Placenta previa, an abnormal condition of pregnancy in which the placenta overlies or is approximate to the cervix, occurs statistically once in every 200 pregnancies. The likelihood is doubled in multiple gestation pregnancies, leaving a 1% rate with singletons. Many conditions increase the risk of occurrence, including fibroid tumors of the uterus, diabetes mellitus, previous uterine surgery, smoking, increased parity, maternal age greater than 35 and history of prior placenta previa.
Painless, bright red bleeding in the second or third trimester is the primary symptom. Such bleeding ranges from scant to heavy and may resolve only to start again days or weeks later. Abnormal fetal presentation is also associated with placenta previa, with the baby lying oblique or transverse in 15% of cases.
The maternal mortality rate is less than 1% and the fetal mortality rate ranges from 15-20% with the primary risk sequelae being premature birth and maternal hemorrhage and fetal exsanguinations due to placenta abruption. In one study, the rate of blood loss following cesarean section associated with placenta previa was almost twice that of cesareans for other complications (1154 ml +/- 924 vs. 632 ml +/-357).
- Leigh Morris Jarvis, Midwifery Today Issue 51
The uterus retains its protective role toward the foetus throughout the first two stages of labour in one site--at the placenta. Uterine muscle at the placental site remains resistant to hormones promoting contractions. During labour the uterus must continue to provide a good blood supply to the foetus and to protect the vulnerable placental site from the powerful expulsive contractions of the second stage of labour which might tear the placenta from the uterus and deprive the foetus of oxygen.
The placenta is the site of progesterone and B-endorphin production and, because progesterone is a small steroid hormone, it can filter through cell membranes as well as enter the blood stream for diffusion. The placental site, being closer to the site of production, will receive more progesterone than the rest of the uterus.
Uterine muscle cells at the placenta site grow bigger than cells elsewhere. This bulge acts as a cushion to prevent placental uterine muscle stretching, and therefore contracting, during the first two stages of labour. Once the baby is born the placenta separates, and the placental site can also contract for the third stage of labour. I suspect that foetal hormones also have a role to play in maintaining the resistance of the placental site to contractions in the first and second stages of labour. Once the cord is cut foetal blood no longer reaches the placental site and the placental site starts to lose its resistance to contractions.
When the placenta is situated at the top of the uterus, where the muscle is thickest and most powerful, labour tends to be longer since some of the most powerful muscle is prevented from contracting. Also these women have a higher incidence of retained placenta and postpartum haemorrhage, suggesting a different hormonal response of fundal muscle.
- Margaret Jowitt, Childbirth Unmasked, Wooller, Lodge, & Arms, 1993
A key to preventing postpartum hemorrhage is to not rush the delivery of the placenta. Almost all postpartum hemorrhage is caused by the intervillous spaces not having a chance to contract and help control the flow of blood. Also, the overmanipulation of the uterus to facilitate placental delivery can cause lobes to be left on the uterine wall which result in uneven contraction of the uterus. These lobes need to be manually removed to prevent postpartum hemorrhage and infection. This is not any fun for the mother or the midwife! I have seen many physicians and a few midwives who will not give the placenta time to delivery on its own. But a policy of hands off, unless there is due cause, is the most important key to preventing postpartum hemorrhage. I have seen some bad postpartum bleeds which may have been avoided if the practitioner had not intervened and overmanaged the placenta delivery.
- Margarett Scott, CPM in Midwifery Today Issue 48
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Two clients in the past two weeks gave birth in hospitals and were given IV antibiotics for Strep B in the birth canal. I have always been under the impression that Strep B in the birth canal carried a very small risk to the baby, and so it wasn't necessary to spend too much time stressing over it. It seems, however, that there is a trend, at least with the doctors in my area, to treat Strep B as an extremely risky thing--for example, a client's baby was kept in the hospital for three days for observation because the mother had a labor under 5 hours, and the antibiotics hadn't had time to take effect.
How risky is Strep B in your opinion? What have you done when you've encountered it with clients? Do you even test for it?
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Question of the Week
I would like to hear how midwives deal with long, long prodromal labors. In a recent birth the woman began prodroming on a Saturday evening and didn't sleep for four nights. She finally went active on Tuesday evening and got to complete on Wednesday morning. But by the time she got to complete she had no energy left to push and no urge to push. Fetal position was favorable.
Now that research is saying that morphine use in labor leads to increased incidence of drug addiction for the child later in life, I don't even feel comfortable recommending hospitalization for sleeping the mother. Alcohol was out because she began having trouble with nausea/vomiting on Monday evening, and homeopathy didn't resolve that.
- Karen, CPM, LM
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Question of the Week Responses
Q: I have a client (gravid 5) who has come
to us with a history of retained placenta three times in the last three
births. Is there something to do to prevent it?
A: You might try delaying the clamping of the pulsating cord or manipulating it at all. I understand there are two valves in the placenta's cord, and after full pressure and volume of the blood has transfused into the baby these valves close down, the placenta then pulls away from the mother's womb and is said to be expelled within 15 minutes of the child's birth. The placenta, like a blood-bag, contains over 20 percent to over 50 percent of the infant's blood. Why risk depriving the baby of any of it?
The intervention of clamping the cord before the placenta is expelled is man's doing and it is believed to traumatize the valves. Try full delayed cord clamping; it is highly recommended and there is no good medical reason to interfere with the design of nature.
A: Complications of later pregnancy are the topic of my Ph.D. thesis. One suspected cause of retained placenta in our hypothesis and that of others is that thrombophilic events during pregnancy triggered by elevations in serum homocysteine cause tiny areas of necrosis which then cause the placenta to malfunction when it is supposed to let go after delivery of the baby.
For my thesis, we are currently trying to determine if the amount of folate in the diet of women with low efficiency versions of folate metabolising enzymes is linked to this problem. We are measuring mothers' homocysteine levels in pregnancy as well as their blood folate and trying to discover if this is connected to the problem of retained placentas. We don't know the answer yet, but if we are right, then additional folic acid given right through pregnancy and up to the end of pregnancy would be valuable in preventing this problem for susceptible women. As folate supplementation has few if any side effects and our hypothesis is biologically plausable, your particular mother might want to consider this even though our research is not finished yet, and knowing that we might end up showing there is no effect at all. Our research to date has shown most women are not getting enough folate from their diet even with the new supplementation of flour and rice and pasta in Canada and the United States. I would recommend giving additional folic acid as well as B12 and B6 (which act as coenzymes) beyond what she normally takes until she delivers. At minimum she should be on a standard prenatal vitamin.
- Natalie K Bjorklund
A: Make sure the mother is not taking an excess of vitamin E, in the last trimester particularly (no more than 200-400 I.U. per day). Especially make sure that she is not using any kind of lotions on her stomach for stretch marks that may contain vitamin E. Serate is one I've come across in my area that too many women use with the result of a horribly retained placenta. Vitamin E is fat-soluble and will build up in the body and cause the placenta to adhere to the uterine wall.
- A.H., midwife
A: Did you check the hemoglobin level? The moms and myself who've had retained placenta have had a level of 10 or less. I don't know ultimately if there is a correlation but it may be worth investigating.
- Nicole Gauthier-Schatz, certified yoga teacher, doula, midwife-apprentice
A: I have learned too much vitamin E during pregnancy can contribute to retained placenta. Perhaps diet in some other way may be implicated. Angelica after delivery is sometimes used to help expel the placenta. I have also learned that when a uterus is jittery with contractions after delivery (of baby and placenta), it is indicative of retained clots which are brought out by vigorous massage. Then the uterus can properly "clamp down" and remain firm.
- Beth Germano
Why OB STARE? In Latin, it means "to be by the side." We are beside the mother, the father, and of course beside the baby. OB STARE is a magazine about Motherhood and Childhood. It is aimed at midwives, parents and institutions. All ideas are welcome. OB STARE is a Spanish language journal.
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I also felt the "call" of wanting to welcome babies at an early age, I think when I was about seven or eight, but I didn't realise it before I had to choose what college I should attend after high school. I thought I wanted to be a pediatrician because someone told me that a pediatrician always attended births, and I loved babies. When I got to the last class in high school, I wanted to study medicine to be a doctor, but over the years I got very bad at math and physics and without those subjects you cannot attend medical school in our country.
Then my best friend got pregnant and I went with her to an independent midwife (there are a lot in the Netherlands) and during the time we were there I spoke with this woman and suddenly I knew what I wanted! Before I went to midwifery school I attended nursing school for two years and every day there was a drag; I hated to do what the doctors said and to work in a clinic one way or another; I realised I'm not a teamworker in any hierarchic way.
When I got pregnant in 1996 the midwife whom I attended in an apprenticeship took me under her wings again and while I got more and more pregnant, a practice of my own was realized. I have had my own practice for almost four years now and in our region the teamwork between the several midwives is famous all over our country. Every day when I drive through the village or every night while I'm called out of bed I feel so lucky with the "job" I'm doing!
Responding to Phil Watters, referring to maternal deaths related to pregnancy related problems;
Today there is a great richness of knowledge and information about healthy and illness-preventing nutrition during pregnancy, (ex. Anne Frye's Holistic Midwifery, etc). The problem is that few women have access to this relatively "new" information. There has been an enormous amount of increased awareness in the past 10 years about the importance of organic food, but from what I read in Anne Frye's book, it seems there isn't enough education about proper nutrition (protein, calories) during pregnancy. It seems to me, from what I have learned until now in my studies, that nutrition has a direct effect on the outcome of pregnancy, and that if it is lacking then the pregnancy can become high risk in several ways. What do all of you experienced doctors and midwives out there think? What other factors than nutrition play part (high cesarean rates, ignorance about harmful substances during pregnancy, etc)?
- Aiyana Gregori, student of midwifery
International midwives, please direct your questions, comments, and needs to "International Connections." We're here to help you!
More on kegels [Issue 3:13]:
Your letter seems to demonstrate the belief that the commonly known "kegel exercise" is beneficial only for tightening and contracting. If this is the case you have missed half the picture! I emphasize that every bit of time spent in contracting the muscle must be matched with an equal amount of time releasing and relaxing it. Thirty-four weeks is an ideal time to focus on letting go and removing all resistance in the pelvic floor. I suggest to all my women that they pair a certain word with the sensation of complete surrender of the pelvic muscles so that I can whisper it to them while they are pushing. Since I live in a Spanish-speaking country we often use the word "sótano" (cellar or basement) as well as the simple and gentle reminder "dar espacio" (make room).
I do not think encouraging women to stop exercises at 34-40 weeks will make any difference. Don't forget that although the pelvic floor muscles may be stronger in primips, it's probably because they have not been stretched before, not because the women religiously practice pelvic floor exercises! Certainly many of the women I have worked with have never practised these exercises, primips or not, although some undertake other forms of exercise which will help strengthen the pelvic floor anyway. The other thing is that the cervix works very differently in a primip compared to a multip and this is more likely to account for a longer labour.
- Alison Andrews
We've usually experienced primips to have a longer labor (of course there are the exceptions). This has been going on since the beginning of time. Kegels as we know them have been around for how long? I'm sure there are places in the world today where women (primips included) don't practice kegels at all. Do they have faster first labors due to lax muscles? I've taught and encouraged hundreds of women (pregnant and not) to do kegels. I stress the importance of it being a life-long habit. I'd love to think all those women are faithfully doing their kegels daily. The reality is, as in any exercise, it's usually the very motivated who keep up the regimen. So, this is my thought: if primips traditionally have a longer labor with or without being faithful with their kegels, then don't ever encourage a pregnant woman to stop doing kegels in hopes for a speedier delivery. It seems to me, any muscle in good form will help the process for which it's intended. At the end of our pregnancies we have hormones to help soften muscles and prepare the region to "give way." (As a footnote: I'm a grand multip: seven pregnancies and six wonderful children. I'm 49 years old. I've done kegels on and off for years but not faithfully. A couple of years ago I found it harder to hold my pee in when I sneezed. I started kegels and have done them daily since then. I can tell the difference.)
I have referred several women with cholestasis/severe itching to acupuncture treatments, with good success.
- Karen Ehrlich, CPM, LM
Re Mindi's question about finding information about breech births 100 years ago: My friend is an antiquarian bookbinder and I've seen some pretty incredible texts--medical/midwifery/herbal--in his workshop. Most of the older (1500-1700) are in Latin but from 1750 and on you can find information in English. Bookbinders, dealers, book shows are good places to look. University libraries are great places to look as well. I have Delee's obstetrical textbook for nurses from 1911.
In response to the woman who was measuring large and was losing hope of having a homebirth [Issue 3:13]:
During my last two pregnancies I measured large. When I was 28 weeks I was measuring as 32. For my second pregnancy I had an ultrasound--it was an ultra-waste. Only one baby was found. When I started measuring big with my third child, I was measuring up to 5 cm over what I should be. We just figured it was a big baby and we were right. No ultrasound was done. A diabetes test was done and it came back negative. I had a natural birth with no drugs/interventions. My last baby was our perfect "10"--a perfect 10 pounds. I had no tears and she did not get stuck. I gave birth on my side because my midwife suggested that big babies come out easier that way and she was right.
You will be just fine! Relax, eat healthy, exercise and you too will have a great experience like I did.
- Heidi, AAHCC
Please don't berate yourself so much. It sounds as if you really know what part of the concern is (cookies, cookies, cookies). You started pregnancy 25 lbs overweight; you've gained 22 pounds. Your dream seems to bring into consciousness what has been subconscious.
I would suggest that your midwife is being cautious and reasonable by requesting an ultrasound. This will be used as a base for future care. It does not mean you have caused irreparable damage to your baby.
Start now and listen to what your body is telling you. Eat sensibly, with healthy food choices. Get exercise (walking, swimming) and quit hitting yourself over the head! Guilt is a big issue for many women. You DO have control over your food intake and your guilt level. Yes, you realize that the cookies aren't the best choice. Change it now--you have the power. Make the rest of your pregnancy focused on the positive. Love yourself!
- MJM, midwife
I think that you should read Anne Frye's book Holistic Midwifery, the section about nutrition and eating, and instruct yourself more about the importance of nutritional content rather than "weight gain." If your doctor or midwife doesn't seem to know much, or you need more information, speak with other midwives (in person, hopefully).
- Anon., student midwife
I've always used Bag Balm for stretch marks. I have very few from pregnancy after four children and it really helps alleviate the itching. I've also found Burt's Bees Carrot Balm to be useful for dry or stressed skin.
In response to the question about swelling during pregnancy [Issue 3:13]:
The first and most important thing to do is to rule out any preeclampsia or possible causes of toxemia. Check out diet, (See Anne Frye; Holistic Midwifery Vol. 1). She explains very clearly the relationship between toxemia and diet. Rule out all possible dangerous causes before trying "simple herbal remedies." This is very important.
- Aiyana Gregori
Increase potassium intake with potassium-rich foods. This can be difficult considering bananas can constipate, apricots are high in sugar (fructose) and that at the point of swelling--late pregnancy--many women have a hard time adding one piece of food to their diet as it is. Another VERY successful option is to take one capsule of potassium daily. In my own pregnancy, despite excellent health and nutrition, I experienced uncomfortable swelling around my 35th week. At the beginning of my 36th, I took a potassium capsule and by the next morning the swelling was down substantially. I expected it to be full blown by the time I went to bed that night but it wasn't too bad. I took another capsule the next day and saw even more improvement. I continued with the capsules once a day for the duration. On the days that I forgot to take it the swelling returned. Of course, adequate water intake should not be neglected.
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