Retained Placenta
A preglandular Cause of Low Supply
As mentioned in the overview, there are many factors that may contribute to low supply.
Different causes can impact milk supply at different stages of lactation, and retained placenta is a relatively common cause of low or absent supply in the immediate days/weeks following delivery.
There’s a good likelihood of reaching a full supply after removing the “stuck” placenta.
If identified early, and in the absence of other underlying factors, most parents can increase their milk production to fully meeting their baby’s needs in a few weeks.
What is retained placenta?
In the context of this discussion, retained placenta refers to retained placental fragments (RPF), rather than a delay in delivering the placenta. Typically the placenta is delivered as one big piece, however, if it’s not, there is a risk that a piece(s) of placenta may be left in your uterus.
Not only does retained placental fragments pose an increased risk of postpartum hemorrhage and mortality, it can be a cause of Lactogenisis II failure, for reasons I will explain below.
In other words, if there’s placenta left in your uterus, your “milk may not come in”. Now I normally hate the term “milk coming in” because parents already have milk, even prior to the delivery of their baby. Colostrum is milk and you already have food ready and waiting for the birth of your baby.
However, In the case of retained placenta, the transition from colostrum to “mature” milk doesn’t happen. For many parents the experience of “milk not coming in” is very real, even if they do small milk volumes.
Symptoms of retained placenta:
There are three main types of retained placenta (placenta adherens, trapped placenta, placenta accreta), and luckily, most retained placenta is appropriately managed in the hours following delivery.
In cases where placental fragments are left behind - as may happen with partial placenta accreta- the following signs & symptoms may occur.
Prolonged vaginal bleeding
Heavy bleeding with large clots/ pieces of tissue
Foul smelling discharge
Uterine/abdominal pain
Fever
Note about retained placenta : Notice that I didn’t say that low milk supply was a symptoms of retained placenta. While it certainly can be, and low supply occurs along side it, there are people who have full, even overabundant supplies, with retained placenta. If you are having any signs of retained placenta, regardless of your breast milk volume, please see your provider.
How does retained placenta affect milk supply?
The signal that your baby was born and that it’s time to start the process of increasing milk volume is the delivery of the placenta.
During pregnancy its the placental hormone progesterone that prevents the process of lactogenesis II from occurring by binding to prolactin receptors in the lactocytes (the cells that make milk).
Once the placenta is delivered, the hormone-landscape changes, allowing prolactin to do its job. Roughly 2-3 days after delivery, you should notice an increase in breast fullness followed by an increase in milk volume.
Retained placental fragments disrupt this process by continuing to kick off the hormone progesterone & estrogen.
The size or amount of retained placenta may be a contributing factor in the differences we see in the effects on milk production. Another possibility is that those who obtain a full supply despite of having retained placenta, may have underlying health issues (such as hyperprolactinemia) that overcome the effects of progesterone.
Until the placental fragments are removed or absorbed back into the body, it’s possible that they will secrete enough progesterone and/or estrogen to inhibit the normal milk transition process.
Another possible cause of low supply post retained placenta is due to the effects of postpartum hemorrhage. It’s been long noted that large blood volume loss, even if not enough to affect the pituitary gland (such as with Sheehan’s syndrome) can have an effect on milk supply.
Without pituitary gland damage, low supply due to a large blood loss volume is usually temporary and improves as your lab work normalizes.
How can I find out if I have retained placenta as the cause of my low supply?
Diagnosis of retained placenta is usually based on clinical symptoms, but may include ultrasound examination or MRI.
Additionally, when exploring if retained placenta is a cause of delayed or absent Lactogenesis II or low supply, we use lab values to help aid in our investigation.
The labs that would be helpful in identifying if retained placenta (or the effects of retained placenta) is the cause of low supply include:
Full CBC
Progesterone & estrogen (Estriodal 1, 2 & 3)
Prolactin
Iron Panel
And if you experienced 1,000 ml or more of blood OR had a significant drop in blood pressure OR lost consciousness at any time post delivery, the additional labs will be needed:
Cortisol Levels
ACTH
TSH/ Free T4/ Free Ts/ Thyroid Antibody
LH/FSH
Testosterone
Hemoglobin A1C
Insulin growth factor (IGF-1)
There are reported cases of pituitary damage occurring at low blood loss volumes (< 500 ml) which makes gauging which lab work to start with a bit tricky.
If your provider is unwilling to put in lab requests, you can order the labs for yourself through Ulta Labs and take in the order forms to your local laboratory. Ulta labs is generally the least expensive option of the “order yourself” companies and they often have coupons for further discounts.
Analyzing your lab work
Once you get your labs drawn, the next step is to analyze the data. Ideally this would be done alongside your primary care provider, but I often find there’s a shortage of knowledgeable providers who are able to accurately assess lab work with regards to low milk supply.
One complicating factor is that there is often not a universally agreed upon “optimal range” or is there an deep understanding of the “optimal range” for lactation, which can differ significantly.
When identifying causes of low supply, I find it’s best to work with a Savvy International Board Certified Lactation Consultant (IBCLC) who is very knowledgeable on not only the hormones that are responsible for initiating and maintaining lactation, but also, the impact each of these hormones have on each other and other body systems.
I offer lab analysis to all of my clients included as part of a typical lactation consultation, however I also offer lab analysis as an independent service.
Though assessing the lab values will not resolve low supply on its own, having someone tell you which labs may be relevant to your current supply issues, which lab work you still need for further testing, and whether or not your labs are within optimal range can be helpful.
Lab work analysis is NOT a substitute for a full lactation consultation, however, I find that it’s helpful for those looking for validation, guidance, and support in identifying why they aren’t making a full supply.
Once you submit your labs, you will receive an invoice which must be paid before I send out the analysis.
Disclaimer: By submitting your labs for analysis you are agreeing to the following-
I understand that submitting these results for Shondra Mattos, IBCLC to review is NOT a substitute for a formal lactation consultation and that any feedback provided is NOT a diagnosis. I am requesting a review of my labs solely to garner more information about the potential impact on lactation based on my submitted lab results. I understand that Shondra Mattos, IBCLC can only review the results that were uploaded and that she can only provide information regarding the lactation impact of the lab result ranges from the labs provided. I understand that the lab results submitted may be missing important tests needed to get a clear picture of the relevant medical/hormonal situation which may be affecting lactation and that some tests may have been performed incorrectly. As such, Shondra Mattos, IBCLC may suggest getting additional lab work to be done by your provider or lab and resubmitting labs for another review at full cost to you. I am aware that Shondra Mattos, IBCLC is offering a 10% discount on econsults and that a formal consultation will be needed to create a plan for addressing concerns.