Any professionals out there, or someone with experience of this?

[nunnie]

I had a retained placenta which had to be manually removed with my first baby.

I had an EMCS with DS due to him being brow and distressed.

I am pregnant again and need to decide between VBAC and ELCS.

If I go for a VBAC and I have a retained placenta, can they still perform a manual removal or does it increase the risk of a uterine rupture?

A manual removal will not cause uterine rupture.

Agree with laluna - definately wont cause a rupture. Also, it probably wont happen again:)

A manual removal increases the risk of a uterine rupture but it is very, very rare. I've never seen a rupture at a maunal removal even when it was a VBAC. I don't remember the figures though, sorry.

It was a question in an obstetric exam I had the other week. And it definetly does as it was somethign I'd revised.

I've been told the opposite, that it probably will happen again, as it was stuck to scar tissue, and i have added more scar tissue into the mix with my EMCS which I should have said was only just over 5 months ago

If it isn't likely to increase my chances of a rupture then I am not certain about my ELCS decision but I have plenty of time to decide and will probably change my mind more often than my knickers (which is a lot at the moment )

Your risk of retained placenta is still small, but statistically higher than if you have never had one and increased slightly more by the c/s.

Still more likely not to get stuck than to get stuck but no stats for this.

For a Dr to rupture your uterus by doing a manual removal would also be extremely rare and they would have to be very rough indeed for this to happen, and they are quite careful doing the mrop due to how soft and delicate the uterus is following childbirth, for instance they wont use any instruments.

Your chance of a uterine rupture is much higher during labour and that is very low at 1:200, so Id go for the VBAC as you've laboured and birthed before. If the stats for a VBAC for someone who has not delivered vaginally before is about 70% successful (as in our hospital), you're success rate will be significantly higher than that.

Obviously no-one can give you any guarantees, so you have to make sure you're comfortable with the risks and benefits.

If your last retained placenta was due to scar tissue adhesion rather than it just not being got out before the cervix clamping down then there is a definate increased risk of you having another retained placenta.

I think the risk of uterine rupture during a manual removal are rarer than the risk of rupture during labour. So less than 1%. Plus if it did happen during a manual removal you are in the right place - in theatre with a spinal in situ and the Dr right there. It would be quickly apparant what had happened and should be easily sortable. But its so unlikely to happen.

Thank you for the advice I have plenty of time so there is no need for a definate decision yet, and I might find out a bit more at my Consultant appointment, as my section was carried out under general I don't really know what happened, I don't even know if it is possible for a placenta to be stuck in a section of the the person carrying out the surgery to know if it was retained, if that makes sense.

Things might make more sense if I knew what happened if anything out of the ordinary.

You seem to be quite knowledgeable on this subgect so hope you don't mind me asking this.

Have I increased my chances of a rupture due to my stupidity in falling pregnant again so soon? I also have been getting pain in the right side of my scar, which is the side I did have a previous infection on, and is also the side that gave me alot of pain after the section resulting in me spending most of the day in delivery being nil by mouth as they thought I would have to go back in to theatre, it is very red whereas the rest of my scar is looking pretty good and even faded in places. I intend to speak to my consultant about it, I was just putting it down to still knitting together or similar. As you are here can I ask is this normal, or should I be concerned about it?

Also if I was to have a VBAC would they do the removal (if I needed one) under GA? Probably not a question you can answer as it probably depends on the policy or Consultant, but I thought I'd ask anyway.

The pain is probably due to some pulling of the scar tissue or adhesions under the skin as your uterus and tummy starts to grow, and it will probably be worse on the side of the infection as its more likely to have built up some adhesions due to the infection.

I would think that your chance of a scar rupture would be very slightly higher due to having this baby soon after your c/s but youre still very low risk of this happening and they will monitor you closely in labour for this.

If you can imagine when you get pregnant and the egg implants itself in the wall of the uterus, this is where the placenta will form and if there is a bit of bumpy scar area, then the implantation is more likely to take place there. If the placenta starts growing on the scar, there is an increase in the chance of it getting stuck after baby is born. When you have your scan, if the placenta is posterior or fundal (at the top), then probably less chance of a retained placenta.

And mrop is usually done under spinal/epidural, as its safer than a general anaesthetic.

Sorry to be a pest.

I labour very very quickly with my first I arrived and was pushing within 5 minutes, with my 2nd I arrived pushing, my worry is I might not get the chance to be monitored during labour for this reason.

My retained placenta was put down to a previous history of endometreosis and scar tissue caused through that, so I was told that it is liklier to happen in subsequent pregnacies, as my DS was born EMCS I didn't get chance to test out this theory so it is the not knowing that is annoying me really.

The reason I asked about GA is not just because the procedure itself is the most undignified and degrading thing I have ever had done, but also I have very little faith in a spinal and at a time when I likely to be anxious this fear will now only add to it.

I suppose it is something else to add to my ever increasing list of questions for my Consultant.

hum...

Your notes should be able to tell you if it was true placenta accreta and if it had grown into previous scarring too. Rather than just being "put down" to this diagnosis, it may be worth checking that this wasn't a throwaway comment and that it was actually documented as such in your notes. Just a thought!

If it was, and you are concerned about history repeating itself, check that the location of the placenta is clear from your scars on a scan maybe. If this is still a grey area (may be close, but not sure) then an MRI scan should say with more certainty.

Best of luck!

Thank you carlyvita, it was documented as being attatched and difficult to remove due to scar tissue, this is what I was told when I discussed it during my last pregnancy with the consultant, I was told it was likely to happen again and there was no way of preventing or diagnosing it. Was set to discuss if I wanted a managed 3rd stage at the 36 week appointment, but DS came on the Sunday before so didn't get the opportunity.

As I am uncertain of where the original scat tissue was and if infact it was just in one place, I am not certain how the scan will give me this information unless it is attacthed to the CS scar which will be more obvious.

I don't think they would carry out an MRI without reasonable grounds and I don't think my neurotic mummblings would fall under that heading.

Should have said the throw away comment may have been to link the scar tissue to the endometreosis.

Placenta accreta is quite different to a retained placenta as it means that the placental tissue has grown through the lining of the uterus rather than being attached to it and can lead to several other problems. Just sounds like yours has been attached to the scar tissue from the endometriosis.

I think the Docs can probably discuss the likelihood of it happening again if they have an idea of where the scar tissue is in the uterus (which is unlikely unless you had investigations for this and they had a look in the uterus) and where the placenta is attached, and you can see that on a scan - shouldn't need an mri for that. If they can't tell about where the scarring is in the uterus, they can only guess if it will happen again though.

Ive seen hundreds of MROPs in theatre as Ive been a mw for a long time and the spinal / epidural should be completely effective and the anaesthetist would almost certainly be reluctant to do a GA without good reason. Agree with you that its not a nice procedure though:(

Btw - which hospital are you booked at?

I never had a problem with spinal with my manual removal, but during my CS I was given a spinal and when they began to cut I could feel it, it was decided the spinal had failed to work and I was knocked out. So this is why I am a little fearful of it happening and to be honest apatr from knowing where and what goes there during a mrop, I can't actually imagine what happens and how it feels when they start pulling and tugging at the placenta and I don't fancy finding out if that makes sense. I know it is rare for a spinal to fail, but as it's now happened to me the rare word seems to mean nothing.

Placenta accreta was never mentioned and until you have mentioed it now I had never really known what it was, so I am certain it wasn't that, it was definatly stuck to scar tissue and not embedded in the uterus.

I am booked in at Preston Sharoe Green Unit.

Sorry mintpurple can I just ask one more thing?

If it is attatched to the CS scar and doesn't come away naturally will they still do a manual or is that too dangerous (not sure what I think they would do instead really)? Or if it is obvious it is stuck to the CS scar on the scan will they advise an ELCS (not sure if they can cut there if the placenta is there)? I already have a long list of questions I don't want to ask what could be silly ones and waste his/her much needed time.
I think it is becoming clear I know nothing sorry

I can understand your apprehension about the spinal then:(

As for the placenta - it still has to come out so yes they would do a mrop even if it was on the scar. Just read your other thread about c/s and if it was on the scar or anterior, they would still do the c/s by cutting through the placenta, so there would likely be a bit more bleeding. They do it this way for any anterior placentas or ant. placenta previa, and usually done by the consultant or very experienced senior registrar as its a more tricky c/s as it has to be done quickly to minimise bleeding. (sorry - dont want to scare you by giving all the gory details!)

Not too gory at all, you have been very very helpful thank you so much for taking the time to answer my questions.

You're welcome - good luck whatever you decide:)