The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
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Orgasmic Birth -- the documentary! ABC's 20/20 will be airing a segment about Orgasmic Birth on May
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Club Previa
- This is a very upbeat site put together by a mom, Karen Cork, who had
placenta previa.
Placenta praevia:
information for you - patient information from the Royal College of
Obstetricians
The Saari Kempaainen study revealed that 150 women were diagnosed as having placenta praevia; when they got to term only 4 women actually had it. In the control arm the women who were not exposed to ultrasound also had 4 women whose placenta praevias were discovered when they went into labour. Both sets of women had caesarean sections and there was no difference in outcomes. The researchers did not investigate the amount of stress a diagnosis of placenta praevia could have caused in the 146 misdiagnosed women. This research shows that early diagnosis of placenta praevia is irrelevant and a complete waste of time, yet doctors and midwives persist in telling women they have low lying placentas.
The
relevance of placental location at 20-23 gestational weeks for prediction
of placenta previa at delivery: evaluation of 8650 cases.
Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M
Ultrasound Obstet Gynecol 2001 Jun;17(6):496-501
"CONCLUSION: At 20-23 weeks, a combination of routine transabdominal and indication-based transvaginal location of placental position is a powerful tool in predicting placenta previa at delivery. The advantage of determining placental position at this stage of pregnancy is a low false-positive rate compared to at earlier stages of pregnancy. We conclude that an overlapping placenta at 20-23 weeks has the consequence of a high probability of placenta previa at delivery. An overlap of 25 mm or more at 20-23 weeks seems to be incompatible with later vaginal delivery. "
See also Related
Articles
Low lying placenta
from Danny Tucker's pages
[from ob-gyn-l]
My pet peeve are the ultrasound reports. Why do the sonographers insist
on reporting 'marginal previas' at 15 week ultrasounds? I have even ordered
ultrasounds later in pregnancy for other reasons and the report will say
that the previa "resolved". I had an old but well-respected OB tell me
when I was a student that the placenta actually had 'fingers' and it could
'crawl up the uterine wall' to its appropriate place.
They report it that way for medical-legal reasons. The guidelines say
that in the 2nd trimester one must comment on the location of the placenta.
If one does not and there is a previa later, they are guilty of violating
the standard of care for an ultrasound.
I keep trying to teach the residents that placentas do not move, they
are attached to the uterus. If it "resolves" at 37 weeks or at 15 weeks
or at any other time, then it never really was. It only looked like it
was. The problem is that until the head gets down into the lower part of
the uterus, the placenta which is a big bag of blood(fluid) can just sort
of ooze down there around the cervix and look like a PP. In case you hadn't
noticed, this is one of my soapboxes. It gets me to respond every time.
The residents say "Oh no, here he comes again."
I take issue with the statements "teach residents that placentas do not move, they are attached to the uterus.". and "resolves at 37 weeks or at 15 weeks or at any other time, then it never really was. It only looked like it was." (See below).
Yes, the placenta is attached, but I have seen serial studies in which
the positions were quite different,.... they changed. As have many other
folks, that is why the phrase "Placenta Migration" came into being after
sonography was developed. But the placenta is not crawling with fingers.
Dr. Harris Fineberg elegantly explained this phenomenon, as trophotropism.
The tendency to grow toward better nutrition and away from poorer nutritional
states. Look it up in a medical dictionary. Or see the discussion in the
OBGYN.net Forums below (we've been through this before, search
for placenta+previa). Or better yet, buy my book, DuBose TJ, FETAL SONOGRAPHY,
W. B. Saunders Co. 1996 and read pages 358-362. ;-)
I agree that the main reason for the constant comment is medical-legal. Also, if the placenta has a portion, which is slightly across the internal os demonstrated by sonography, then that is how it must be called at that time. Even though we all realize that later it will probably be higher up.
One last thing. The report (Dx) is usually issued by a Sonologist (M.D.).
The sonogram is often done by, and a Sonographer's Impression (but that
isn't a Dx) may be given by a Sonographer, RDMS, to an M.D. who does issue
the Dx. This medical-legal stuff does drive me crazy too, but it is real,
and we must deal with it as long as the lawyers are about.
You heard the placenta? Please explain. What, exactly, in the
placenta makes a distinct noise you can hear with a Doppler?
I always go "placenta hunting" with my Doppler at around 35 weeks. The
placenta makes a very different sound than the heart or even the cord.
There is a very distinct "swoosh" sound with the placenta. If I cannot
find the placenta at all, I usually assume that it is just too posterior
to locate via Doppler. One good way to practice getting the sound difference
down, is by simply placing your Doppler at the top of the fundus on all
of your mommies at around 35 weeks. Since so many placentas are at the
top of the fundus, you will have a chance to experience that sound, then
when it is low lying, or in some other strange place, you will know
that sound. :-)
It is also easy to hear with the fetoscope. Sometimes when the HT are
not loud enough for the mom to hear she can still hear the placenta with
the fetoscope.
I just can't see how the Doppler, which is only responding to blood flow velocity, can sound different if the blood vessels it's "seeing" happen to be in a placenta.
Have you verified this by marking where you "hear" the placenta, then
having ultrasound done to confirm it? Has anybody done such a study? If
this phenomenon is true, it should be easy to demonstrate it.
I don't know if any studies have ever been done on this, and I have
never sent a woman for ultrasound for the sole purpose of confirming that
the placenta is where I think it is. But on that rare occasion when I have
had to send a woman for an ultrasound, I always double check (usually I
go with the mom for her US) the location of the placenta. It helps me to
determine if I am accurate most of the time. Which... I am usually pretty
accurate. Has anyone else also had this experience?
I have done this many times. I don't routinely placenta hunt, but have
often suspected an anterior placenta. I'm sure many of us have had the
experience, the mum is complaining of lack of fetal movements even at 20
weeks, even if multip, and placental sounds are heard anteriorly, making
getting a FH difficult, even with a dop. You often have to listen for FH
very low or from fundus down. In the last couple of years, I or the midwife
I was working with had occasion to have u/s done on some of these women,
for other reasons, and we always marked the reports, that we had predicted
the anterior placenta. I don't think we had any that we thought were anterior
that were not.
I was taught this too, and have always noted it on my charts just in case we needed a u/s during the pregnancy. On occasion a subsequent u/s agreed with this; but not often!
I chart it as "Loud vessels heard upper right quadrant etc." and I think that's what they are.
We can't tell by looking at the placenta after birth whether our guess
about location was right (Unless the membranes are in good shape and then
we can only confirm whether the placenta was high or low, but NOT posterior,
right, anterior, left etc.).
I've had my Doppler assessments of placental location verified by U.S. One thing I look for in addition to the placental souffle is a cord insertion. I make a note in pencil on my chart so when I get the US report I can verify my assessment then erase!. It's one of those things you want to be able to erase, as the medical community thinks you're nuts to think you can locate the placenta w/o us.
When I got one of my Medisonics Dopplers, from Cascade, it came with
a bunch of printed info on use of the Doppler. It had a study included
on locating the placenta with the dop., and instructions. I found it to
be of mild interest, so I didn't exactly memorize it. But I do remember
that it gave specific instructions for locating a posterior placenta with
the dop. Posteriors are harder to pin down.
I use an Allen fetoscope and have heard the difference between heart
and placenta, when listening it covers a larger area than when hearing
a cord or the baby's heart as well as swooshing differently ; )
Low lying placentas can present some difficulty because of femoral pulsing.
I also find these are the heart tones most difficult to hear with a fetoscope.
We determine the approximate location of implantation after the birth.
If the hole in the membranes is close to the edge of the placenta, that
confirms it :-)
Yep -- I always look for the hole to confirm my suspicions -- It was
very interesting to see after the people last summer who supposedly had
the vasa previa. (Long story, if you have subscribed recently) That was
not the case, but U/S also showed very low lying placenta. Hole was right
ON placental lobe. I have seen that a few other times, but of course, we
didn't know to worry until after the fact! I've been listening to placentas
since I was an apprentice -- one of the first things I was taught. I believe
it's easier to hear a placenta with fetoscope, but is possible with Doppler
-- I've heard cord right above pubic bone, several times, too, with dop
-- meaning probable cord around the neck. (I even palpated that once) I
use Doppler to confirm position, all the time. Can figure out OP and OA,
etc., by finding the actual heart. I love using the Doppler in those ways,
and it makes me feel less guilty about using the Doppler instead of the
fetoscope!
You Betchya! You can hear a difference between cord, placenta and fetal heart. Do a simple demonstration project with your office Doppler and then confirm with your ultrasound machine...better yet have the u/s report in hand UNREAD and then listen and see if you can hear the difference. If you get good at Dopplers (Dopplers are for wimps) get out your fetoscope and see if you can distinguish placental souffle (spelling?).
Here is your chance to publish a very straight forward study that may
decrease the "need" for ultrasounds and save insurance companies big bucks.
Here's something else you can hear w/ a Doppler...fetal breathing movements.
Taught to me by an OB (high-risk fetal-maternal medicine type) that I did
a placement with. Hard to describe, but very distinctive, once you've heard
it. Reassuring during those last weeks of pregnancy, as that's one of the
signs of fetal well-being.
oh, PLEASE try to describe it! -- that would be an excellent skill to
learn, reassuring for those questionable babies -- especially for my moms
who won't get U/S.
Well, here goes. It sounds like a subtle, rhythmic "whoosh", very soft, and much softer than the placental or uterine souffle, also usually much slower, as well. The sound is caused by an increase in vascular resistance with the breathing movement, or so I was told. If you're lucky, with a skinny mom, you can also see it at the same time. This is not the same as hiccups, which usually sound quite loud w/ the Doppler, and the movement much more jerky and distinct.
I've noticed it a number of times since I was taught about it. The only
problem w/ using it intentionally is around the periodicity of fetal activity
which occurs in about 90 min cycles. You could wait a long time at a sitting
before you heard it.
[from ob-gyn-l]
Blood flow through the intervillous space has a sound like wind blowing
through the trees. (Frequently Aspens) However so does blood flowing through
veins. This could possibly lead to a correct diagnosis of a general placental
location in some cases, but I doubt that it would work with consistent
enough accuracy to replace ultrasound. I know of no studies. The above
reflects expert (I hope) opinion based on a few facts and a lot of experience.
[from ob-gyn-l]
I see the apparent migration as simply growth of the uterus. no change
in implantation site, simply more area between the cervical margin and
the placental edge. the decrease in previas seen on u/s at term being due
to a decrease in the proportion of uterine wall occupied by placenta at
term compared to the proportion at 16-20 weeks . and no i have no good
evidence for this.
Often, an anterior placenta takes up some room in the front of the mom's belly that would otherwise be occupied by the baby's back. This can sometimes cause the baby to be somewhat posterior, although this tends to correct itself as the baby moves lower into the pelvis and the back moves down, beyond the placental location.
Sometimes, in an effort to correct this apparent posterior position, moms will spend a lot of time on hands and knees. This can be a problem with an anterior placenta in that then the baby's weight is right on top of the placenta, which can cause some cord compression, especially with big babies or low fluid levels. This can result in minor fetal distress or meconium.
So moms with anterior placentas who are doing hands and knees might
want to limit the time to 2 or 3 minutes at a stretch.
Can anyone help provide information about the implications of an anterior placenta? I've searched my medical texts and the Web and found nothing other than the implications regarding placement of the needle for amniocentesis.
Are there any implications for fetal growth or labor and delivery?
I can imagine that an anterior placenta might predispose a baby to a posterior presentation, and possibly even to a breech presentation.
If the blood vessels are less dense in the anterior uterus, perhaps there could be implications for mild IUGR. But then one might expect reduced risk of postpartum hemorrhage.
I'm labor coaching for a client whose OB mentioned it with one of those
"Well, this bumps you up into a higher level of risk" tone of voice, and
she was worried.
No problems, other than sometimes posterior,( baby curls around placenta),
or harder to hear FHTs because of loud souffle.
I'm kind of wondering why you're worried about it...I figure that lots
of women have anterior placentas. There has been a suggestion that they
may somewhat predispose to posterior presentations, but the only thing
that I find is that women (particularly multigravid) may feel less fetal
movement with them. I figure that this is because there is more "insulation"
between the fetus and the outside world, as it were. In one instance not
too long ago, I was sure the placenta was anterior, but the mother was
worried about fetal movement. Sent her for U/S and guess what? I was right.
Only thing I noticed was that the baby consistently laid on the opposite
side of the uterus to the placenta. Everything else was completely normal.
Wouldn't the only risk be during the ( waaaay outside) chance that she would need a c-sec? Because if the placenta is anterior making the incision would be dicey-they would have to deliver the placenta and the babe at the same time, and blood loss could be a concern.
I had a low lying anterior placenta with my 2nd pregnancy, and the only
challenge was hearing my son! Sometimes it took a good 10-15 mins. to get
clear heart tones. Maybe this is what the doc is concerned about? It would
seem that using a doptone would make that easier (my mw used a fetoscope).
Other than that everything.
I don't know of anything significant with anterior placenta placement.
It just may make the FHR harder to pick up depending on the baby / placental
positions. The only other problem would be that if a cesarean section was
needed the OR team would have to be careful (and would hopefully be able
to determine placental placement prior to the incision).
Can be harder to palpate, to get clear FHT; mom may perceive less movement.
There is some evidence that women with anterior placentas feel quickening
later and also experience less fetal movement. I don't know how much research
has been done on it but it does make some logical sense.
I've definitely found this to be true in my practice. Moms need lots
of reassurance about late perception of fetal movement. I tell them that
the placenta acts as a pillow between the moving baby and their abdominal
muscles, which sense the baby's movement. The baby is still active, but
the movement is "muffled" by the placenta.
The main thing is that if the mother has ever had a C-section or anything
that could scar the anterior endometrial area then she is at higher risk
for placenta accreta.
Because the Cesarean scar is in the front of the uterus, i.e. the anterior,
an anterior placenta may be implanted directly over the uterine scar.
Sometimes this causes the placenta to grow into or through the uterine
wall so that it does not detach properly after the birth. This can
be a life threatening situation and is well outside the scope of midwifery.
Surgery in the presence of Placenta accreta, increta and percreta [see item 6] from the Royal College of Obstetricians and Gynaecologists:
"Women who have had a caesarean section in a previous pregnancy and who have a placenta praevia subsequently should be considered at high risk of having a morbidly adherent placenta. In such cases particular attention should be focused to confirming or excluding this diagnosis using ultrasound imaging. When present, senior anaesthetic and obstetric input are vital in planning the delivery."
"The association between placenta praevia and placenta accreta is strong, with a relative risk of 2,065 compared to women with a normally sited placenta.30 This is also associated with scarring of the lower segment of the uterus, and the risk of placenta accreta in the presence of placenta praevia rises relative to the number of previous uterine incisions.30-32 Ultrasound imaging,33 colour doppler and power amplitude ultrasonic angiography34 and magnetic resonance imaging35 have all been shown to be valuable in the diagnosis of placenta accreta, increta and percreta."
Diagnosis of
placenta praevia and accreta after previous caesarean
You can search for placenta percreta at PubMed. There are some hints that ultrasound or MRI might be able to diagnose or rule out placental problems with a placenta that is located over the uterine scar.
MRI
appearance of placenta percreta and placenta accreta.
Maldjian C, Adam R, Pelosi M, Pelosi M 3rd, Rudelli RD, Maldjian J.
Magn Reson Imaging 1999 Sep;17(7):965-71
"MRI is useful for identifying the presence and extent of placenta accreta/percreta."
I came across the following in "The Accoucheur's Emergency Manual" by Yingling, first published in 1921 in India, at a time and place where cesareans were not readily available. I think most of us agree that a cesarean section is the preferred approach with placenta previa, but I also think it's important to have this tucked away in the back of your mind, just in case:
In placenta praevia I fully recommend the method or plan of Dr. H. N. Guernsey, which is "in puncturing the membranes through the placenta and evacuating the liquor amnii." "The finger must explore a sulcus between the cotyledons of the placenta, and with the same hand a female catheter, previously concealed in the palm, must be forced through the placenta and the membranes during a pain." "The liquor amnii must be drawn off slowly: and as surely as it thus flows, so surely will the haemorrhage cease. After the waters have pretty much escaped, the finger may take the place of the catheter, and aid in tearing the orifice larger, so that the presenting parts may descent." This method applies whether the placenta is central or only partially over the os uteri.
I like to save up these tricks and hope and pray we will never be in a situation to need them. Re -- old treatment for previa -- rupturing membranes was always the first trick -- it often allowed the presenting part to settle down and put some pressure on the bleeding areas, and might make labor proceed more rapidly. Tearing through he placenta might make the birth go faster too -- but in those cases the life of the baby was pretty much forfeit. They were just trying to get the kid out before the mom bled to death.
Thank goodness we live in a time and location where surgery is available
for previas and other problems.
Actually, a midwife friend told me of assisting at a birth in a very rural area where there was an undiagnosed placenta previa. The mom was a multip and the birth was proceeding very quickly. They tore an opening in the placenta, and it must have moved around the baby's as the cervix dilated, and baby was born just fine. I'd hate to think of the stress level for everyone involved, but this kind of approach doesn't automatically mean that the baby would die.
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