Manual Placenta Removal and Umbilical Cord Oxytocin Injection for Postpartum Hemorrhage Management in Nigeria: A Narrative Review of Evidence from 2020 to 2026

Background: Postpartum hemorrhage (PPH) remains the leading cause of maternal mortality in Nigeria, with retained placenta serving as a major contributor to severe obstetric hemorrhage, puerperal sepsis, and emergency surgical interventions. This narrative review synthesizes evidence published between 2020 and 2026 regarding the clinical utility, procedural safety, health systems feasibility, and comparative effectiveness of manual removal of placenta (MRP) and intra-umbilical vein (IUV) oxytocin injection in Nigerian health facilities. Methods: A comprehensive synthesis was conducted using peer-reviewed journal articles, national clinical guidelines, WHO policy briefs, and implementation study reports published between January 2020 and October 2026. Data were extracted and analyzed across five thematic objectives: epidemiological burden, MRP procedural dynamics, IUV oxytocin effectiveness, health systems readiness, and priority research gaps. Results: National modeling and facility audits reveal an estimated 28,669 annual PPH deaths in Nigeria, with retained placenta accounting for 0.53% to 1.80% of vaginal deliveries and up to 12.5% of primary PPH cases. Unbooked status (71.4%–88.1%) and grand multiparity are major risk factors. While MRP remains the standard operative intervention for retained placenta, it carries substantial risks of severe hemorrhage, uterine perforation, shock, and puerperal sepsis (12.5%–24.1%), particularly when performed in primary care settings without general anesthesia or parenteral antibiotics. Conversely, IUV oxytocin injection (10–30 IU in 20–30 mL normal saline via the Pipingas technique) delivers concentrated uterotonic therapy directly to the retroplacental bed, significantly shortening third-stage duration and reducing blood loss without invasive uterine instrumentation. However, wide implementation is severely hindered by health system bottlenecks, including a 74% degradation rate of stored oxytocin due to cold-chain failures, acute shortages of long gauntlet gloves, and inadequate emergency transport pathways. Conclusion: IUV oxytocin represents a highly effective, non-invasive first-line intervention for retained placenta that can minimize emergency MRP transfers and surgical trauma. Integrating IUV oxytocin into Basic Emergency Obstetric and Newborn Care (BEmONC) protocols alongside heat-stable carbetocin scale-up, calibrated drape adoption (E-MOTIVE bundle), and midwife task-sharing is urgently needed to lower maternal mortality in Nigeria.