Retained Placenta: Causes, Symptoms, Risks & Treatment (India)

• A retained placenta means the placenta has not been delivered within 30 minutes of birth (active management) or 60 minutes (physiological management).
• The most common cause is a uterus that does not contract strongly enough to peel the placenta off; the most serious is placenta accreta, where the placenta grows into the uterine wall.
• Prior caesarean sections, anaemia, and a previous retained placenta are the biggest risk factors — all especially relevant for Indian women.
• It is treated with extra uterotonic medicines, an empty bladder and gentle cord traction, and if needed, manual removal under anaesthesia.
• Retained tissue can sometimes show up days or weeks after discharge as fresh bleeding, fever, or smelly discharge — this is an emergency, not something to wait out.
• With the right preparation, most women who have had a retained placenta go on to have uneventful future deliveries.

The placenta is the organ that fed and oxygenated your baby for nine months, attached to the inner wall of your uterus through a network of blood vessels and finger-like structures called villi. After birth, the uterus keeps contracting. These contractions shear the placenta away from the uterine wall — usually within 5 to 15 minutes — and then clamp down on the blood vessels that fed it, which is what controls bleeding.

When this orderly sequence fails, the placenta stays put. Obstetricians define a retained placenta as failure to deliver the placenta within 30 minutes of birth when active management is used, or within 60 minutes with physiological (expectant) management.

Delivering the placenta is the final stage of childbirth — sometimes called the third stage of labour. To see where it fits in the whole recovery picture, our overview of what happens after delivery walks through the hours and days that follow.

• Placenta adherens — by far the most common. The uterus simply does not contract strongly enough to peel the placenta off the wall. It is still attached only superficially and can usually be coaxed out.
• Trapped placenta — the placenta has detached but the cervix has closed (or a full bladder is in the way) before it can be pushed out, so it is stuck behind a closed door.
• Placenta accreta spectrum — the most serious. Placental tissue grows abnormally into the uterine muscle (accreta), deeper into the wall (increta), or even through it to nearby organs like the bladder (percreta). Here the placenta cannot separate at all, because it has no clean cleavage plane.

Placenta accreta is increasingly recognised in India for one main reason: rates climb steeply with each previous caesarean section, and our caesarean rates — especially in private hospitals, where they often exceed 40% — are among the highest in the world.

Accreta is the type that most often leads to major haemorrhage and, sometimes, a hysterectomy. The risk is higher when a low-lying placenta sits over an old C-section scar. If you have had a previous caesarean, your placenta's location matters — our guide to placenta position explains anterior, posterior, low-lying and previa, and a dedicated guide covers placenta previa in detail. Every C-section adds to future risk, which is why placental position is reviewed so carefully when you have had one before.

• Previous caesarean deliveries — the strongest predictor for placenta accreta; risk multiplies with each subsequent C-section.
• A previous retained placenta — this substantially increases the chance it happens again.
• Prior uterine procedures — a previous dilation and curettage (D&C), fibroid removal (myomectomy), or removal of uterine fibroids.
• Uterine anomalies — such as a bicornuate or septate uterus.
• Preterm delivery before 34 weeks, and prolonged use of oxytocin during labour.
• Advanced maternal age (especially over 35) and high parity (five or more births).
• Conditions that overstretch the uterus — polyhydramnios, twin or multiple pregnancy, or a very large baby — which weaken contractions.

Two factors deserve special mention in the Indian setting.

The first is anaemia. More than half of pregnant women in India are anaemic according to national NFHS-5 data, and a tired, iron-depleted uterus contracts less effectively — making both retained placenta and heavy bleeding more likely. Correcting anaemia before delivery is one of the most powerful things you can do. See our guides to anaemia in pregnancy and iron deficiency in women.

The second is late or no antenatal care, which means risk factors like placenta accreta are not picked up before birth. When accreta is anticipated, your obstetrician will plan delivery at a centre with a blood bank, interventional radiology, and an obstetrician–anaesthesia team — sometimes alongside urologists if the placenta is growing near the bladder.

In the labour room, diagnosis is clinical — the obstetrician times the third stage and inspects the placenta and membranes for completeness.

When retained tissue is suspected after discharge, ultrasound is the main tool. A transvaginal or transabdominal scan shows echogenic (bright) material inside the uterine cavity, sometimes with increased blood flow on Doppler. Blood tests check for anaemia (low haemoglobin), infection (a raised white-cell count), and clotting status.

• Empty the bladder — a full bladder can physically block the uterus from contracting, so a catheter is passed.
• Controlled cord traction with uterine support — gentle, steady traction on the cord while the uterus is held and massaged.
• A second uterotonic — typically oxytocin, or increasingly in India a single dose of carbetocin, which lasts longer.
• Manual removal — if these measures fail, under regional or general anaesthesia the obstetrician inserts a hand into the uterus, finds the plane between placenta and wall, and gently sweeps the placenta off. A single dose of intravenous antibiotic (usually a cephalosporin) is given to prevent infection.
• If accreta is found — and the placenta will not separate — the team decides between leaving it in place to involute slowly (conservative management) or a hysterectomy. Most Indian tertiary centres proceed to hysterectomy if bleeding is uncontrolled, because the risk of life-threatening haemorrhage is high.

When retained tissue is identified days after discharge, the approach depends on how much tissue remains, how unwell you are, and whether you are bleeding actively.

Small fragments, with no infection or heavy bleeding, can sometimes be managed expectantly with uterotonic medicines (such as misoprostol or methylergometrine, on prescription) and close monitoring. Antibiotics are added at the first sign of infection.

When bleeding is significant or the scan shows substantial retained tissue, surgical evacuation — a D&C or, increasingly, suction evacuation under ultrasound guidance — is done in hospital. Hysteroscopic resection is a more precise, specialised option in select centres.

Indian PPH protocols include a tranexamic acid (TXA) infusion to reduce bleeding, especially within the first three hours of secondary PPH, in line with FOGSI and ICOG guidance. Afterwards you will need iron supplementation — sometimes intravenous iron sucrose — to rebuild blood counts, plenty of rest, and a follow-up scan to confirm the uterus has cleared. Recovery is supported by good postpartum nutrition: iron-rich Indian foods like palak, ragi, dates, jaggery, eggs and lean meats.

A retained placenta is taken seriously mainly because of two complications.

Postpartum haemorrhage (PPH) from retained tissue can cause dangerous blood loss, shock and, if not treated promptly, organ failure — which is exactly why FOGSI and the WHO recommend active management of the third stage for every birth.

Infection (sepsis) from infected retained tissue can spread to the bloodstream and become life-threatening within hours.

Longer term, aggressive curettage can occasionally cause intrauterine adhesions (Asherman's syndrome), which may affect future fertility. Severe blood loss can also rarely trigger Sheehan's syndrome (damage to the pituitary gland), causing problems with milk production and hormones. And the emotional impact is real: a frightening third stage raises the risk of postpartum depression and anxiety. If your mood feels off in the weeks after birth, our guides to baby blues versus depression and postpartum depression can help you tell the difference and find support.

• Antenatal care that identifies placenta praevia, accreta or structural problems through second- and third-trimester ultrasound, including accreta screening for women with a prior C-section, so delivery can be planned safely.
• Correcting anaemia with iron-folic acid supplementation — mandated for all pregnant women in India under the Anaemia Mukt Bharat programme — to support stronger uterine contractions.
• Active management of the third stage, which the WHO recommends for every birth because it substantially lowers the risk of PPH.
• Careful inspection of the placenta after delivery — both surfaces, all cotyledons and the membranes — to confirm nothing is left behind. If there is any doubt, a manual exploration under anaesthesia is safer than waiting.
• Planning ahead if you have had a retained placenta before: your next delivery should be at a centre with full surgical and blood-bank backup.

Recovery after manual removal or surgical evacuation depends on how much blood was lost and whether infection set in. Most women stay 24 to 72 hours longer than after a routine birth and receive intravenous fluids, antibiotics, iron and uterotonics.

Once home, expect heavier-than-usual lochia for a few days, mild cramping (similar to period pain), and tiredness. Paracetamol is the safest pain reliever while breastfeeding. You will likely be on oral iron for 2 to 3 months and a short course of oral antibiotics. Your six-week review should include a pelvic exam, a haemoglobin check, and often a repeat scan to confirm the cavity is empty. Many of these sensations are normal — our guide to how your body feels at 6 weeks postpartum sets expectations. This is also the time to discuss contraception, because ovulation can return within four weeks, even before your period does — see postpartum contraception for safe options while breastfeeding.

• Fever above 38°C (100.4°F).
• Return of bright-red bleeding heavier than a period after about day 10, or soaking a pad in an hour.
• Passing large clots.
• Foul-smelling vaginal discharge.
• Severe pelvic or lower-abdominal pain.
• Dizziness, fainting, breathlessness, a racing heart, or chest pain — these can signal heavy blood loss and need emergency care.
• Feeling generally very unwell, shivery, or unable to care for yourself or your baby.

Having had a retained placenta does raise the chance of it recurring — so tell your obstetrician early, ideally at the booking visit before 12 weeks.

Before conceiving again, make sure your haemoglobin is optimised and that any scars or adhesions from your previous management have been assessed (sometimes with saline-infusion sonography or hysteroscopy). During pregnancy, your placental position will be reviewed carefully in the second trimester and again around 32 weeks. If you had a prior caesarean and the placenta lies over the scar, additional accreta screening with expert ultrasound or MRI is recommended.

Delivery should be planned at a centre with a blood bank and a multidisciplinary team, and active management of the third stage will be used routinely. The reassuring bottom line: with the right preparation, most women with a single prior episode of retained placenta have a smooth, uneventful next birth. For related recovery topics, see our guides to postpartum pains and hormones after birth.

• WHO recommendations for the prevention and treatment of postpartum haemorrhage
• WHO Guidelines for the Management of Postpartum Haemorrhage and Retained Placenta
• FOGSI (Federation of Obstetric and Gynaecological Societies of India) — Good Clinical Practice Recommendations on PPH
• WOMAN Trial: Tranexamic acid for postpartum haemorrhage (The Lancet)30638-4/fulltext)
• RCOG Green-top Guideline No. 27a — Placenta Praevia and Placenta Accreta
• National Family Health Survey (NFHS-5), India — Maternal anaemia data
• Anaemia Mukt Bharat — Ministry of Health and Family Welfare, Government of India