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  5. Common obstetric problems, intrapartum labour ward
  6. Retained Placenta Management (552)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   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.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Retained Placenta Management (552)

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.