IV access and availability of emergency equipment and medications.
• Failure to manage a retained placenta promptly can lead to massive postpartum hemorrhage, hypovolemic shock, disseminated intravascular coagulation (DIC), and maternal death.
• What if? If the patient was already bleeding heavily with signs of shock (e.g., hypotension, tachycardia) before the 30-minute mark, the immediate priority would be resuscitation with IV fluids and blood products, while simultaneously preparing for immediate manual removal of the placenta, without waiting for 30 minutes to pass.

How to Approach the Question

• First, identify the clinical scenario: The patient is in the third stage of labor, which is the period after the baby's birth until the placenta is delivered.
• Next, analyze the key information provided: The placenta has not delivered within '30 minutes' despite 'active management'. This is the classic definition of a retained placenta.
• Recognize that a retained placenta is an obstetric emergency due to the risk of postpartum hemorrhage.
• Evaluate each option based on standard obstetric protocols for a retained placenta.
• Eliminate Option A (tocolytics) because it would worsen bleeding.
• Eliminate Option B (waiting longer) because it is dangerous and deviates from the standard of care.

Concept Tested & Keywords

• Concept Tested: Management of Retained Placenta
• Stem keywords: third stage of labour, placental separation, fails to deliver, 30 minutes, active management
• Lead-in keywords: most appropriate next step
• Clinical cues: Failure to deliver placenta within 30 minutes despite active management is the key indicator for retained placenta requiring intervention.

Question ID

Q0ncpMfTaOubABVNrkkUEh

Copy ID

Reference Book

E6 Obstetrics Williams p. 13-28

E6 Midwifery Obstetrics and Gynecology Nursing Sandeep Kaur p. 50-58