October 16, 2002
Volume 4, Issue 34
Midwifery Today E-News
“Placenta Accreta”
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Quote of the Week

"In today's world of ultrasound on demand, amniocentesis, and even attempted cloning, the unproven assumption is that the more parents know about their unborn babies, the better."

- Elizabeth Bruce

The Art of Midwifery

Sometimes a postpartum mother feels a little disturbed that she can't seem to urinate even though she feels she needs to. I sprinkle three drops of peppermint essential oil into the toilet bowl before she sits. The aroma relaxes her so she can urinate more easily. Be careful, however, that none of the oil gets onto the mother (e.g., from the toilet seat) because it tends to irritate the skin.

- Renata Hillman

Share your midwifery arts with E-News readers! Send your favorite tricks to mtensubmit@midwiferytoday.com.

News Flashes

A study from Northwestern University Medical School in Chicago hypothesized that if 100,000 pregnant women who had a previous low-transverse scar were routinely scheduled for a repeat cesarean rather than be allowed to labor for a VBAC, almost 118,000 women would have another cesarean, 5,500 women would suffer complications, and $179 million dollars would be spent. Almost 1,600 women would have to undergo another operation to prevent the probability of one major adverse neonatal outcome.

- Grobman, et al., Obstetrics and Gynecology, (2000)

Placenta accreta

Placenta accreta (PA), an abnormally firm attachment of the placenta to the uterine wall, consists of three variants: In placenta accreta, which occurs in 75-78% of all such cases, the placenta is attached directly to the muscle of the uterine wall. In placenta increta, which occurs in approximately 17% of cases, the placenta extends into the uterine muscle. In the remaining 5-7%, the placenta extends through the entire wall of the uterus and is termed placenta percreta. The variants of PA occurs in 1 in 540 to 1 in 70,000 deliveries, with an average of approximately 1 in 7,000. The number of women with PA may be increasing because of the increasing number of women with previous cesarean sections.

In PA, the abnormally firm attachment of the placenta to the uterine wall prevents the placenta from separating normally following delivery. The retained placenta interferes with uterine contraction, which is necessary to control bleeding after delivery. Severe bleeding and surgical attempts to control bleeding are the major sources of maternal morbidity and mortality with PA, and blood transfusions are required in more than 50% of patients.

The principal newborn complication of PA is prematurity, with an average gestational age at delivery of 34-35 weeks. Correlation with prenatal mortality has not been proven. PA occurs with placenta previa 10% of the time. In patients with placenta previa, PA correlates with the number of previous c-sections, and maternal age greater than 35 and placental location overlying the previous uterine scar also increase the risk of PA. Other reported risk factors include multiple previous pregnancies, previous uterine surgery, and previous D&C. PA remains asymptomatic until delivery, but it may be possible to detect it with transvaginal ultrasound.

Source: www.geocities.com/cutebootee/PlacentaAccreta.html

PA is fast on the rise, due primarily to the dramatic increase in cesarean sections. Any type of uterine surgery increases risk of developing PA with subsequent pregnancy, though none more so than cesarean section. The more cesareans, the greater the risk of developing PA. When placenta previa or a low-lying anterior placenta is present in a woman who has had one previous cesarean section, the risk of placenta accreta is 30%. It jumps to 40% or higher in women who have had more than one previous cesarean section.

Statistics indicate that placenta accreta was a rare occurrence from 1930 to 1950, with approximately 1 case in over 30,000 deliveries. From 1950 to 1960, the number increased to 1 in 19,000, and by 1980 to 1 in 7,000. The most recent information suggests that the incidence has now risen to 1 in 2,500 deliveries.

PA is a potentially fatal complication for the mother because of hemorrhage — blood loss typically ranges from 3,000 mL to 5,000 mL. Other potentially fatal complications include disseminating intravascular coagulation, which can result in death or amputation of lower limbs, transfusion reactions, other complications accompanying blood transfusions such as HIV or hepatitis, allo-immunization, fluid overload and, less commonly, infection and multiple organ failure. Surgical morbidity includes emergency hysterectomy, bowel injury, urological injuries including urethral trauma and bladder lacerations requiring surgical resection. Patients with accreta are at increased risk for blood clots (for example pulmonary embolism) and adult respiratory distress syndrome.

The majority of women with PA will lose their uterus in an attempt to control the bleeding, a procedure called cesarean hysterectomy, and 10% of women with PA die of its complications, most usually from hemorrhage or the complications of blood transfusions, infection or multiple organ failure.

- Elphie Hosler


  1. Miller A, David. Obstetrical Hemorrhage. Obfocus, 2000.
  2. Resnick, Robert. Managing Placenta Accreta. Contemporary OB/GYN, 2001.
  3. Gibson, Faith. VBAC Alert Placenta Previa/Accreta. American College of Domiciliary Midwives, 2000.

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Forum Talk: Cystocele

A client had a quick, natural birth but pushed for three hours because baby was between OT and OP. All was fine, mom had a small tear, but everything seemed to be normal. Now she recently felt like things had all shifted down -- her bladder, her cervix, everything seemed to be almost falling out. Her doctor told her she has a cystocele. More information?

- Sarah

Go to our forums to share your thoughts and experience.

Question of the Week: Gestational Age Assessment

Q: Has anyone developed their own system for newborn gestational age assessment? The New Ballard Scale seems more elaborate to me than is necessary for term babies who are born at home. I know experienced midwives can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.

- Amy Kieffer, student midwife

Send your responses to mtensubmit@midwiferytoday.com.

Question of the Week Responses: Team Midwifery

Q: I'm curious to find out about midwives working in teams; that is, a few midwives who share in seeing women/couples during pregnancy, alternating being on call for births, having homebirths or hospital births, caring for families after birth. I would like to know more about the work environment, both the logistics of the routine and how pleasant it is to work under such arrangements.

- Helena, midwife

A: We are a practice of seven midwives. To practice the way we do, at least four midwives are needed. Using an example of a group of four midwives, you'd have two teams of two midwives. One team shares the same clients, and so does the other team. Each team works like this: One of the two midwives is on call, so she doesn't do any clinic. She attends all the births, does home postnatal visits and responds to all the calls from the team's clients. The other midwife is off call and does all the clinics and sees all women cared for by these two midwives who need a visit that week. Each midwife is assigned a number of clients to see as the primary midwife until 28 weeks gestation. After 28 weeks, each woman starts seeing alternately the second midwife of that team and her primary midwife. So at 31 weeks, she sees the second midwife (work it out on a schedule; you'll see it falls well).

We switch on and off call on Wednesdays at noon so that we all come in for a team meeting/peer review and report time on Wednesday morning. We do a bit of clinic every week during the off-call portion of the week.

The midwife on call from team A is always paired with the midwife on call from team B, so that becomes the on-call team. Since you always need two midwives at each birth, your group needs at least four midwives to work this way. That gives us seven days on call and seven days off call, giving us each one weekend out of two with our family. Our clients love this system, and find us much more available. The pager isn't ringing during a consultation, and appointments aren't cancelled.

In our group of seven midwives, some work full time, some part time. One weekend we have four (three part time, one full time) midwives on call; the other weekend we have three (one full time, two part time) midwives on call so that the hours on and off call are shared as evenly as possible. We calculated how many births each midwife should attend as primary (case load) and as the secondary (the midwife who lends a hand to the primary midwife when the woman is pushing and who only stays for the birth of the baby and the placenta and leaves shortly after when all is well). We keep a record handy so we know who to call when a birth is imminent. But we still have a small problem: The part-timers end up being called more often as the second midwife because the full-time is less available, having more births as a primary midwife (she's been up all night with her clients, it's not easy to get her back out of bed to come in as a second).

Always being on call leads to exhaustion, premature aging and kids who need therapy for being children of midwives! We are slowly moving away from the vocational, mission-style practice to something closer to what we tell our clients to do: Take care of yourself, then your family; do not overwork; take time to breathe, live, walk, feel life pass by — hopefully more slowly.

-Christine Roy
Quebec, Canada

A: My business partner and I share an active homebirth practice and have worked successfully together for nine years. We attend about 50 births a year. We split all the income evenly regardless of who attends which clients at any given time. We also share the call schedule equally, carefully planning ahead for vacations and conferences and family needs, etc. It basically comes down to about one week on, one week off.

When I'm on call, I do all the prenatals and births, receive and answer phone calls, and do office work. When I'm off call, I'm available for consultation, backup for long births or appointments that aren't rescheduled. We also have two very capable apprentices who share going to births and prenatals, so there are always two people at each birth. We both try to attend consultations (first-time inquiry appointments), home visits (at 35 weeks) and the six-week postpartum visit, even if we're "off call." If one of us must be gone longer than two weeks from the practice, we individually hire another midwife to cover our on-call time. We also share all the expenses evenly except for individual pieces of larger equipment such as Dopplers. We are not very high tech. We have an office space, but we do not do ultrasounds or lab work. Most of our clients pay out of pocket.

This system has worked well for us for many years. The only drawback is that when it's busy, it's very busy because one person is doing births and appointments. We try to step in and help each other liberally, but sometimes one of us is out of town more than the other. Recently, for example, I found I had done 12 of the last 15 births! This seems to even out over time, though.

We don't make promises to our clients about who will be at their birth. I think they actually feel very well supported because there are more of us to go around, and we can be very nurturing. This arrangement also prevents midwife burnout. We both practice very similarly, and we're friends. Our skills complement each other.

We schedule business meeting with all four of us every 10 days to review clients and other issues. We divide the responsibilities pretty well. For example, I type birth certificates and keep statistics, and my partner does billing. When we have a big mailing or a pile of copying, we share the load. We both work very hard at making this work. Good communication is everything, hence the business meetings. It's a bit like having another life partner!

-Merilynne Rush
Ann Arbor, MI

The BirthLove Web site has helped many women grow trust in birth and in their bodies. It has helped women resist Cytotec, find good midwives, and stop believing everything their doctors say. There are hundreds of homebirth stories: unassisted VBAC, fathers' stories, twin (and triplet home VBAC!) stories, breech stories -- for things that people get sectioned for daily, there are homebirth stories on the site. Marsden Wagner, MD is a contributing expert, as are Sarah Buckley, MD, Gloria Lemay and Gretchen Humphries. BirthLove has changed and saved lives through education, communication and love. Become a member of BirthLove today and be inspired!

With Woman

by Gloria Lemay, compiled by Leilah McCracken

Being Proud to be Paid for Birth Work

It took a lot of time on the path of martyrdom for me to really understand that self sacrifice does not serve anyone. I have done many births in my career for free because I "felt sorry for" the couple. This is a kind of arrogance about others that usually ends in disaster. It seems now particularly ridiculous that I did a lot of this free work when I was a struggling single parent with two little kids who I could barely feed. What was I thinking? I would burn out my friends with unreasonable requests for babysitting, let my pantry get bare, be exhausted and cranky with my children, and still not collect money from the clients because they were "so poor." Learning to see others as whole, complete, capable adults took a long time.

When we charge a fair fee for service as other workers do, we then leave the relationship with the client whole and complete. I remember doing a birth for a couple for a ridiculously low fee because I was told he was a seasonal worker and they really wanted to have a birth in their own home. About three months after the birth, the family phoned to tell me they were going on a trip to Disneyland. I was very resentful and did not want them to have a nice holiday when I had gone into debt to be at their birth. It was a lesson learned. Now I'm thrilled when my clients tell me they are buying nice things because they owe me nothing.

Even if people have a tough time with finances, they can still sell things if they want the service you offer. There are enough pop bottles on the street to generate the money for a doula. Often, grandparents would love to pay for a doula service for the new grandchild. There is a way to pay $50 per month for a year if one really wants a doula.

I love this quote from Dr. Kloosterman of Holland, who is an obstetrician and a great friend to the natural birth movement: "All over the world there exists in every society a small group of women who feel themselves strongly attracted to give care to other women during pregnancy and childbirth. Failure to make use of this group of highly motivated people is regrettable and a sin against the principle of subsidiarity."

It's important to note that Dr. Kloosterman doesn't say "give care for free or for a ridiculously low return." "Make use of this group" does not mean "make this group into martyrs." I have seen so many good women come and go from the birth movement who did not have a balance between what they give and what they receive. It simply doesn't work to be dishonest about our own needs and the needs of our own families when we are going to births.

Gloria Lemay is a private birth attendant in Vancouver, BC, and is a contributing expert at BirthLove.
Read more from Gloria on Midwifery Today's Web site: "Pushing for First-Time Moms".
Note: This article is also published online in French and Spanish.


What Do Readers Think?

Childbirth of the future will not primarily be in hospitals, but in the home, and the primary health professional for most women will not be the physician, but the midwife. Furthermore, the primary rights and responsibilities for childbirth will not be upon the professional, but upon the parents because it is they who must bear the responsibilities of raising the child.

-21st Century Obstetrics Now!, published in 1977

Twenty-five years later, how accurate is this statement?

As we know, preeclampsia [Issue 4:33] starts when the placenta is formed, but it does not show up until later, usually at about 32 weeks gestation. I have had several clients who have been diagnosed with preeclampsia. As soon as it was suspected, I encouraged the women to cut out all carbohydrates (except a piece of fruit daily) and eat good protein such as baked chicken, eggs, cheese, peanut butter, steak, etc. Also, I suggested they take a 15-minute walk every day, followed by rest, and drink purified water with lemon to help eliminate excess fluids from the body. It works to help reverse the effects of preeclampsia and allow the baby to stay put until it's time. Too much sugar and generally a bad diet contribute greatly to this disease. I have been a doula for 14 years and I am also a certified childbirth educator.

-Terry Gyde, CCCE

To Sarah in regard to a client having a stillborn baby [Issue 4:33]: This is a great little site I came across — gentlebirth.org/archives/stillbornKLR.html

I just finished a series of childbirth education classes, the last of which was a breastfeeding class. At the end, the instructor gave me a handful of business cards that said, "License to Breastfeed in Public; It's the Law!" and cited the appropriate Texas House bill. On the back, starting with "Thank you for nursing your baby in public," it encourages the recipient to continue nursing in public. Then it asks the recipient to write in about a positive or negative nursing experience so that the Texas Breastfeeding Initiative can send the business owner a letter.

I looked over both sides of the card and thought, "Well, all right!" I'm supposed to hand the cards out to anyone I happen to see nipping, and I can order more free from the health department.

So now I really am a card-carrying boobist. I guess I should get a box of these things and head out to the mall (and the next La Leche League meeting).

- Jolene, posted on misc.kids.breastfeeding

Many of us often ask, Is there anything I can do to make the world a better place? I found something we all can do. Please go to Oprah's official site. On the site look for the title This Week On Oprah, then look for the title Last Week's Shows. Click on it, then look for Can We Save Anima Laval's Life? She has been sentenced to death by stoning. This sentence will be carried out as soon as she weans her baby. She is convicted of committing adultery. I believe all women all over the world should "shout" as loud as we can against this terrible treatment. You can do this by following the directions on this site and sending the letter that is already there for you. Your action will be like throwing a small stone into a puddle, and maybe we will create waves!

- Theresa

I would like to say how much I enjoy receiving your publication. I want to one day be a midwife, and I look forward to any new information that comes my way. Thanks for everything.

- Jesse Fisher

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

EDITOR'S NOTE: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


The International School of Traditional Midwifery in Ashland Oregon is accepting enrollment for February 2003 classes. Contact us at 541-488-8254 or visit us at www.globalmidwives.org

QUEEN JIN'S HANDBOOK OF PREGNANCY is now available for you. Secrets of raising a wise & healthy child in the womb have spread from ancient China through the Far East & now to mothers & fathers in America. www.northatlanticbooks.com or www.amazon.com 106 pages $14.95

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