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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Retained placenta and uterine inversion

Obstetrics and gynaecology · UK scope · Sources checked 7 Sept 2026 · Clinical review pending

RapidFull
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Replace an inverted uterus promptly

An absent abdominal fundus with a vaginal mass, bleeding, pain or shock after birth suggests uterine inversion.

Action: Call obstetric and anaesthetic help, resuscitate and attempt skilled manual replacement. Leave an attached placenta in place initially, withhold uterotonics until reduction and escalate failed replacement to theatre.

Synopsis

Assess a prolonged third stage, arrange safe placental removal when required, and recognise inversion requiring immediate reduction alongside maternal resuscitation.

  • A prolonged third stage is thirty minutes after active management or sixty minutes after physiological management.
  • Secure intravenous access for retained placenta and arrange obstetric review.
  • Do not routinely give intravenous oxytocics solely to deliver a retained placenta without excessive bleeding.
  • Uterine exploration and manual placental removal require anaesthesia.
  • Reduce an inverted uterus before removing a placenta that remains attached.
  • Uterotonics support haemostasis after replacement but can hinder reduction beforehand.
  • Both haemorrhagic and vagally mediated shock can accompany inversion.
  • Reassess persistent bleeding after removal or reduction using the full PPH pathway.

Key red flags

Heavy bleeding during a retained third stage requires urgent treatment rather than completion of an observation interval.

Sudden pain, collapse and a uterine mass in the vagina suggest inversion even when visible loss seems modest.

Failure to identify a normal placental separation plane raises concern for accreta spectrum and makes forceful removal dangerous.

Investigation priorities

01
Maternal observations and cumulative blood lossFirst step

Distinguish stable retention from immediate circulatory compromise.

Management branches

Stable retentionAssess and arrange safe removal

The third stage exceeds the appropriate interval without substantial bleeding or instability.

  1. Explain the concern, establish intravenous access, review third-stage medicines and continue maternal observations and loss measurement.
  2. Arrange obstetric review and transfer if the woman is outside an obstetric unit; attend to bladder emptying and comfort.
  3. Do not use umbilical vein agents or routine intravenous oxytocics simply to deliver a retained placenta.
  4. Prepare indicated manual removal with anaesthesia, a competent operator and equipment and personnel ready to treat haemorrhage.
  5. If separation is abnormally difficult, stop forceful attempts and request senior management for possible accreta spectrum.

Key medicines

Terbutaline to facilitate inversion reductionThe OAA inversion action card specifies 250 micrograms subcutaneously when a uterine relaxant is needed during attempted replacement in theatre.This acute specialist use is distinct from routine retained-placenta management. Monitor pulse and blood pressure because tachycardia or hypotension may worsen an already compromised circulation; do not let administration delay necessary further correction.
Oxytocin after reduction or for indicated atonic bleedingA cited 10 IU/mL concentrate regimen gives 5 IU diluted and infused intravenously over 5 minutes, followed by a titrated infusion if severe atony persists.Do not give to contract a uterus that is still inverted. Check the actual formulation and local infusion prescription, monitor cardiovascular effects and fluid balance, and review continuation once tone and bleeding improve.
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Sources and review status5 sources · checked 7 Sept 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.

  • NICE NG235: retained placenta and third-stage care
  • OAA: uterine inversion emergency action card
  • Oxytocin concentrate: postpartum SmPC regimen
  • Bricanyl injection: terbutaline safety information
  • All Wales: PPH and abnormal placental separation

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom