Placental problems

What is it?

Placental abruption. The placenta pulls away from the wall of the uterus before the baby is born. The baby loses part of their oxygen supply and the mother bleeds. Blood can collect behind the placenta and be invisible, which is why the amount of visible bleeding does not tell you how serious it is. ³ See the maternal page.

Placenta previa. The placenta lies over the opening of the cervix. As the cervix opens, the placenta would tear, so vaginal birth is not possible and delivery is by planned cesarean. It usually presents as painless bleeding in the second half of pregnancy. ²

Placenta accreta spectrum. The placenta grows abnormally deeply into the wall of the uterus, and sometimes through it. It will not separate after birth, and attempting to remove it causes massive bleeding. It is strongly linked to previous cesarean delivery combined with placenta previa. Guidance addresses finding it before birth and planning the delivery. Outcomes are better when it is anticipated. ²

Placental insufficiency. A placenta that does not deliver enough oxygen and nutrients, usually showing as fetal growth restriction. It is often linked to preeclampsia. The baby has less reserve for labor. That is why growth-restricted babies cope less well with contractions. ^{3 4}

Cord and membrane problems also belong here. They include an abnormal cord insertion. They also include vessels running through the membranes, which can bleed heavily if they tear.

What does standard care look like?

Placental location identified on ultrasound, and rechecked later in pregnancy where it was low early on. ²

Screening for accreta spectrum in those at risk, particularly with previa and a previous cesarean, with delivery planned at a center with the right resources. ²

Monitoring of fetal growth, with Doppler study studies and biophysical profiles where growth restriction is identified. ³

Assessment of bleeding in pregnancy, and of abdominal trauma, since abruption can follow apparently minor trauma. ⁴

Continuous fetal monitoring in labor where placental function is a concern. ⁴

Antenatal corticosteroids where preterm delivery is anticipated, and magnesium before 32 weeks. ^{5 6}

Rh immune globulin after bleeding in an Rh-negative person. ⁷

The placenta sent to pathology where there is any concern about the pregnancy or the baby. ¹

What can go wrong?

Previa not identified, or a low-lying placenta not rechecked later in pregnancy. ²

Accreta spectrum not anticipated in someone with previa and a previous cesarean, so the delivery happened without the planning and resources it needed. ²

Bleeding in pregnancy not assessed, or abdominal trauma not followed by a period of fetal monitoring. ⁴

Growth restriction not identified, because growth was not monitored.

A growth-restricted baby labored without recognition of the reduced reserve. ⁴

A concerning fetal heart rate not acted on. ⁴

The placenta not sent to pathology, which loses the single most informative record of what happened before labor. ¹

Rh immune globulin not given after bleeding in an Rh-negative person. ⁷

Whether any of this amounts to a departure from the standard takes a physician expert reading the whole record.

Which injuries can follow?

For the baby

• HIE, particularly after abruption, which is one of the acute events recognized as capable of causing it. ¹
• Cerebral palsy where injury is significant. ⁸
• Preterm birth and everything that follows. ⁹
• Low blood sugar in a growth-restricted baby with few stores. ¹⁰
• Neonatal seizures. ¹¹
• Stillbirth.

For the mother

• Postpartum hemorrhage, which in accreta spectrum can be massive and can require hysterectomy. ^{2 12}
• Placental abruption as an injury in its own right.

What does this look like in the records?

The placental pathology report is the document to request. It is often filed separately from the rest of the chart, and many families never learn it exists. Ask for it by name. ^{1 13}

It can show infection of the membranes. It can show clots in the placental vessels. It can show long-standing poor blood flow, and it can show abruption. It describes the weeks and months before labor. That is why it often answers questions the labor record cannot.

From the prenatal record

• Every ultrasound, including placental location and any rechecks. ²
• Growth scans with estimated fetal weights and percentiles.
• Doppler study studies and biophysical profiles.
• Any episode of bleeding or trauma, and what was done.
• Rh immune globulin doses. ⁷

From the labor and delivery record

• The fetal monitoring strip. ⁴
• The operative note, including the appearance of the placenta and how it was delivered.
• The measured blood loss. ¹²
• The cord blood gas and Apgar score scores. ¹⁴

What can you do this week?

1. Request the complete labor and delivery record for you and your baby. The records request builder writes the letters for you.
2. Write down what you remember while it is fresh, using the delivery timeline builder.
3. Read how to read your labor and delivery records before the records arrive.
4. Check the deadline to file in your state with the statute of limitations lookup.