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May 2025 RDS newsletter now available. Expand this announcement to view.

Welcome to the May 2025 update from the RDS team

1.     RDS deployments

Three small-scale releases took place during April and May, including the following fixes and improvements:

  • Applying moderate severity security patch to Umbraco.
  • Fixes to:
    • Random ordering of tiles on mobile app
    • Simultaneous issuing of multiple copies of content review alerts
    • Content display on mobile app for the left hand menu navigation option
  • Whitelisting of Jotforms outcomes pages so that recommendations for action can be displayed following completion of a form or calculation.

2.     RDS performance

Two short outages took place on the mornings of 12th and 22nd May. Tactuum is still investigating the root cause and will report on this shortly.

3.     Redesign of Gentamicin and Vancomycin calculator interfaces

New designs have been produced which make the health board name and calculator title clear to the user on these calculator pages, with a warning message and link to ensure users access the right calculator for their board. These designs have been implemented in a test environment and are now under review.

4.     RDS Redesign, archiving and version control

We now plan to release at end of July 2025 the following major enhancements:  redesigned Right Decision Service homepage, new search and browse interface, upgraded archiving and version control, and capability to edit content adopted from the Shared Content Library. We will provide slides and demos in advance of the release to introduce users and editors to the new functionality.

5. Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Monday 16 June 12.30-1.30 pm
  • Tuesday 24 June 3.45-4.45 pm

Running usage statistics reports using Google analytics

  • Wednesday 11th June: 2-3pm

 To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

6.New RDS toolkits

The following toolkits were launched during March 2025:

7.New RDS developments

Work is progressing on a number of decision support systems that are part of the wider Right Decision Service platform, beyond the web and mobile apps:

  • The Patient Reported Outcome Measures system. A minimum viable product version will be available for functional testing by key stakeholders at end of July.
  • Pharmacogenomics decision support as an extension of the current high risk prescribing decision support integrated with primary care electronic health record systems. This is part of a European research and innovation project.
  • Planned Date of Discharge decision support system to be tested in NHS Lanarkshire. Will undergo user acceptance testing in July with a view to piloting from November.

8. Implementation projects

Public library services in Inverclyde, East Renfrewshire, Glasgow Life, Angus, Falkirk and Stirling have come forward to work with the RDS team, the Scottish Library and Information Council and local Realistic Medicine leads, to develop their role in engaging citizens in Realistic Medicine. This includes promoting the Being a partner in my care app: Realistic Medicine Together. This provides tools and resources to support conversations about what matters to the person,  shared decision-making and self-management.

 

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

 

 

Retained Placenta Management (552)

Warning

Objectives

The aim of this guideline is to standardise management of retained placenta in order to minimise harm to the patient and reduce the risk of associated PPH.  

Please report any inaccuracies or issues with this guideline using our online form

Retained placenta is defined as a placenta that remains in the uterus 30 minutes after active management of the third stage or 60 mins if management of the third stage is conservative .This occurs in 2-3% of all deliveries and is a risk factor for post partum haemorrhage (PPH). Haemorrhage, infection and genital tract trauma are recognised complications of the management of retained placenta. 

Associated GGC policies:

Risk factors for retained placenta

  • Previously retained placenta
  • Multiparity
  • Maternal age > 35 years
  • Induction of labour
  • Preterm labour
  • Placenta Previa / abnormally invasive placenta
  • Uterine anomalies eg. Bicornuate uterus, fibroids
  • Previous uterine surgery or instrumentation

Causes

  • Full Bladder
  • Constriction ring
  • Morbidly adherent placenta
  • Detached cord
  • Uterine anomaly

Management of 3rd Stage

If the placenta is undelivered after 30 minutes of active management / 60 minutes ofconservative management and patient stable with no significant bleeding

  • Do not leave woman unattended
  • Regular maternal observations : pulse, blood pressure, respiratory rate every 15minutes
  • Position change to upright
  • Empty the bladder. If cannot pass urine then catheterisation should be carried out
  • Encourage breastfeeding or nipple stimulation
  • Call Obstetric specialty trainee earlier if concerns regarding bleeding or becomes haemodynamically unstable

Conservative management only : at 60minutes if placenta not delivered  give 10iu IM syntocinon and wait a further 30 minutes if no active bleeding.

If undelivered by 45 minutes active /  90 minutes conservative

  • Call Obstetrics Specialty Trainee to review and inform labour ward co-ordinator
  • Regular maternal observations : pulse, blood pressure, respiratory rate every 15minutes
  • Site IV access - large bore 16G grey cannula, and obtain FBC/ G+R
  • Commence IV fluids - 1000ml crystalloid ( Compound sodium lactate (Hartmanns) solution or Sodium Chloride 0.9%)
  • If bleeding consider syntocinon infusion (40iu syntocinon in 500ml sodium chloride 0.9% or compound sodium lactate at 125ml/hr). Do not start routinely as may make MROP more difficult.
  • Accurate weighed estimated blood loss should be documented as a running total.

Obstetric Specialty Trainee:

  • Offer vaginal examination
  • Examination in the room is appropriate with verbal consent and if signs of separation have occurred, providing analgesia is adequate. Be prepared to abandon attempts and move patient to theatre if there is active bleeding or patient discomfort.
  • Use of umbilical vein uterotonic drugs is no longer recommended
  • Obtain informed consent for theatre
  • Inform anaesthetist and theatre staff
  • If there is significant delay in transfer to theatre consider indwelling catheter and cross match

Consent should include:

Risks of bleeding, infection, trauma to uterus or cervix, failure to remove all tissue, blood transfusion, repeat procedure, balloon insertion, laparotomy  and hysterectomy.

Theatre procedures

  • Surgical pause and review of consent
  • Ensure analgesia is functional
  • Aseptic technique - clean and drape
  • IV Antibiotic cover - 1.2g of co-amoxiclav OR clindamycin 600mg IV + gentamicin
  • Empty bladder
  • Stabilise fundus with non dominant hand
  • Gently insert hand through cervix and identify the placental plane
  • If plane between placenta and uterus not easily defined consider placenta accreta and inform on call consultant. Do not pull on cord or placenta.
  • Using the side of your hand and a sweeping motion sweep the placenta from the uterine wall
  • Guard the fundus to avoid uterine inversion
  • Grasp the uppermost portion of the placenta and aim to remove the whole placenta in one piece
  • Check the cavity is empty - if in doubt call obstetric consultant on call
  • Massage fundus
  • Inspect for tears and repair as required
  • IV syntocinon infusion should commence ( 40iu of syntocinon – 500ml of Compound sodium lactate over 4hours if active bleeding has occurred)
  • Document in notes and debrief patient when appropriate
  • DATIX to be completed if PPH or other complications
  • Use of PPH section in notes to be completed where appropriate.

Post-op debrief

Patients who have had a retained placenta should be advised that all future deliveries should occur in an obstetric led unit as they have a higher risk of post-partum haemorrhage.

Second trimester loss: retained placenta

Conservative management may be considered for up to 180minutes in the absence of bleeding or shock. However if no signs of separation have occurred within 60minutes then manual removal may be appropriate. 

Editorial Information

Last reviewed: 01/08/2022

Next review date: 31/08/2027

Author(s): Judith Roberts.

Version: 2

Approved By: Obstetric Clinical Governance Group

Document Id: 552

References

National Institute for Clinical Excellence (2014) Care of healthy women and their babies during childbirth. CG190: NICE.