Placenta and Placental Problems The normal placenta1,2 Placenta is derived from both maternal and fetal tissue

with approximately one fifth derived from fetal tissue at term. It comprises a large number of functional units called villi which are branched terminals of the fetal circulation allowing transfer of metabolic products. At term, the normal placenta: Is blue-red in colour and discoid in shape. Is between 15-22cm in diameter. Is 2-4cm thick. Weighs 400-600g (15% normal neonatal weight). Has a maternal surface that is divided into lobules or cotyledons with irregular grooves or clefts. Has a smooth, shiny, translucent fetal surface covered in amniotic membrane. The normal umbilical cord: Is 55-60 cm long and 2-2.5 cm in diameter. Should have abundant Wharton's jelly with no true knots. Contains 2 arteries and 1 vein. Can arise from any point on the fetal surface of the placenta. Abnormalities of shape, size and surfaces1,2 Circumvallate In approximately 1% of cases, there is a small central chorionic area inside a paler thick ring of membranes on the fetal side of the placenta. This is associated with an increased rate of antepartum bleeding, prematurity, abruption, multiparity and perinatal death.3 Succenturiate lobe These are accessory lobes. Large torn vessels within the fetal membranes but beyond the edge of the delivered placenta are suggestive of an undelivered lobe and the uterus should be further explored for retrieval. Succenturiate lobes are associated with retained placenta and increased risk of postpartum infection and haemorrhage. They appear to be associated with increasing maternal age and are more common in women who have received IVF.4 Bipartite placenta This is uncommon: the placenta appears as a bilobed structure joined by main vessels and membranes. If retained after birth, it can cause bleeding and septic complications. Again one should examine a small placenta for evidence of missing lobe and recover without delay. Placenta membranacea Failure of the chorion laeve to atrophy means that placental cotyledons form an envelope around the greater part of the uterine wall. This is associated with antepartum and postpartum haemorrhage as well as retained placenta. Placenta in multiple pregnancy Fraternal twins have either two distinct placentas or fused but there are always two distinct chorions and amnions. With identical twins the situation depends upon the timing of the division of the fertilised ovum: they can have two distinct placentas and sets of membranes or many different types of fusion with possible interchange of blood supply. Abnormal placental attachment or separation Placenta accreta/percreta/increta2,5,6 These are conditions where the placenta is abnormally strongly attached to the uterine wall. Incidence is about 1/2,500 deliveries. All are associated with retained placenta requiring surgical removal and high risk of postpartum haemorrhage. It may be partial (accreta where there is diffuse penetration into the myometrium), more significant as the myometrium is deeply invaded (placenta increta) or even crossing the uterine wall and invading the peritoneum (placenta percreta). Risk factors7

 Previous caesarean section Placenta praevia Advanced maternal age The incidence of placenta accreta is thought to be increasing due to the rise in caesarean section deliveries. Management RCOG guidelines8 suggest: Where available, colour flow Doppler ultrasonography should be performed in women with placenta praevia to antenatally diagnose a morbidly adherent placenta. Where this is not available locally, they should be managed as if they have placenta accreta until proved otherwise. Where placenta accreta is thought likely, consultant anaesthetists and obstetricians should plan and manage the delivery. Crossmatched blood should be available. The risk of haemorrhage, transfusion and hysterectomy should be discussed with the patient as part of the consent process. Repeated attempts to manually remove a placenta accreta can produce severe haemorrhage and the treatment in this circumstance is usually hysterectomy. Conservative management is sometimes applied where the preservation of fertility is paramount (leaving the placenta in place with or without therapeutic uterine artery embolisation or surgical internal iliac artery ligation or methotrexate therapy) but these may be complicated by delayed haemorrhage and the ultimate necessity of hysterectomy.

Retained placenta9 This occurs when placenta remains in uterus for more than 1 hour. It risks post-partum haemorrhage and was identified as the cause of 18% of severe obstetric haemorrhages in one American series.10 A physiological third stage takes about 30 minutes and the use of syntometrine and controlled cord traction to actively manage the third stage usually means delivery is achieved in 10 minutes. Causes of retained placenta include: Placenta adherens (myometrium has failed to contract behind the placenta). Trapped placenta (placenta has detached but is trapped behind a closed cervix). Partial accreta (where a small area of accreta prevents detachment). In developing countries, retained placenta occurs in 0.1% deliveries but is associated with up to 10% mortality. In developed countries, it is more common (3% vaginal deliveries) but is rarely associated with maternal mortality. If the placenta does not separate readily: Avoid over vigorous cord traction (the cord may snap or uterine inversion may occur) Examine the abdomen - is the uterus well contracted? If so, the placenta may be separated but trapped by a closed cervix. Rub up a contraction. Try to put the baby to the breast. Give further syntometrine. Empty the bladder. Umbilical vein injection of saline solution plus oxytocin may be effective. 11 A trapped placenta may respond to glyceryl trinitrate (500 mcg sublingually). 12 If these measures fail, prepare to deliver the placenta manually under anaesthetic.

Placental abruption2 Separation of the placenta before delivery of the fetus occurs in approximately 1/77-89 deliveries causing bleeding from the placental bed of a normally situated placenta. A severe form, where >50% placenta is involved, occurs in 1/500-750 deliveries usually causing fetal death.There are two main forms: 1. Concealed (20% of cases) - where haemorrhage is confined within the uterine cavity and is the more severe form. 2. Revealed (80%) - where blood drains through the cervix, usually with incomplete placental detachment

and fewer associated problems. Marginal haemorrhage occurs with a painless bleed and clot located along the margin of the placenta with no distortion of its shape. It is usually due to the rupture of a marginal sinus. Women should be admitted for observation and fetal monitoring. Risk factors13 Trauma (RTA or iatrogenic e.g. ECV) PET Multiparity Previous abruption Smoking Cocaine use Multiple pregnancy Thrombophilia Intrauterine infections Polyhydramnios Presentation Usually with sudden abdominal pain and shock. Uterus feels hard, tender or 'woody'. Fetal parts are difficult to palpate. Where <1000 ml blood has been lost, the fetus is hypoxic and may show signs of fetal distress. Where >1500 ml blood has been lost, the woman is usually in shock and the fetus is dead. Treatment is to restore blood volume and deliver baby immediately. Abnormal location of placenta - placenta praevia See separate article on Placenta Praevia. Cord abnormalities1 Marginal insertion of cord (Battledore) This occurs where the cord has a marginal rather than central insertion to the placenta. It is not of clinical significance. Velamentous cord insertion and vasa praevia Velamentous cord insertion is where the placenta has developed away from the attachment of the cord and the vessels divide in the membrane.If the vessels cross the lower pole of the chorion, this is known as vasa praevia and there is high risk of fetal haemorrhage and death at rupture of membranes. Risk of vasa praevia is increased in:14 IVF pregnancies Bilobate or succenturiate placenta Second-trimester placenta praevia It can be diagnosed prenatally by ultrasound examination and good outcome depends on prenatal diagnosis and elective caesarean section prior to the rupture of membranes.5 Abnormal length of cord A long cord (>100 cm) is associated with increased risk of fetal entanglement, knots and prolapse of the cord.15 A short cord (<40 cm) may be associated with a poorly active fetus, Down syndrome, cord rupture, breech position, prolonged second stage, uterine inversion and abruption. However, a short cord does not seem to impede vaginal delivery except where excessively short (<13 cm) in association with a fundal placenta.16 A normal length cord may become relatively short because of multiple looping around the baby's neck. Abnormal number of vessels A single uterine artery is associated with increased risk of fetal anomalies, particularly trisomies,17 and cord compression

Abnormal Delivery You are said to have a normal delivery if you deliver your child vaginally at full term, with the babys head coming first, without any instrumentation. Episiotomy is considered to be normal.Even twins are considered to be abnormal-medically speaking .Though in layman's term a normal delivery is Baby In Normal Position

Not every woman experiences a text book pattern of delivery. You may have variations in the course of labour. Inspite of these variations you may have safe delivery and a healthy baby. The variations are: Variations in the time of labour. Variations in the positions of the baby. Variations in conducting the vaginal delivery (operative vaginal delivery). Prolonged Labour The word difficult labour or dystocia suggests that labour has failed to progress normally and is causing difficulties for you and your baby. Delayed progress of labour can be due to various causes. If the labour doesnt complete within-18 hours in case of the first time pregnant woman and 12 hours in case of those who have had a prior delivery,it is considered prolongued. Causes of prolonged labour: Factors causing delayed progress of labour are: Inadequate intensity and frequency of uterine contractions. Overdistention of the uterus (in cases like twins or large baby). The position of the baby in your uterus is not favorable. Pelvis is not adequate for the passage of the babys head. Then Caesarean section is a best option . Some medications have been given to you for pain relief or to decrease the perception of contractions (epidural anaesthesia) These sometimes have an effect of prolonging labour, particularly the second stage. If you have not completely evacuated your urinary bladder / bowels, they may rarely cause failure of progress of labour. In most hospital enema is given during the 1st stage of labour. Effects of prolonged labour: This difficulty in progress of labour may lead to: Exhaustion of the mother. 3. Increased post partum bleeding. Increased chances of trauma to the genital tract. Increased chances of operative deliveries like, forceps, vacuum. Decreased supply of oxygen to your baby. Increased chances of infection in the uterus. On admission in the hospital Your doctor will do the following things. Try and rule out the different causes of prolonged labour. Assess your condition by checking your pulse, blood pressure, uterine activity and cervical dilatation. Assess your babys condition. To hasten the process of labour your doctor might adopt various measures.

 Rupture the membrane. To augment the labour. To see the colour of the amniotic fluid. Start intravenous drip of oxytocin if needed after ruling out inadequacy of pelvis. Give antibiotics to prevent infections. Mode of delivery: Your doctor may consider operative vaginal delivery by the forceps or vacuum .OR May consider caesarean section, if no satisfactory progress in cervical dilatation / descent of the head of the baby/ any irregularities in your babys heart rate suggestive of foetal condition being compromised.

Malpresentations: Your baby is said to be in a normal position if it is facing toward the mothers back with the face angled toward the right or left, and upside down with the head coming first (vertex presentation), with the neck bent forward, chin tucked in and arms folded across the chest. Any variation from this position makes your babys journey through the birth canal difficult, sometimes hazardous and occasionally impossible. Hence known as malpresentations. Causes of Malpresentations: Many factors lead to malpresentations such as: Pre-Trem Labour Multiple pregnancy.i.e twins,triplets etc. Excessive / less amount of amniotic fluid in the uterine. Some congenital abnormalities in the baby. Any abnormality of the uterus. The malpresentations include: Breech presentation. Face presentation. Brow presentation. Occipito posterior position.(Back labour) Transverse lie. Shoulder presentation.

Breech Presentation:

When the buttocks of your baby is the presenting part (i.e. the 1st part of your baby to be delivered) your baby is in a breech presentation.

Spontaneous change in position In most cases, the breech detected earlier in the pregnancy spontaneously turns to the head down position as the pregnancy progresses.Your doctor can confirm the position of the baby by an abdominal examination / USG. This spontaneous change of position of breech does not occur in and may persist as breech in: Breech baby with extended legs. Twins. Less amount of amniotic fluid. Any abnormality of the uterus. Risks in vaginal deliveries Trauma to your genital tract. If the umbilical cord gets compressed after the delivery of the buttocks, but before the head delivers out, then there may be decreased supply of oxygen to your baby. There may be some injuries to baby while delivering despite best care by your doctor. Excessive pull on the neck while the head is being delivered out. During vaginal delivery, the buttock comes out early as they are easily compressible. But the after coming head being hard and less compressible may (occasionally) get stuck at the outlet of the birth canal such head can be removed by using forceps . Correction of breech position: IF near full term, the position of the baby is breech, your doctor can change the position of the baby to head down by the maneuver called external cephalic version'The procedure is not done if: You are having marked increased in blood pressure. Previous births by caesarean section . Your pelvis is not adequate for the passage of your babys head. Your babys head is hyper-extended, i.e. the back of head touches the back of the baby. You are having any malformation of uterus or fibroids or other problems in the birth passage. Twins If you have previous pre-term delivery or the placenta is low lying . On admission to the hospital : Your doctor will examine you and will monitor your uterine contractions, your progress of labour and your babys condition and decide about the mode of delivery. Mode of delivery: In primigravidas (1st time pregnant woman) the vaginal delivery of breech is difficult because the mothers birth canal has not been stretched by a previous delivery. In such cases, caesarean section gives the option

of well-planned delivery, under controlled conditions. Although, the delivery maneuver is the same, it is done under anaesthesia as an open procedure. Hence, it is easier to handle any difficulties in the delivery of your baby. In multigravidas ( women who have delivered a child before ) vaginal delivery can be considered as a good option before going for a caesarean section. Caesarean Section is a must in cases like; Large baby Suspicion of an inadequacy of the pelvis. Prolonged labour . Baby with intrauterine growth retardation. Previous caesarean section. Oligohydramnios (less aminiotic fluid) Pre-term labour. Other associated complications like placenta praevia, hypertension in pregnancy. However it is a question of personal choice as risks of vaginal breech delivery cannot be completely ruled out. So the doctor will be the right person to guide you. The aim is to have a safe birth for you and your baby, regardless of the route chosen.

Face Presentation

This is a rare variety of presentations of your baby in which there is complete extension of your babys head almost touching to the back. In this case, the baby's face is delivered first rather than the top of the head. Causes of face presentations: Lax and pendulous abdomen due to multiple births. Pelvis is inadequate or flat. Congetial malformations of the baby such as cysts in the neck, thyroid problem. Increased tone of the baby's muscles present at the back of its neck. Loops of cord around the neck. On admission to the hospital: Diagnosis of the face presentation is usually made at the time of labour. It can only be suspected on abdominal examination.Your doctor will do your internal examination to: Feel the mouth, nose, cheekbone and chin of your baby thus confirming if your baby is in a face presentation. Check for the adequacy of the pelvis. He will also rule out associated complicating factors like increased blood pressure, post caesarean pregnancy, post caesarean pregnancy, post maturity etc.

To confirm the diagnosis USG can be done if available. In case of emergency an X-ray of your abdomen may be required.

This can also help: To exclude bony congenital malformation of the baby. To note the size of the baby. Mode of delivery: Your doctor is the best person to decide the mode of delivery. i.e. either by vaginal delivery or by a caesarean section Early caesarean section is done in cases of: Inadequacy of your pelvis. Big baby. . Associated complicating factors. The risks includes: A chance of umbilical cord coming out first at delivery. Prolonged labour Injury to the birth canal. Excessive post partum bleeding.

Brow Presentation:

When your babys neck is moderately arched so that the brow presents first i.e. the head lies in between the normal position and the face presentation. This is a very rare type of presentation, commonly unstable and converts to either the normal position or the face presentation. On admission to the hospital: Similar to the face presentation, the diagnosis of the brow presentation is made at the time of the delivery.This position is confirmed by your internal examination and USG.Your doctor will do an internal examination to: Confirm the brow presentation. Check for the adequacy of your pelvis. Your doctor will rule out any associated complicating factors. Mode of delivery: For a while your doctor may observe the progress of labour. If your baby spontaneously converts to the face presentation or the normal position, vaginal delivery is possible. Caesarean section is the best option for the persistent brow presentation associated with complicating factors.

Transverse Lie:

When babys spine lies perpendicular to your spine, it is called as transverse lie. When the babys spine is placed oblique to the maternal spine. This is known as oblique lie.

uterus with transverse lie. In oblique lie, if the head of the baby is above the navel of the baby then during labour this position is mostly changed to the breech position. uterus with oblique lie Causes of transverse and oblique lies are: Lax and pendulous abdomen. Twins more common for the 2nd baby. Excessive amniotic fluid. Inadequate pelvis. Pelvic tumours like fibroids, ovarian cysts. Congenital malformation of the uterus like a septum. In both the transverse and oblique lie, commonly during the delivery the shoulder comes first and is known as shoulder presentation Back labour (Occipito Posterior Position): Normally the baby lies facing the mothers spine in an upside down position.In occipito posterior type of malpresentation, the baby faces infront, with its back towards the mothers side (right / left) Diagnosis: Your doctor will do an internal examination to confirm the occipito posterior position and to check for the adequacy of pelvis.

Diagram of structure felt on internal exam: Hell also rule out other risk factors, which will need a caesarean section like: Pregnancy induced hypertension. Post maturity. Post caesarean pregnancy .

Big baby. Mode of Delivery: Occipito posterior per say does not require a caesarean section.Vaginal delivery may be opted but a careful watch has to be kept.A liberal episiotomy may be required. There may be a slight delay. In most cases delivery is spontaneous. In other few cases forceps / vacuum may be required. A Caesarean section is opted in cases of:

 Presence of any risk factors. Foetal distress. Improper uterine action. Maternal distress (exhaustion) in case of prolongation of labour. Multiple Pregnancies When more than one foetus simultaneously develops in the uterus, it is called multiple pregnancy. The most commonly seen type of multiple pregnancy is the twin pregnancy. I.e. two babies in the uterus. Rarely, development of three foetuses (triplets) four foetuses (quadruplets) may also occur. Twins: Identical Twins:Identical (maternal) twins are the result of a single ovum fertilised by a single sperm, which later divides in 2 separate cells. These form 2 different foetus. Both foetuses have same placenta, same sex and look similar. Non Identical Twins:Non Identical (fraternal) twins are the result of 2 eggs being fertilized by 2 different sperms at the same time. Each foetus has its own placenta. The sex of the babies may differ / may be same, depending on the sperm. Causes: The factors related to twin pregnancy are: Advancing age of mother, between 30 35 years Family history of twins from the maternal side. Drugs used for induction of ovulation in infertility cases e.g. Gonadotriophin therapy clomiphene citrate. Diagnosis: H/O ovulation inducing drugs for infertility. Family h/o twinning. The symptoms of normal pregnancy are exaggerated. 1. Increase nausea and vomiting in early months of pregnancy. 2. Increase chances of swelling of the legs varicose veins. 3. Unusual enlargement of abdomen 4. Excessive foetal movements. 5. Increased weight gain as there are 2 babies growing in the uterus.

 Your doctor can also locate two separate spots with two distinct heart sounds. Sonography is the best investigation to show about the twin pregnancy.Antenatal management of twins: Diet: Increased dietary intake of 300 Calories more than in a normal pregnancy (600 Calories more than pre-pregnancy diet Supplementation of Iron, folic acid other vitamins, Calcium etc. Avoid excessive physical strains. Antenatal visits should be more frequent. Mode of Delivery: This depends on the position of the foetuses in the uterus. If both the babies are lifting vertically in the uterus a vaginal delivery may be possible. If both are in a transverse / oblique lie , a caesarean section is a must. If one is vertical and other is transverse than your doctor will be a better person to judge and decide the mode of delivery.

Operative Vaginal Deliveries: Forceps and Vacuum extraction: Forceps and vacuum extractors are used to assist the mother to deliver her baby in certain cases when spontaneous birth is not possible.Common indications include: Prolonged second stage. Maternal exhaustion (pulse, respiratory, temperature elevated, too tired to push). Foetal distress (irregular heart beat, meconium in amniotic fluid). Mother unable to push (e.g. under epidural anaesthesia, suffering from respiratory or cardiac disease). Forceps:

Forceps are twin steel blades that are placed in the vagina and secured on either side of the baby's head. The blades are locked and the doctor pulls until the head is delivered.The forceps that is in use in modern day obstetrics is the low or outlet forceps. There are certain pre-requisites required before the use of forceps, the main being that the head of the baby is almost fully rotated, the scalp is easily visible, the cervix is fully dilated, and the mothers urinary bladder is empty. Vacuum:

Vacuum extractor (or ventouse) is a cup made of steel or a soft flexible plastic cup. It is attached to a suction device to help pull out the baby. The vacuum extractor is placed on the top of the baby's head and the suction is activated. With activation of the suction, the scalp of the baby is sucked into the cup helping in creating traction. The doctor then pulls and during pulling if the head is not rotated, it will spontaneously rotate till the head is born. The vacuum extractor can also be applied to an un-rotated head, which is more commonly done. With both of these instruments, mothers may very well need an episiotomy to facilitate insertion of the instrument. Risks: In the past forceps was thought to be a fairly dangerous or risky procedure.In todays obstetric practice, the forceps is used to facilitate easy delivery of the head of the baby. Risks of the vacuum extractor to the baby are less than forceps. Complications occur much less often with the vacuum extractor than with forceps. Forceps and Vacuum for epidural anaesthesia Epidural anaesthesia may interfere with your ability to push your baby out. So in case you have been given an epidural anaesthesia there are chances of application of forceps or vacuum even though you do not have any medical indications. Another rare occasion where instrument delivery is required is when the mother has an established heart disease and the exertion of pushing and exhaustion may lead to a further reduction of the efficiency of the heart.Your doctor will discuss the procedure with you if it is required. In experinced person's hands, the risks are minimum.