Placenta examination

Reviewed: February 15, 2019

Introduction

Upon delivery of the neonate during the third stage of labor, the patient is encouraged to give a gentle push to
assist in the expulsion of the placenta, which is no longer needed. The practitioner (or in some cases the nurse)
places the expelled placenta in a container and examines it to ensure that no portion has been retained inside
the uterus.

Placental and umbilical cord abnormalities and other maternal or fetal conditions are indications for pathologic
examination of the placenta, which is considered a highly valuable investigative tool.1 Such conditions may
include preterm delivery, excessive bleeding, maternal or fetal infection, and congenital anomalies.1 2 Stillbirth
(past or present) is also an indication for pathologic examination of the placenta.2 3 4

The placenta may present with the shiny, glistening fetal side showing (known as the Schultze mechanism) or
with the red, raw, rough-shaped maternal side showing (known as the Duncan mechanism). (See Placental
presentations.) The specific side of the placenta that presents first is not considered clinically significant.

PLACENTAL PRESENTATIONS

The placenta presents with the fetal side showing or with the maternal side showing.

Schultze mechanism

The initial presentation of the shiny, glistening fetal side of the placenta, called the Schultze mechanism,
indicates that the placenta separated first at the center and then at the edges.

Duncan mechanism

The initial presentation of the red, raw, rough-shaped maternal side of the placenta, called the Duncan
mechanism, indicates that the placenta separated first at the edges.

 
 

 
Equipment

Gloves
Scale
Specimen container of appropriate size with lid
Label
Laboratory biohazard transport bag

Implementation

Gather the necessary supplies.

Perform hand hygiene.5 6 7 8 9 10
Put on gloves to comply with standard precautions.11 12 13
Examine the placenta for completeness to determine whether any portions have been retained in the uterus.
Also inspect it for hematomas or calcifications (white–yellow areas), which are a sign of an aging
placenta.
Note the number of blood vessels; most commonly there are two arteries and one vein.
Assess the size of the placenta. Generally, in a term pregnancy the umbilical cord measures approximately
22" to 24" (55 to 60 cm) in length and 0.8" to 1" (2 to 2.5 cm) in diameter. Note any variations from these
measurements.14
Examine the umbilical cord for the presence of Wharton jelly and any kinks or knots.
Note the site where the umbilical cord is inserted into the placenta. (See Types of umbilical cord insertion.)

TYPES OF UMBILICAL CORD INSERTION

Types of insertion of the umbilical cord into the placenta are velamentous, battledore placenta,
succenturiate placenta, and circumvallate placenta.

Velamentous

With velamentous insertion, which is rare, the umbilical cord blood vessels begin to branch at the
membranes and then travel onto the placenta. It's associated with placenta previa and multiple
gestations. Velamentous insertion of the umbilical cord may lead to an increased incidence of cord
compression and, therefore, possible fetal hypoxia. Vasa previa is a rare condition occurring with this
type of cord insertion that may lead to the tearing of one (or more) of the fetal blood vessels during birth,
causing fetal hemorrhage and possible fetal demise.
 Battledore placenta

When the umbilical cord is inserted into the side of the placenta instead of centrally, it's known as
battledore placenta insertion. This presentation has no known significance.

Succenturiate placenta

Succenturiate placenta insertion indicates the presence of an accessory lobe of the placenta that may be
separate from the main placenta. The placenta has two or three lobes instead of the normal singular
lobe. Succenturiate placenta insertion is associated with retention of part of the placenta, which may
lead to postpartum hemorrhage and infection. Management may include manual removal of the placenta
by the practitioner.

Circumvallate placenta

Circumvallate placenta insertion indicates a double folding of the amnion and chorion, which form a ring
around the umbilical cord on the fetal side of the placenta. Circumvallate placenta insertion is associated
with an increased incidence of late-term abortion, antepartum hemorrhage, preterm labor, and possibly
fetal death.15

Examine the amniotic sac for color; typically, the membranes are gray, wrinkled, shiny, and translucent. A
greenish cast to the membranes may indicate that the amniotic fluid has been stained with meconium.
Note the odor of the placenta and its membranes. A foul odor may indicate an infection.
Weigh the placenta if indicated. Normally, the placenta weighs about one-sixth the weight of the
neonate.16

If pathologic examination is indicated

Place the placenta in a specimen container and close the lid securely.
Label the specimen container in the presence of the patient to prevent mislabeling.17
Place the labeled specimen in a laboratory biohazard transport bag and send it to the pathology
department.13
Remove and discard your gloves.12 13
Perform hand hygiene.5 6 7 8 9 10
Document the procedure.18 19 20 21

If pathologic examination isn't indicated

Dispose of the placenta appropriately.13

Remove and discard your gloves.12 13
Perform hand hygiene.5 6 7 8 9 10
Document the procedure.18 19 20 21

Special Considerations

Consider the patient's and family's cultural beliefs before disposing of the placenta. Some cultures have
views about the disposal of the placenta, including the location and timing of the disposal. The patient
may request to take the placenta home and dispose of it according to her beliefs (such as drying, burning,
burying, or eating it). Although these beliefs may vary from your facility's protocol, you're responsible for
respecting the cultural beliefs of the patient and family.

Documentation
Document the number of blood vessels and any knots in the umbilical cord, the weight of the placenta, whether
the placenta appeared intact, and any foul odor. Also document whether the placenta was sent to the pathology
department, disposed of according to your facility's protocol, or sent home with the patient per her request.

References
1. Roberts, D. J. Gross examination of the placenta. (2018). In: UpToDate, McKenney, A., & Barss, V. A. (Eds.). 
2. Roberts, D. J. The placental pathology report. (2018). In: UpToDate, McKenney, A., & Barss, V. A. (Eds.). 
3. Pásztor, N., et al. (2014). Identification of causes of stillbirth through autopsy and placental examination
reports. Fetal and Pediatric Pathology, 33, 49–54. (Level IV)
4. Pinar, H., & Carpenter, M. (2010). Placenta and umbilical cord abnormalities seen with stillbirth. Clinical
Obstetrics and Gynecology, 53, 656–672. (Level VII)
5. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports, 51(RR-16),
1–45. Accessed January 2019 via the Web at https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
6. World Health Organization. (2009). "WHO guidelines on hand hygiene in health care: First global patient
safety challenge, clean care is safer care" [Online]. Accessed January 2019 via the Web at
http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf (Level IV)
7. The Joint Commission. (2019). Standard NPSG.07.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
8. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Infection control. 42 C.F.R. § 482.42.
9. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.21. Healthcare
Facilities Accreditation Program: Accreditation standards for acute care hospitals. Chicago, IL: Accreditation
Association for Hospitals and Health Systems. (Level VII)
10. DNV GL-Healthcare USA, Inc. (2018). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance - revision 18.1. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
11. Accreditation Association for Hospitals and Health Systems. (2018). Standard 07.01.10. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
12. Siegel, J. D., et al. (2007, revised 2018). "2007 guideline for isolation precautions: Preventing transmission
of infectious agents in healthcare settings" [Online]. Accessed January 2019 via the Web at
https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
13. Occupational Safety and Health Administration. (2012). "Bloodborne pathogens, standard number
1910.1030" [Online]. Accessed January 2019 via the Web at
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level
VII)
14. Miller, L. A. (2013). The placenta as expert witness. The Journal of Perinatal and Neonatal Nursing, 27, 110–
111. (Level VII)
15. London, M. L., et al. (2016). Maternal and child nursing care (5th ed.). Boston, MA: Pearson.
16. Silbert- Flagg, J., & Pillitteri, A. (2017). Maternal and child health nursing: Care of the childbearing
and childrearing family (8th ed.). Philadelphia, PA: Wolters Kluwer.
17. The Joint Commission. (2019). Standard NPSG.01.01.01. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
18. The Joint Commission. (2019). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals.
Oakbrook Terrace, IL: The Joint Commission. (Level VII)
19. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2018).
Condition of participation: Medical record services. 42 C.F.R. § 482.24(b).
20. Accreditation Association for Hospitals and Health Systems. (2018). Standard 10.00.03. Healthcare
Facilities Accreditation Program: Accreditation requirements for acute care hospitals. Chicago, IL:
Accreditation Association for Hospitals and Health Systems. (Level VII)
21. DNV GL-Healthcare USA, Inc. (2018). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines
and surveyor guidance - revision 18.1. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
Additional References

Joseph, R., et al. (2016) A literature review on the practice of placentophagy. Nursing for Women’s Health,
20, 476–483. (Level V)
Martines, R. B., et al. (2016). Pathology of congenital Zika syndrome in Brazil: A case series. Lancet, 388,
898–904. (Level VI)
Nakayama, M. (2017). Significance of pathological examination of the placenta, with a focus on
intrauterine infection and fetal growth restriction. Journal of Obstetrics and Gynaecology Research, 43,
1522–1535.
Rheinboldt, M., & Delproposto, Z. (2015). Sonography of placental abnormalities: A pictorial review.
Emergency Radiology, 22, 401–408. (Level VII)