When a Placenta Turns to Pain

Editor’s Note: This article previously appeared in a different format as part of The Atlantic’s Notes section, retired in 2021.

Another reader adds her story to the series on women’s health:

My husband read Joe Fassler’s piece the other day and immediately told me, “Hey, there’s an article on The Atlantic that sounds just like what happened to you.” After my second C-section, I initially felt great, but within a week, I started having severe abdominal pain. I went to the ER, and the on-call doctor did a cursory exam and told me he thought there was nothing seriously wrong with me because I wasn’t running a fever. He sent me home with a few Vicodin and told me I should think about seeing a psychologist for postpartum depression.

The pain continued to worsen, and I saw my own OB first thing the next week. She immediately sent me for an ultrasound and found that I had retained placenta that had turned into a uterine infection. I ultimately needed two surgeries to remove a fallopian tube and later an ovary. If the ER doctor had taken my pain seriously and asked about my bleeding, I could have been given antibiotics and potentially avoided all of the complications.

Speaking of retained placentas, Suzanne Nguyen wrote an Object Lesson on the organ:

I had not given much thought to placentas until the one inside me refused to come out. ...

After a standoff involving two shots of oxytocin and a nurse tugging unsuccessfully on the umbilical cord, the placenta and I were wheeled into the operating room. A doctor dug her hands and tools inside me and retrieved it. The placenta was quickly whisked away before I could even catch a glimpse. No one mentioned its fate to me. I’d guess that it was disposed of as biohazardous waste, maybe after a poke or two from the pathologist. It seemed like an unceremonious end, even for an organ that is unflatteringly nicknamed “the afterbirth.”

But for women who don’t have access to adequate hospitals, the retained placenta is a “significant cause of maternal mortality and morbidity throughout the developing world,” according to the journal African Health Sciences. “It complicates 2% of all deliveries and has a case mortality rate of nearly 10% in rural areas.” The African magazine Parents lists “the reasons a placenta is retained”:

Full bladder. This alone may cause placental retention and it is advisable to empty bladder before delivery.

Associated problems. If the uterus is not well contracted, blood vessels in the uterus are therefore not well closed and the woman continues to bleed after delivery.

Late placenta delivery. Delivery of the placenta after more than 30 minutes when the baby has been born increases the risk of excessive bleeding, a condition known as post partum haemorrhage (PPH).

Small-retained pieces of placental tissue may not be detected immediately. This may cause heavy bleeding after 24 hours (secondary PPH). Such an occurrence may even take place six weeks after delivery.

Infection. This is also a known complication of retained placenta. After removal of the placenta, the mother should be put on antibiotics. [...]

Treatment of retained placenta depends on the cause. Breastfeeding and nipple rubbing causes the uterus to contract. This helps the placenta to separate and therefore be expelled.

Changing to a more upright position, from a sitting or lying position helps the placenta to separate due to the force of gravity. Injection of oxytocin and controlled cord traction prevents retention of the placenta. This is active management in placental delivery.

Manual removal of the placenta under anaesthesia can be done in theatre. The bladder must be emptied first before this is done. Manual removal can involve a doctor placing their hand inside the uterus and gently removing the placenta from the uterine wall.