Do you really think?

February 12th, 2010 § 0 comments § permalink

“Do you really think that one-third of babies really need to be born through a zipper on the abdomen?”

Placenta Previa

February 12th, 2010 § 0 comments § permalink

My preceptor and I had a discussion about previa sparked by my question as to whether or not previa could be the cause of bleeding in earlier pregnancy. (She said yes. I had only remembered bleeding from previa to occur in late pregnancy.) So, like all good students, I took advantage of this learning opportunity (more like opportunity to really remember what I learned), and got out the books. Here’s what I found, with my comments in italics.

Previa occurs when the placenta implants either partially or completely over the internal os of the cervix. It occurs in 1 out of every 200 births. I didn’t realize it occurred that often! If enough of the cervical opening is obstructed, softening, effacement and dilation of the cervix will cause the placenta to separate or tear around the margins of the internal os with accompanying rupture of underlying blood vessels and bleeding.
Placenta previa can become symptomatic during the late first or second trimester, but it most commonly manifests with a “warning bleed” at 28 weeks or later, because this is when significant cervical change most commonly begins. A warning bleed is usually painless, fluid, bright red bleeding, because it occurs just at the cervix. Some clots can form if the blood pools in the vagina, such as may occur during the night. Would the earlier warning bleeds occur more commonly in multips, who tend to have earlier cervical changes during pregnancy?

Predisposing factors:
Women over 35 are three times more likely to have a placenta previa. Why? Is the uterine lining more scarred the more cycles you have—similar to the increase in risk of previa if a woman has had five or more D & Cs, which also cause trauma to the uterine lining?

A large thin placenta, simply because it takes up more of the uterine surface.

Multiparity (A theory is that the trophoblast seeks out a new area to implant during each pregnancy; if several pregnancies preceded this one, there will be less such areas in the uterine lining.) But that theory doesn’t really make sense when considered in light of the increased risk of previa with a previous uterine previa. The risk is 12 times greater!

If the lining of the upper uterine segment is deficient, the placenta may spread out over more of the uterine wall in an effort to maintain an adequate blood supply.

Endometritis following a previous pregnancy. Looks like anything that causes damage to the uterine lining increases your risk of placenta previa.

Uterine scars increase the risk of previa; with four or more cesareans there is a 10% risk of previa! The risk of previa and accreta rises from 5% chance in a unscarred uterus to 24% with 1 scar, 47% with two scars, 40% with 3, and 60% with four or more cesarean scars.

Repeated pregnancies with little time between.

A history of previa makes it 12 times more likely that a woman will have another placenta previa. That seems like a surprising jump.

You would think, as the theory stated above suggests, that the placenta would seek an unscarred and “unused”, so to speak, portion of the uterus in which to implant. However, the fact that the placenta is so much more likely to implant over the cervix again if it did so before, makes this theory seem untrue. I really wonder if the increased likelihood of a repeat placenta previa is caused because the placenta is more likely to implant where it did before (or on a scarred/damaged portion of the uterus), or, if the factors that caused the first placenta previa were still present, and were a cause of the second previa. That would be something very interesting to investigate. =)

I love interesting discussions sparked by a real-life situation, or question that lead me to interesting thoughts and discoveries.

This little tangent reminds me again—interventions lead to increased risks. Cesareans are not a risk-free procedure! I’m glad we have them when we really need them, but women should be properly informed regarding their risks—especially when it is not actually necessary (elective cesareans, for instance).

The information and statistics for this post were taken from Holistic Midwifery by Anne Frye.

Coming to Term and Pushed

February 12th, 2010 § 0 comments § permalink

I did a lot of reading during my couple days of break before plunging into my next module of homework (which by this point, I’ve already started). I ran by the library, scanned the maternity/pregnancy section, and grabbed an armful of books to peruse.

Pushed sparked my VBAC post, and Coming to Term: The truth about Miscarriage is likely to spark another post—one on fertility, and miscarriage.

Stay tuned!

Pick your Risk: thoughts about VBAC

February 12th, 2010 § 0 comments § permalink

After posting what I did about the VBAC discussions during the workshop last week, you may be somewhat surprised about the tone I take in this post. Fasten your seat belts…

This weekend, I’ve been reading Pushed: the painful truth about childbirth and modern maternity care by Jennifer Block. Her observations on VBACs remind me of my own, while having long discussions on them with my preceptors.

In today’s world, the prevailing view is that a cesarean is almost, if not totally safe. And, in many people’s minds, even safer than vaginal birth. Midwives and homebirth advocates may sometimes sound as if we believe that vaginal birth is almost, if not totally safe, and a cesarean is one of the most dangerous thing that could befall a mother. There is another view, however—that both vaginal birth and cesarean delivery have their risks.

We confront risks daily, as we go about our lives. We make risk/benefit decisions all the time. However, often, when mothers confront the decision of how their baby will be born, they are often given a false sense of security in the form of a c-section.

Cesareans carry more than the initial risks of major (not minor) abdominal surgery, which include infection, increased blood loss (about twice that of a vaginal birth), decreased bowel and respiratory function, longer recovery time (and usually much more painful), reactions to the anesthesia, and a risk of additional surgeries. These are the initial risks to the mother, which are mentioned rarely enough. However, there are also the long-term risks that are even less often mentioned: abnormal placental implantation (risking placenta abruption, placenta acreta, percreta, increta with accompanying risk of hysterectomy), increased risk of ectopic pregnancy, adhesions (scar tissue that connects layers of tissue), infertility, and the risks and difficulty of the procedure increase with each successive section.
Then there are the risks to the baby: premature birth (if the due date was incorrectly calculated), respiratory problems, low APGAR scores, fetal injury (rare, but the baby can be nicked when the surgeon creates the incision).

Too often, mothers are given only the benefits of a c-section, without being fully informed as to the risks for now, and the risks for later (not to mention that women are rarely told how difficult it will be for them to find a supportive care provider if they ever decide they want a vaginal birth with a subsequent pregnancy!).

With VBAC come the risks of uterine rupture, of course, but only about .3% greater than with a repeat cesarean. In an out-of-hospital birth, if uterine rupture occurs, the outcome is pretty grim for mom and baby. But, on the other hand, a mother doing a VBAC in hospital is likely to encounter a set of interventions that increase the risk of uterine rupture (induction, augmentation, etc).

My take, then, on this issue is that mothers must fully inform themselves of all possible benefits and risks that accompany the various available options (in or out-of-hospital, vaginal birth, or cesarean delivery), and then take responsibility for their actions. Decide with which risk you are most comfortable, and go with it, because the truth is…we cannot eliminate risk in this world.

When an intervention is recommended…

February 8th, 2010 § 0 comments § permalink

If an intervention is offered, or recommended, you should always ask:
What could happen if I don’t do this? How likely is it that that will actually happen?

If it’s a test, ask:
What difference is there if I don’t do this test? How will you care for me differently if I allow this test, vs. if I don’t allow this test? Will the results of this test change the outcome?

Don’t assume that everything offered is necessary. Ask questions, and then decide. =)