Prophylactic antibiotics can be considered with manual placenta removal, though evidence regarding effectiveness is inconsistent. Complications can include major hemorrhage, endometritis, or retained portions of placental tissue, the latter of which can lead to delayed hemorrhage or infection. Management entails manual removal of the placenta with adequate analgesia, as medical intervention alone has not been proven effective. History of a prior retained placenta and congenital uterine anomalies also appear to be risk factors. Risk factors for retained placenta parallel those for uterine atony and PAS and include prolonged oxytocin use, high parity, preterm delivery, history of uterine surgery, and IVF conceptions. Thus, retained placenta can occur in the setting of significant uterine atony, abnormally adherent placenta, as with placenta accreta spectrum (PAS), or closure of the cervix prior to placental expulsion. Normal placenta delivery requires adequate uterine contractions, with shearing of the placenta and decidua from the uterine wall and expulsion of the tissue. It may also be diagnosed if a patient experiences significant hemorrhage prior to delivery of the placenta. Retained placenta after vaginal delivery is diagnosed when a placenta does not spontaneously deliver within a designated amount of time, variably defined as a period of 18-60 mins.
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