By The PPH Foundation
The moment a baby is born, attention often shifts to celebration and relief. Yet the minutes that follow delivery are among the most critical in determining a mother’s survival. The safe delivery of the placenta is not a routine formality, it is a lifesaving step. When placental tissue or membranes remain in the uterus, severe bleeding can follow.
In the context of postpartum haemorrhage, tissue refers to retained placental fragments, membranes, or blood clots that prevent the uterus from contracting effectively. Without full contraction, the blood vessels at the placental site remain open, leading to continued bleeding. While uterine atony is the leading cause of PPH, retained tissue is a significant contributor and can quickly become life threatening if missed.
Retained placenta complicates an estimated 1 to 3 percent of vaginal deliveries globally. Even small fragments can interfere with uterine contraction. In some cases, the placenta fails to separate naturally, requiring manual removal by a trained provider. Abnormal placental attachment, including placenta accreta spectrum disorders, further increases risk and often requires advanced obstetric care.
Dr Eunice Atsali, a member of the End PPH Initiative, explains that the third stage of labour demands as much vigilance as the delivery itself. She notes that every placenta must be carefully examined after birth to confirm it is complete. If a portion is missing, immediate evaluation is necessary. According to Dr Atsali, overlooking retained tissue can result in preventable haemorrhage within minutes or delayed complications hours or days later.
Risk factors for tissue related PPH include prolonged labour, induced labour, preterm birth, previous retained placenta, and previous uterine surgery. Women with abnormal placentation are at particularly high risk and should deliver in facilities equipped for comprehensive emergency obstetric care.
The warning signs of retained tissue include persistent or heavy bleeding after placental delivery, passage of large clots, abdominal pain, and a uterus that fails to remain firm. In delayed cases, women may present with prolonged bleeding, foul discharge, fever, or signs of infection. Severe blood loss may lead to dizziness, pallor, rapid pulse, low blood pressure, and shock.
Prevention relies on skilled birth attendance and active management of the third stage of labour. The routine use of uterotonics, controlled cord traction by trained providers, and systematic inspection of the placenta reduce the risk significantly. Preparedness with emergency equipment and referral pathways is equally essential.
Management requires rapid assessment and decisive action. Uterine massage and additional uterotonics may be administered initially. If retained tissue is suspected, manual removal of the placenta or uterine evacuation is performed under appropriate anaesthesia and infection prevention measures. Intravenous fluids, tranexamic acid, and blood transfusion may be required depending on the severity of blood loss.
Dr Atsali emphasizes that preventing deaths from tissue related haemorrhage is achievable with vigilance, training, and timely intervention. Ensuring that no fragment is left behind is not simply a clinical task, it is a commitment to safeguarding every mother’s life.
Sources
World Health Organization, WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage
World Health Organization, Trends in Maternal Mortality
FIGO Guidelines on the Management of Postpartum Haemorrhage
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