March 5, 1999
Volume 1, Issue 10
Midwifery Today E-News
“Placenta Previa”
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In This Week's Issue:

1) Quote of the Week
2) Join In!
3) The Art of Midwifery
4) News Flashes
5) When Placenta Previa Occurs
6) Placenta Previa at Term
7) Placenta Previa: Predisposing Factors
8) Switchboard
9) Midwifery Today Question of the Quarter
10) Letters
11) Coming Themes

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1) Quote of the Week: You gain strength, courage and confidence by every experience in which you really stop to look fear in the face.

- Eleanor Roosevelt

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2) Join In!

Thirteen years ago, Midwifery Today was founded to provide a forum for the voices of midwives and birth practitioners everywhere. Today, your many voices are still our greatest strength. We encourage you to keep that tradition going in E-News by writing for us. Write your own story, how you got involved in birth practice, what your most burning issues are in regard to birth, techniques and arts you've learned or read, news or musings about anything related to the childbearing year.

Because brevity is an important concern, keep your words to one to three paragraphs. If you start writing and you find you must go on longer, we would be happy to consider your work for Midwifery Today magazine, The Birthkit newsletter, or an online article. Share your knowledge, stories and insights--they really matter to a lot of others out there like yourself.

- Jan Tritten, editor

Write to: mtensubmit@midwiferytoday.com

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3) The Art of Midwifery

Be Patient

There is a subtle art to deciphering the trivial from the meaty in casetaking. Make time for your database kinds of questions (preferably done first, to establish the context of what may follow) and leave time for the story, the personal, and/or what may seem a bit of rambling. E.M. Cioran once said, "Crucial things often come to the surface at the end of a long conversation. Great truths are often said on the doorstep."

- Alison Parra Bastien

Upright Position

An upright position for birth eliminates the possibility of supine hypotension syndrome. This condition can occur when a pregnant women lies on her back. The weight of the uterus can compress the major blood vessels--the aorta and inferior vena cava--interfering with the woman's circulation and causing a lowering of her blood pressure. When a woman is in a vertical position, the baby's direction of descent is down and out, in harmony with gravity.

- Susan Smith, RN

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4) News Flashes

When Manual Exams Are Risky

Researchers at the University of Toronto's maternal infant and reproductive health research unit have concluded that multiple manual vaginal exams not only predict risk of chorioamnionitis in women with ruptured membranes, but that they are a risk. Research showing that multiple vaginal exams increase rates of infection, however, has not translated into a change in clinical practice.

Women given eight or more manual vaginal exams have rates of infection five times greater than women with three or less, based on a controlled trial of 5,041 women whose waters broke at term and before labor began. Chorioamnionitis and longer duration of active labor were found to be the two most important predictors of postpartum fever.

- Birth Gazette, Vol. 14 No. 4

Sickle Cell Disease and Pregnancy

A study to assess the maternal and fetal outcomes of pregnancy in women with sickle cell disease evaluated 445 pregnancies in 297 women. Of the pregnancies, 28.8 percent ended in elective abortions, 6.5 percent in miscarriages, 0.7 percent in stillbirth, and 63.6 percent resulted in live births. Overall the most frequently recorded maternal complications were preeclampsia (14 percent), toxemia (11 percent), premature labor (9 percent), premature rupture of membranes (6 percent), and eclampsia (1 percent). The overall proportion of live births following at least 28 weeks gestation compared favorably with the national rate.

Infants were at greater risk of prematurity, and low birth weight, especially if they were of the Hemoglobin SS genotype. Preeclampsia and acute anemia episodes appeared to be particular risk factors for small for gestational age infants in women with SS. However, except for an increased rate of neonatal jaundice, the infants appeared to be healthy.

Researchers were clear that advice on pregnancy avoidance for women with sickle cell disease, even for those with the SS genotype, is inappropriate and is not justified by scientific evidence.

- MIDIRS

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5) When Placenta Previa Occurs

There are four types or degrees of placenta previa: lateral, in which the lower margin of the placenta dips into the lower uterine segment and the major portion of the placenta is normally attached to the upper uterine segment; marginal, in which the placenta reaches the internal os when it is closed, but does not cover it; partial, in which the placenta covers the closed internal os, but does not do so when the os is fully dilated; and complete, in which the placenta covers the os, even when the cervix is fully dilated.

Placenta previa occurs in approximately 1:200 pregnancies, and it is more common in multiparous than primiparous women. Large placental size is a risk factor. Women with a history of cesarean birth have been shown to have a 3.9 percent incidence of placenta previa in a later pregnancy, possibly due to the presence of the scar on the lower uterine segment. Other risk factors include increased maternal age, parity independent of age, and cigarette smoking.

Some women with placenta previa experience a number of small episodes of painless bleeding. In fewer than 20 percent of cases is there no warning bleeding. Severe bleeding is more usual as labor progresses or following obstetrical interference such as a vaginal examination. The main clinical feature is absence of pain.

A pregnant woman who reports blood loss should be asked by her midwife to save soiled clothing so extent of blood loss can be assessed. Once the blood loss has subsided, a gentle speculum exam to exclude cervical causes of bleeding may be performed.

Although bleeding from placenta previa in its early stages is not immediately life-threatening to mother and fetus, without prompt attention the situation can quickly deteriorate. Risks to the mother include shock from hypovolemia. The prognosis for the fetus is far from good in cases where the area of placental separation is significant. Hypoxia occurs due to diminution of placenta blood flow from maternal hypotension and anemia, in addition to a reduction in the area of attachment.

- Louise Silverton, The Art and Science of Midwifery

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6) Placenta Previa at Term

If no serious hemorrhage has made it imperative to act earlier, at about the thirty-eighth week the mother with placenta previa is examined in hospital. A careful one-finger manual exam is done to determine if the placenta is encroaching upon the lower uterine segment, in which case the practitioner will rupture the membranes and normal labor will ensue; or if the placenta reaches the margin of the cervix either posteriorly or anteriorly or covers the os, in which case a cesarean will be performed.

Postpartum hemorrhage may complicate the third stage of labor since there are few oblique muscle fibers to control bleeding from the placental site in the lower uterine segment.

In mothers who have had previous cesarean sections, placenta previa accreta may occur when the placenta is morbidly adherent to the previous uterine scar. Serious hemorrhage may occur when attempts are made to separate the placenta.

- Betty R. Sweet, Mayes' Midwifery, Bailliere Tindall, 1988.

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7) Placenta Previa: Predisposing Factors

1. Women over 35 are three times more likely to have a placenta previa.
2. A large, thin placenta. These are more likely to cover the cervix simply because they take up more of the uterine surface.
3. Multiparity. Theoretically, 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.
4. 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.
5. Endometritis following a previous pregnancy.
6. Uterine scars. In one study, the rate of previa in an unscarred uterus was 0.26 percent, 0.65 percent after one cesarean, 1.8 percent after two, 3 percent after three, and 10 percent after four or more, a 38-fold increase.
7. Repeated pregnancies with short intervals in between.
8. A history of previa. Women with a history of previa are twelve times more likely to have a recurrence.
9. Multiple gestation, due to the large placental implantation site(s).
10. Any disturbance of the healthy formation of the uterine lining.

- Anne Frye, Holistic Midwifery Volume 1, Labrys Press, 1995.

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8) Switchboard

This is in response to Jill Cohen's discussion of the use of epidurals [E-News Issue No. 9]. I am a CNM who does hospital births. My consultant physician and I are backups for the licensed midwives in town. When an exhausted woman like the one Jill describes is brought into the hospital, I take over her care (with the LMs still there as support as well). I very rarely use epidurals for these or any of my moms. I have found IV analgesia such as Demerol or Nubain along with Pitocin to work very well to relax an exhausted woman and get her labor going again. I suggest that IV analgesia be tried for these women before getting an epidural. You may find, as I have, that an epidural is very rarely needed. In my thinking, homebirth and hospital birth under epidural analgesia are the two opposite ends of the spectrum.

Kate Simon
New Mexico

I would like to write a thesis for my master's degree on measurement of quality of life in pregnancy and puerperal women. One of the few instruments of assessment is the Inventory of Functional Status in pregnancy and after childbirth. But here in Portugal it is impossible to access information on this subject. Could E-News readers please help me, possibly in the form of bibliographic references and contact with people who work with these themes? How can I get access to this instrument and the permission to use it in my investigation?

- Rosalia Marques
mop24776@mail.telepac.pt

As a practicing midwife in Australia, I want to thank you all for this wonderful global "village" as you called it a couple of issues ago. I am amazed at how much shared knowledge there is in our field and how willing everyone is to share their knowledge and teach others.

I have had confirmation of information I have gleaned elsewhere and some interesting comments coming through, perhaps shedding new light onto knowledge I already had. Your latest issue on breastfeeding is a case in point.

A friend of mine, some twenty years or more ago now, breastfed an adopted child successfully for about a year. She had breastfed her first baby, then her second was severely affected by cystic fibrosis which was diagnosed at only a few days old due to acute bowel obstruction occurring at that time.

When Tanya was diagnosed, the doctors advised her parents that breastfeeding was completely out of the question and they went along with that. Liz and her husband decided they'd never risk having another child of their own due to the risk of cystic fibrosis rearing its head again, so they adopted a third child when Tanya was about three years old. Liz breastfed him from the time she took him home at about three weeks of age. I believe she "supply lined" for the first few days until she had her lactation really going, then went from there.

Thanks again for your newsletter. I read it with interest and take it to work with me. It is great having the main subject matter at the top of the letter, too.

- Jane

I have breastfed both my girls. I believe it is the most natural, beautiful way to feed a baby. I do have a question, though: Is it normal to, after a while, feel like you don't want to breastfeed anymore? I don't want to give my daughter a bottle, but sometimes I just don't want to breastfeed her. Or is this part of postpartum depression? I would never give my daughter formula as long as I could breastfeed, but I just get aggravated sometimes, and feel like I should just start giving her baby food. Can you help me? I need some insight on this.

- Amber

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9) Midwifery Today Question of the Quarter: What is your favorite homebirth story?

Join us in our Golden Issue--No. 50 of Midwifery Today magazine--and tell us your story. Please adhere to a 275 word limit. We'll choose the three best stories for publication! Send your submissions to editorial@midwiferytoday.com or Midwifery Today Question of the Quarter, PO Box 2672, Eugene, OR 97402 USA by March 15.

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10) Letters

I am nearly forty, a mother of three children ages four to ten, starting a Waldorf school and finishing nursing school in May, 1999. I hope to start CNEP in November, 1999. I have been a childbirth educator and doula for many years. Every day that I work in mainstream medicine I have that "where do I belong here?" feeling come over me. Labor and delivery is such a mechanistic, disrespectful experience. Sadly, most women I see don't articulate their feelings about this. It comes down to "don't let me experience any pain and do anything you need to do to me, but make sure the baby is healthy." When I work in labor and delivery, I usually don't have enough time to help a laboring woman regain her sense of trust in the birth experience and impart the knowledge that being an active participant in her birth can change her life. Midwifery Today, you have been a lifeline, a voice of sanity in this insane field called "health." care. Thank you, thank you for being present. You break down my isolation and remind me there is hope.

- Tanya M.
Oak Park, IL

I work as a RNC on a LDRP floor and also in home care (maternal/child). Your newsletter is very interesting and informative. I enjoy reading it.

- Laura Burgess BSN, RNC

I am subscribed to the new newsletter and I love it. It is really great the way it is organized by topic for easy filing.

- Sabrina

Thank you very much for forwarding the email newsletter. I will forward it to all my friends in Latin America who speak English... but it sure would be fabulous to have this in Spanish!! Let me know what your adventures are in the future for translation.

- Ann Davenport

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12) Coming Themes

Tell E-News readers what you think about:

- smoking and pregnancy
- infections
- ultrasound
- epidurals
- educating the public
- education
- posterior labor
- cesarean section
- postpartum blues/depression
- meconium aspiration
- tear prevention


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This publication is presented by Midwifery Today, Inc., for the sole purpose of disseminating general health information for public benefit. The information contained in or provided through this publication is intended for general consumer understanding and education only and is not intended to be, and is not provided as, a substitute for professional medical advice, diagnosis or treatment.

Midwifery Today, Inc., does not assume liability for the use of this information in any jurisdiction or for the contents of any external Internet sites referenced, nor does it endorse any commercial product or service mentioned or advertised in this publication. Always seek the advice of your midwife, physician, nurse or other qualified health care provider before you undergo any treatment or for answers to any questions you may have regarding any medical condition.

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The content of E-News is copyrighted by Midwifery Today, Inc., and, occasionally, other rights holders. You may forward E-News by e-mail an unlimited number of times, provided you do not alter the content in any way and that you include all applicable notices and disclaimers. You may print a single copy of each issue of E-News for your own personal, noncommercial use only, provided you include all applicable notices and disclaimers. Any other use of the content is strictly prohibited without the prior written permission of Midwifery Today, Inc., and any other applicable rights holders.

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