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Abstract

Background: Retained placenta is one of the causes of post-partum hemorrhage in 
Bangladesh as it is worldwide. If a retained placenta is left untreated, there is a high risk of 
maternal morbidity and mortality and it has inherent risks of infection and hemorrhage. 
Manual removal of placenta which is the recommended treatment of retained placenta usually 
requires regional or general anesthesia. Intraumbilical injection of saline solution with 
oxytocin might represent an important option for management of retained placenta. 
Objectives: The aim of this study was to assess the effect of intraumbilical vein oxytocin in the 
management of retained placenta and to compare it to the risk of manual removal of placenta. 
Materials and Methods: This experimental study was conducted in the department of 
Obstetrics and Gynecology in Dhaka Medical College & Hospital during July to December 
2004. Total 50 patients with retained placenta were included in this study. The patients were 
divided purposively randomly into two groups ---- Groups A and B. Twenty patients in Group A 
were managed by intraumbilical vein injection of 10 units of oxytocin in 20 mL of normal 
saline slowly and 30 patients in Group B were managed by manual removal of placenta. 
Results: Among the patients of Group A, 16 (80%) delivered placenta spontaneously with 
expulsion time of 7--12 minutes. Remaining 4 patients (20%) required manual removal of 
placenta even after intraumbilical vein injection of oxytocin. Group A patients had less 
complications, required less blood transfusion, less antibiotics and less hospital stay 
compared to Group B patients. Conclusion: Intraumbilical vein administration of oxytocin is 
superior to manual removal in the management of retained placenta. 
Key words: Oxytocin; Intraumbilical vein; Retained placenta                                                                                   

J Enam Med Col 2014; 4(2): 102--105

 

Placenta is said to be retained when it is not expelled 
out even 30 minutes after birth of the baby.1 
Retained placental tissue and membrane causes                  
5--10% of post-partum hemorrhage (PPH).2 
Worldwide, PPH remains one of the most common 
causes of maternal mortality. If a retained placenta is 
left untreated, there is a high risk of maternal death. 
Manual removal of placenta which is the 

recommended treatment also carries other risks such 
as immediate trauma to uterus, hemorrhage and an 
increased incidence of puerperal infection.3,4 

Retained placenta is potentially life-threatening not 
only because of retention but also because of 
associated hemorrhage and infection as well as 
complications related to its removal.4 There are now 

Introduction

 

102

Effect of Oxytocin Injection into Umbilical Vein for Management 
of Retained Placenta

1.  Assistant Professor, Department of Obstetrics and Gynecology, Enam Medical  College & Hospital, Savar, Dhaka
2.  Professor, Department of Obstetrics and Gynecology, Ad-din Medical College & Hospital, Dhaka
3.  Professor, Department of Obstetrics and Gynecology, Enam Medical College & Hospital, Savar, Dhaka
4.  Professor, Department of Obstetrics and Gynecology, Enam Medical College & Hospital, Savar, Dhaka
Correspondence Lima Shompa, Email: lshompa@gmail.com

Original Article

Lima Shompa1, Sayeba Akhter2, Khadija Nazneen3, Monnujan Begum4
Received: December 11, 2013   Accepted: April 12, 2014

Journal of Enam Medical College
Vol 4 No 2 May 2014



evidences that manual removal of placenta may be a 
risk factor for infection3, post-partum endometritis 
and risk of increased bleeding by interfering with 
normal mechanism of placental separation.2

Routine administration of oxytocin during the third 
stage hastens placental separation, reduces blood loss 
of delivery and decreases the chance of PPH by 
40%.2 Oxytocin is the first line agent because of the 
paucity of side effects compared with all other 
available agents.5

Umbilical vein injection of saline solution with 
oxytocin might represent an important option for 
management of retained placenta. This relatively 
simple and affordable technique could be used either 
for first response before proceeding to manual 
removal if necessary or as the only response where 
manual removal is not feasible.6 This procedure 
facilitates high concentration of oxytocin to the 
placental bed and uterine wall, resulting in uterine 
contraction and placental separation.7 

Intraumbilical vein injection (IUV) is inexpensive, 
non-surgical, non-aggressive, cheap and pharmaco-
logical method which may be included in the 
treatment of retained placenta before going to manual 
lysis of placenta.8

Regarding retained placenta, findings from 
international studies and clinical researches showed 
that appropriate and adequate management during 
emergency can reduce the mortality and long term 
complications. As there are very few numbers of 
studies done on retained placenta in Bangladesh, we 
designed this experimental study to assess the effect 
of intraumbilical vein oxytocin in the management of 
retained placenta and to compare it to the risk of 
manual removal of placenta.

Materials and Methods
This experimental study was conducted in labor ward 
in the department of Obstetrics and Gynecology in 
Dhaka Medical College Hospital (DMCH), Dhaka 
during the period July to December, 2004. Patients 
who had undergone vaginal delivery and failed to 
deliver placenta within 30 minutes of delivery of the 
baby and admitted with retained placenta irrespective 
of whether active management policy was followed 
or not were included. Patients having comorbidities 
along with retained placenta, having partial 

separation, morbid adhesion and retention of 
placenta for more than 24 hours, who presented with 
chorioamnionitis, complicated 1st and 2nd stage of 
labor and with abruption placenta were excluded. 
Study subjects were purposively randomly divided 
into two groups. Group A included 20 patients who 
were given intraumbilical vein oxytocin and Group 
B included 30 patients who were managed with 
planned manual removal of placenta.

A solution of 10 mL oxytocin diluted in 20 mL 
normal saline (0.9% sodium chloride) was injected 
into the umbilical vein in all patients of Group A 
after the umbilical cord was clamped distally. The 
umbilical vein injection was given over a period of 
30 minutes and traction was avoided until there was 
evidence of placental separation.9 Suprapubic 
pressure was applied while observing for evidence of 
placental separation. No other intervention was 
performed to cause placental separation until at least 
15 minutes after administration of oxytocin. After 
expulsion of the placenta oxytocin was administered 
as indicated.

Comparison between the groups was done by chi-
square test using the SPSS version 16.0. p values 
<0.05 were considered significant.

Results
Total 8501 obstetric patients were admitted during 
the study period. Among them, number of patients 
having retained placenta was 175 (2.05%). Out of 50 
study subjects 32 (64%) patients presented at 38 
weeks of pregnancy and 15 (30%) patients at 39 
weeks. Majority of the patients (38, 76%) delivered 
babies at home. Only 8 (16%) patients delivered in 
DMCH. Delivery was conducted by dai or relatives 
in majority patients (38, 76%). About 62% patients 
were admitted with features of shock and 12 (24%) 
had PPH without shock.

After administration of intraumbilical vein injection 
(IUV) of oxytocin in patients of Group A, placenta 
was delivered in 16 (80%) cases. Four (20%) cases 
required manual removal of placenta. Group B 
patients (30, 100%) were managed with planned 
manual removal of placenta.

Table I shows that in Group A, 5 (25%) patients 
required one unit of blood transfusion, 4 (20%) 
required two units, 4 (20%) three units and 7 (35%) 

 

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J Enam Med Col  Vol 4  No 2 May 2014



patients did not require blood transfusion.   In Group 
B, 6 (20%) patients needed 4 units of blood 
transfusion, 8 (26.66%) needed 3 units, 10 (33.3%) 
required two units, 4 (13.33%) required one unit and 
2 (6.6%) required no blood transfusion.

Table I: Units of blood transfusion per patient 

  Units Group A Group B χ2 value p value
(n=20) (n=30)

Number (%) Number (%)
  0 7 (35) 2 (6.6)
  1 5 (25) 4 (13.3)
  2 4 (20) 10 (33.3) 11.24 0.024
  3 4 (20) 8 (26.66)
  4 0 (0) 6 (20)

Table II shows that in Group A, duration of staying 
in hospital was <1 day in 16 (80%) patients and 2-4 
days in 4 (20%) cases. In Group B, 8 (26.66%) 
patients stayed in the hospital <1 day, 20 (66.66%) 
for 2-- 4 days and 2 (6.66%) patients for 5--7 days. 
The duration of hospital stay was significantly less 
(p=0.001) in oxytocin group.

Table II: Length of hospital stay

 Duration Group A Group B χ2 value p value
 (n=20)  (n=30)

 Number (%) Number (%)

 <1day 16 (80) 8 (26.66)
 2--4 days 4 (20) 20 (66.66) 13.9 0.001
 5--7 days 0 (0) 2 (6.66)

Table III shows that in Group A, 16 (80%) cases 
required no anesthesia or analgesia, 2 (10%) required 
general anesthesia and 2 (10%) needed sedative with 
analgesia. In Group B, 20 (66.66%) patients required 
general anesthesia and 10 (33.33%) cases required 
sedative with analgesia.  

Table III: Types of anesthesia and/or analgesia used 
during removal of retained placenta 

Group A Group B χ2 value p value
(n=20)  (n=30)

 
Types

Number (%) Number (%)
 Sedative with 2 (10) 10 (33.33)
 analgesia
 General anesthesia 2 (10) 20 (66.66) 35.5 0.000
 No anesthesia or 16 (80) 0 (0)
 analgesia

Table IV shows the frequency and types of 
complications at or after removal of placenta. In 
Group A, 2 (10%) cases developed PPH and 18 
(90%) cases had no complications. In Group B, 6 
(20%) cases developed PPH, and 4 (13.33%) cases 
developed sepsis or endometritis. 

Table IV: Frequency of complications at or after 
removal of retained placenta

Group A Group B χ2 value p value
(n=20) (n=30)

 
Complications

Number (%) Number (%)

 PPH 2 (10) 6 (20)
 Sepsis or 0 (0) 4 (13.33) 4.28 0.118
 endometritis
 No  complications 18 (90) 20 (66.66)

Table V shows the use of antibiotics in study 
subjects. In Group A, 16 (80%) patients required 
double antibiotics and 4 (20%) cases required triple 
antibiotics. In Group B, 3 (10%) cases needed double 
antibiotics and 27 (90%) cases required triple 
antibiotics.   

Table V: Frequency of use of antibiotics 

 Antibiotics Group A Group B χ2 value p value
(n=20) (n=30)

Number (%) Number (%)

 Double 16 (80) 3 (10)
 antibiotics 24.95 0.000 
 Triple 4 (20) 27 (90)
 antibiotics

Discussion  
This study showed that during the period from 
January to December 2004 the incidence of retained 
placenta was 2.05% of total obstetric admission in 
DMCH. In a study by Chhabra et al10 in Kasturba 
Hospital, Delhi, it was found that incidence of 
retained placenta was 0.23% of all births over 15 
years. In their study, out of four deaths two women 
delivered at nearby district hospital and were 
referred moribund and died. The policy option was 
that the properly conducted delivery can reduce the 
incidence of retained placenta and if removal occurs 
timely, appropriate care can save life.

Regarding management of retained placenta the 
present study can be compared with a number of 

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studies. In this study, 16 (80%) patients of Group A, 
who were managed  by intraumbilical vein injection 
of 10 units oxytocin in 20 mL normal saline, 
delivered placenta spontaneously with an expulsion 
time of 7 to 12 minutes after injection and 4 (20%) 
patients required manual removal. Study done by 
Golan et al3 using the same methodology showed 
that expulsion of placenta occurred in all of their 10 
cases a few minutes after intraumbilical injection. 
The average injection-expulsion time was 2--5 
minutes. Using the proposed method of oxytocin 
injection into the umbilical cord of retained placenta 
they were able to spare 80% of the patients. A study 
done in department of Obstetrics and Gynecology, 
Liverpool Women’s Hospital, United  Kingdom 
revealed that women  given  an intraumbilical  
oxytocin  injection  had  a significant  increase  in  
spontaneous expulsion of placenta within 45 minutes 
of delivery and fewer manual removal of placenta 
was needed. The result of their study suggested 
clinically important beneficial effect of 
intraumbilical oxytocin injection in the management 
of retained placenta.11 These findings are consistent 
with the present study.
In this study, requirement of blood transfusion was 
less in oxytocin group. This finding correlates with 
study done by Gajvani et al.11 A study done by Das 
SR12 shows that 23.31% cases needed general 
anesthesia while removing the placenta manually. In 
the present study, only 2 (10%) patients in Group A 
required general anesthesia whereas in Group B, 20 
(66.66%) patients required general anesthesia. 
Patients of Group B required exploration of uterus 
and had to stay longer in hospital than patients of 
Group A. 
In this study complications at or after management of 
retained placenta with intraumbilical vein injection 
of oxytocin was less than the non-oxytocin group. 
Among oxytocin group 18 (90%) cases had no 
complications and 2 (10%) cases developed PPH. In 
non-oxytocin group eight patients developed fever 
and sepsis after manual removal of placenta. The 
complications were very less in oxytocin group 
which correlates with the findings of study done by 
Golan et al.3

The present study reveals that intraumbilical 
oxytocin solution is superior to manual removal of 
placenta. As this study was done in a small number 
of patients, we recommend that community based 

study having adequate sample size should be carried 
out to find out further evidence of efficacy and  
feasibility of the method in low resource setting. 

References
1.   Dutta DC. Complications of the third stage of labour.   

In: Hiralal Konar (ed). Textbook of Obstetrics.  6th edn. 
Calcutta:  New Central Book Agency, 2004: 450–454.

2.  Poggi SBH, Kapernick PS. Postpartum hemorrhage and 
the abnormal puerperium. In: Decherney AH, Nathan L 
(eds). Current obstetrics and gynecologic diagnosis & 
treatment. 9th edn. New York: McGraw-Hill, 2003:  
531–552.

3.   Golan A, Lidor AL, Wexlers David MP. A new method 
for the management of retained placenta. Am J Obstet 
Gynecol 1983; 146: 708–709.

4.  Carroli G, Bergel E. Umbilical vein injection for 
management of retained placenta. Cochrane database of 
systematic reviews 2001, Issue 4. Art. No. CD001337. 
DOI: 10.1002/14651858.CD001337.

5.  van Dongen PW, van Roosmalen J, de Boer CN, van 
Rooy J. Oxytocics for the prevention of post-partum 
haemorrhages, a review. Pharm Weekbl Sci 1991; 13: 
238–243

6.  Purwar M. Injection umbilical vein for management of 
retained placenta commentary (17 Nov 2000) WHO 
Reproductive Health Library No. 4, Oxford update 
software.

7.   Neri A, Goldman J, Ganj B. Intraumbilical vein injection 
of pitocin. A new method in the management of third 
stage of labour. Harefuah 1966; 70: 351–353.

8.   Habeks D, Hrgovic Z, Ivanisevic M, Delmis J. Treatment 
of retained placenta with intraumbilical injection. 
Zentralbi-gynakol 2001; 123(7): 415–417.

9.  David H, Chestnut MD. Influence of umbilical vein 
administration of oxytocin on 3rd stage of labour: a 
randomized, double blind, placebo-controlled study. Am 
J Obstet Gynecol 1987; 157(1):160–162. 

10.  Chhabra S, Dhorey M. Retained placenta continues to be 
fatal but frequency can be reduced. Journal of Obstetrics 
and Gynecology 2002; 22(6): 630–633.

11. Gajvani MR, Luckus MJM, Drakeley AJ, Emery SJ, 
Alfirevic Z, Walkinshaw SA. Intraumbilical vein 
injection for the management of retained placenta; a 
randomized controlled trial. Obstet Gynecol 1998; 
203–207.

12. Das SR. Incidence and causes of retained placenta of 
admitted cases in IPD of Dhaka Medical College 
Hospital. [FCPS Dissertation]. Dhaka: Bangladesh 
College of Physicians and Surgeons; 2003.

 

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