Background 41-year-old, Caucasian booked at 13 weeks of her seventh pregnancy. Patient has history of previous six spontaneous abortions followed by surgical removal of uterine septum.

Antenatal patient had uneventful pregnancy up until 33 weeks when she was admitted with threatened preterm labour. Steroids given and patient discharged 24 h later when tightening settled.

Labour patient admitted 3 days later with regular contractions (33 weeks + 5), presentation was breech and patient opted for vaginal delivery. First stage lasted 2 h and patient had assisted vaginal breech delivery under pudendal nerve block.

Procedure Placenta was not delivered an hour following delivery and decision made for manual removal of placenta under spinal anaesthesia.

Manual removal attempted by both registrar and consultant on call but was not successful. Possibility of placenta accereta especially in view of previous uterine surgery was main concern. Ultrasound confirmed that there is a line of cleavage. Removal of the placenta piece meal using sponge holders and guided by ultrasound was attempted. Two sponge holders were used one to fix lower part of placenta and the other to catch a higher portion of placenta. After removal of two cotyledons piece meal, the rest of placenta separated and subsequently delivered. Patient made uneventful recovery with average blood loss.

Conclusion Ultrasound can be useful tool in such circumstances. It helped making it safer to use intrauterine metal instrument soon after delivery as well as visualizing the instruments, placenta and line of cleavage.