Ep 180: The Amazing Placenta


The placenta is an incredible organ (that’s right, it’s an organ!). Developing soon after conception, it is your baby’s lifeline to your body - literally. Everything the fetus needs is delivered through the umbilical cord which is connected to the placenta.

Nutrients and oxygen are brought in while carbon dioxide and wastes are taken out. Hormones to regulate pregnancy are secreted and your body’s rejection of the fetus is prevented. All of this happens within the placenta. It’s really an amazing part of your body and I know you’re going to love learning all about it including what it does, the most common issues that can occur (placenta abruption, placenta previa, placenta accreta) as well as information about consuming the placenta, and lotus birth (where the placenta is left attached to the baby to fall off naturally). 

In this Episode, You’ll Learn About:

  • What the placenta is and what it does
  • What happens when there are concerns with the placenta
  • What the most common placental issues are
  • What puts you at higher risk
  • How common it is to have problems with the placenta
  • What makes placenta accreta so dangerous
  • Why some parents choose to consume the placenta
  • What lotus birth is and whether it provides any benefits

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Transcript

Dr. Nicole (00:00): Are you curious about the placenta? Well, in this episode, you will learn what the placenta is, what it does, and the most common potential problems that can occur with the placenta. And I'll also touch on placenta encapsulation and lotus birth. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OBGYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

(01:02): Hello. Hello. Welcome to another episode of the podcast. This is episode number 180. Thank you for being here with me today. So this episode is all about the placenta. You'll learn what the placenta is, what the placenta does. It's really, really important for a healthy pregnancy, healthy baby. You'll also learn about the most common issues that can occur with the placenta, not that these will occur or that they even very frequently occur because they don't. But these are the most common potential problems with the placenta. One is placenta abruption. That's when the placenta separates away from the wall of the uterus early, one is placenta previa. That's where the placenta is, grows over the opening of the cervix. And then the final is placenta acreda when the placenta grows into the wall of the uterus. So you'll learn about those three conditions. And then I will also touch on consuming the placenta specifically through placenta encapsulation.

(02:03): And then finally, lotus birth, which is non severance of the umbilical cord or keeping the placenta attached to the baby and letting it fall off on its own. All right, so let's go ahead and hop right into it. We're gonna start off with what is the placenta? Well, the placenta is an organ that is incredibly important, in fact, essential for normal fetal growth and development and maintenance of a healthy pregnancy. It begins to form pretty soon after a fertilized egg implants in your uterus. It actually form starts to form around seven to 10 days after conception where it attaches to the wall of your uterus and then your baby is connected to the placenta by the umbilical cord. Side note, I'm gonna do a separate episode on issues that can happen with the umbilical cord. Now the placenta can settle anywhere in your uterus, so it can be a posterior placenta and there's no rhyme or reason I should say, to where it settles.

(03:08): So it can be a posterior placenta where it grows on the back wall of your uterus, an anterior placenta where it grows on the front wall of your uterus. That's, you know, closest to the front. It can be a fundal placenta where it grows at the top of your uterus, and it's going to continue to grow throughout the pregnancy. It gets bigger and bigger throughout the pregnancy. So a 20 week placenta is a lot smaller than a full term placenta. And by the time it's full term, it is about 10 inches long and it is about an inch thick and it weighs around a pound by the time your baby is born. In fact, I encourage you to ask to see your placenta if you're curious at the time of birth. I think it's a really cool organ in general. Now, there are two sides to the placenta.

(03:56): The fetal side is the chorion, the maternal side is the decidua. The chorion, the fetal side is the side that faces in towards the baby. It has this shiny appearance, and the umbilical cord attaches at the center in normal placenta. And then the amnion is the membrane that covers the fetal side of the placenta. The amniotic sac is what the baby grows in. It helps to protect your baby, helps regulate temperature, all of that good great stuff. And that also holds the amniotic fluid. Now, the maternal side, the decidua, that is the side that is attached to the wall of your uterus. And it has this dark, beefy color. I mean, it looks like an organ. It kind of reminds me of the closest thing would be liver, I guess. But it's, um, shaped in lobules that are called codelions, but it's kind of this dark maroon, reddish color.

(04:53): The placenta has, has several incredibly important roles between mom and baby and maintaining a healthy pregnancy. One, the placenta does all of the transferring of oxygen and nutrients from you to your baby. Circulation, it's a complex system how it does that, and it's really pretty cool. It also transfers carbon dioxide in any waste away from the baby into your circulation, and then you get rid of that waste out of your body. The placenta also prevents you from rejecting your body as a foreign being. So for instance, if you got a liver transplant or a kidney transplant in the other transplanted organ blood, anything, if it's not genetically similar or matches, your body will reject it. Pregnancy is the only thing, and I think this is incredibly fascinating, that you can carry a pregnancy that is completely not similar to you genetically. Like you can share absolutely no genetic material whatsoever, yet you can grow this baby and your body will not recognize it as foreign because of the placenta.

(06:07): That's why you can do donor eggs, for instance, because your body will, um, not recognize this baby as being foreign even if you are genetically dissimilar. That's also why you can do surrogacy. And then the placenta also, uh, manufactures or does a lot of hormones that affect metabolism for the baby, affect metabolism for you. Um, steroid hormones, peptide hormones like cholesterol, glycogen, CG that regulate maternal maternal metabolism and fetal growth and development. So the placenta does so, so much important stuff. So let's talk about some issues that can happen when there are concerns with the placenta and the most common problems that may occur. We're gonna start with placenta abruption. Placenta abruption is when the placenta prematurely separates away from the wall of the uterus, and that's typically in the latter half of pregnancy. So 20 weeks or later, thankfully it's not very common. The estimated incidences anywhere from three to 10 per 1000 births.

(07:16): Two thirds of the abruptions are considered severe, meaning that it has potential impacts from mom like needing blood transfusion, hysterectomy, um, something called disseminated intravascular coagulation, where your body consumes all of your factors to clot and then you sub, sub subsequently, ah, that was a tongue twister. Subsequently cannot clot like your blood won't clot after you have dic or it's considered severe if there's a non-reassuring fetal status or there's fetal growth restriction, or if there's, unfortunately fetal death. Abruption is also considered severe if you have a preterm birth or a small baby. So if you have just one of those, not all of those, but if you have any one of those mom issues, baby issues or newborn issues, then it is considered severe and about two thirds of abruptions are severe. Now, when you look at the gestational age for when abruptions are diagnosed, about 60% of them are diagnosed at term.

(08:20): 25% are between 32 and 36 weeks, and then 14% are less than 32 weeks. And a little over half of those, about 56% are going to be diagnosed before labor starts. So in the antipartum period, well, whereas about 44% will be diagnosed intrapartum or during labor. Risk factors for abruption, the most significant risk factor, as you might imagine, is a previous history of abruption. That's going to be the strongest risk factor for abruption. The recurrence risk is about 10 to 15 fold higher than if you didn't have an abruption. And if you have an abruption in your first pregnancy, you have an even higher risk of having abruption in a subsequent pregnancy. Another big risk factor is hypertension. If you have hypertension, you have an approximately five fold increased risk of severe abruption compared with someone who doesn't have hypertension. Getting your blood pressure under control helps to reduce the risk of abruption from hypertension.

(09:31): And then some other, uh, things that contribute to or risk factors for abruption. One is abdominal trauma or an accident. Typically it's gonna be like a severe accident, like a severe motor motor vehicle accident or severe fall down the stairs. Those things are gonna increase your chances of abruption and your risk of abruption is gonna be typically within 24 hours of the event. So we will monitor you for 24 hours for abruption. After 24 hours, then your risk goes down. So abdominal trauma or accident can increase the risk, having preeclampsia increases the risk, a short umbilical cord. Um, and then, uh, older maternal age. And then two modifiable factors are cocaine use. So cocaine use will increase the risk of abruption. In fact, as many as 10% of pregnant folks who use cocaine in the third trimester will develop an abruption. And then cigarette smoking also greatly increases the risk of abruption.

(10:33): It's about a fourfold increase risk of abrupt abruption. And if you, uh, smoke and have hypertension, the two together will further increase the risk of abruption. There are some minor genetic factors that can increase the risk of abruption. You do have a slightly increased risk if you have a sister who had an abruption or if you yourself were born small for gestational age. Interestingly, we've been seeing that maybe getting infected with covid during pregnancy may increase your risk of abruption. We've been finding that covid during pregnancy can wreak havoc on the placenta in general, um, where it just doesn't work as well and function as well. That's why we recommend that for folks who have covid during pregnancy, we recommend starting a baby aspirin to try to reduce some of the inflammation that occurs with the placenta when you're infected with covid during pregnancy, even if it's minor symptoms.

(11:36): So there is some association that maybe getting infected with covid 19 can increase your risk of abruption, but that isn't like definitively fleshed out. All right, so what does it look like when you have an abruption? What are the the clinical features of when you have an abruption have an abruption. So the classic presentation of an acute abruption is that it comes on suddenly with abrupt onset of vaginal bleeding. You may usually, or typically have abdominal pain as well as contractions may also have back pain. If the placenta is posterior because of the blood that is forming inside the uterus, the uterus can feel really, really hard. Like it can feel rock hard. You, you feel it. The belly is like the uterus is really, really firm to the touch. You can't feel like fetal parts or anything. It's just a hard rock, hard firm uterus.

(12:31): And the contractions, because of the blood being an irritant to the uterus, are often back to back. Like no break in between the contractions, they, they come, come, come, come. They're not like super, um, intense in terms of how strong they are necessarily. But they are coming back to back, to back, to back, to back, to back, to back, to back to back. There's a typical labor pattern that you see for abruption, um, the way the contraction pattern is, and you may not have all of those symptoms, but that's kind of the classic presentation of an abruption. Now, the severity of the pain is actually a useful marker for the severity of the abruption. And then in turn, the risk for mom, the mis the risk for baby. So the more severe the pain, the more likely the severe the abruption is, and we need to be more worried.

(13:26): So if you have really intense pain, comes on suddenly, we, we really need to be concerned because the combination of especially intense abdominal pain and any fetal heart rate abnormalities are, uh, an ominous sign for severe maternal mor morbidity like losing a lot of blood suddenly, or even fetal death. Now in contrast, the amount of vaginal bleeding does not correlate with the degree of placenta separation. Okay? The amount of bleeding does not correlate with the degree of placenta separation. So that is not as good of a sign in terms of seeing how severe the abruption is. It's more that pain that gives us the better indication of how severe the abruption is. Now, in 10 to 20% of placenta abruptions, there is no vaginal bleeding or very minimal vaginal bleeding. And really there is only pain. Those are concealed abruptions because the blood is just accumulating inside of the uterus and not coming out of the cervix and vagina. Often you'll see a non-reassuring fetal heart rate tracing when the baby is placed on the monitor in those cases. And then in only a tiny, tiny, tiny number of cases will you see an abruption that is only seen on ultrasound.

(14:52): Now, speaking of ultrasound, ultrasound is not a great way to diagnose abruption because you really can't always see it. So, um, it's, it's mostly a clinical diagnosis. You can sometimes see it on ultrasound if it's a severe abruption, but that's not gonna be the first thing that we look at. And if we don't see a clear abruption on the ultrasound, that doesn't mean that an abruption is not happening. Okay? So it's really based on the clinical symptoms. Ultrasound can give us some additional information, meaning like if we see it, then yes, it confirms it, but if we don't see it, then that doesn't necessarily help us. And if we can't use ultrasound to diagnose it, for sure, clinical diagnosis.

(15:34): So what are the consequences for placenta abruption? So for the mom, the potential consequences are related to, as you might imagine, how severe the abruption. So how much of the placenta has separated away from the wall of the uterus? And same thing for the baby, how much of the placenta has separated away from the wall of the uterus? Because remember, the placenta is the baby's lifeline. So the more severe the abruption, the more issues the baby may have. But for the baby, it's also important the gestational age at which birth occurs with, of course, the further along the baby being born, the better the baby is going to do if there is a placenta abruption. So as I said, as the degree of placenta separation increases the maternal risk, the risk for the baby also increase. But actually most of the abruptions are not severe. Okay? And when we look at the placenta at delivery and estimate how much separated, about 54% of placentas will show less than 25% separation. About 16% of placentas will have a separation of between 25 and 49%. 13% of placentas will have between 50 to 74%, and then 17% of placenta will have more than 75% where it was separated. So most placenta, if there is an abruption, will have less than 25% placenta abruption or placenta separation.

(17:17): And when we look at the potential consequences, again for mom and baby, for mom, it's the excessive blood loss from blood accumulating behind the placenta. Um, that disseminated intravascular coagulation or DIC that I mentioned that can lead to kidney injury. Something called adult respiratory distress syndrome, organ failure, even hysterectomy, very rarely death sometimes, uh, an emergency cesarean is necessary for mom in order to save the baby. Typically, some of the consequences for the baby relate to that sudden decrease in oxygen and blood flow from the placenta, and that can, um, affect birth weight. And if the baby has to be born early, then preterm birth.

(18:04): And then the final thing about abruption, there is something called chronic abruption. Most of the time abruption presents as an acute event. It happens suddenly, um, come, comes on pretty quickly. But there is something called chronic abruption where you could experience light chronic intermittent bleeding throughout your pregnancy. And that chronic bleeding can result in placenta ischemia, lack of blood flow to the placenta that can result in low fluid, something called chronic abruption, aligo hydra sequence. Because of that, the baby can have issues with growth. It also incidentally increases the risk of preeclampsia. If you have chronic abruption and low fluid, that can have a bad prognosis and the pregnancy is gonna require closer monitoring because there are, it's a higher rate of, um, fetal death and then pre-term birth as well.

(19:02): So let's move on and talk about placenta previa. Placenta previa is when there is placenta that covers the opening of the cervix. The internal cervical os the cervix has two openings. Os means open and opening in Latin. So the, the cervix is kind of like a tube, a short tube. And the internal cervical os is the opening of the cervix that is closest to the uterus. The external cervical os is the opening that's in the vagina. So placenta previa is when the placenta covers the internal cervical os. It is not very common. It happens in about four per 1000 births. It is a lot higher around 20 weeks. It can be as high as 2% than um, at 20 weeks compared to birth because most previas that are identified early in pregnancy actually resolved before delivery. So when you look earlier around 20 weeks, it can be higher. When you look closer to birth is gonna be very low because the vast majority of them resolve. And I'll talk about the management of a placenta previa just a minute.

(20:13): So major risk factors for placenta previa. The biggest risk factor, as you might imagine for many things, is having a previ previous placenta previa. So if you had a placenta previa before, it can occur in four to 8% of subsequent pregnancy. So not terrible, but definitely higher. Previous cesarean birth increases the risk for placenta previa and a couple of reviews by even as high as 60% and the risk increases with the increasing number of cesarean births. This is why it's so important to prevent the first cesarean birth because the more cesarean births you have, it increases the risk of having this occur. Also, multiple gestations may have an increased risk or, or do have an increased risk of placenta previa. Some other less significant risk are having previous uterine surgery, increasing maternal age, infertility treatment, smoking, previous pregnancy termination, uh, a boy fetus, uh, previous uterine artery embolization, which is not very common as far as why placenta previa occurs, we do not know it is not known what causes a placenta previa.

(21:34): Okay, so how do we know that there's a placenta previa? So the most common presentation of placenta previa is finding it when that anatomy scan that happens between 16 and 20 weeks. When you get the scan to look at all the fetal anatomy and they look at the placenta, that is when we most often diagnose a placenta previa. And that can be frustrating because it can create a lot of anxiety because you have this thing there, even though the most, most of the time it's gonna resolve, but it does create some anxiety. But typically that's how we're gonna know it's gonna be around the 20 week ultrasound. But know that 90% of those identified on those ultrasound, 90% of those placenta previas will resolve before delivery. Okay? 90% will resolve. And that is thought to be because as the uterus expands and grows up, the placenta expands and grows up away from the cervix with it. Also, it's thought that because the lower uterine segment near the cervix doesn't have a lot of blood flow like that's on purpose, most of the blood flow is at the, the top of the uterus. The placenta is going to grow preferentially towards where more of the blood flow is. Okay? So for that reason, about 90% of placenta previas will resolve by birth.

(23:05): One of the biggest predictors as to whether or not it will persist is how much it covers the cervix. So if it is over the cervix by more than 25 millimeters or 2.5 centimeters, which is roughly about an inch, then the probability of a placenta previa at delivery is anywhere from 40 to 100%. Um, if it's, if it's more than 55 millimeters covering the cervix, the the probability is a hundred percent. So the more it covers the cervix, the more likely it's going to stay there at by birth. And that makes sense, right? And the less that it covers the cervix and the higher the probability that it will resolve. In fact, if it's less than 1.4 millimeters over the internal os the probability of placenta previa delivery is near zero. There is a slightly increased chance of it resolving if it's an anterior placenta, not sure why, but there is a slightly increased chance of it resolving with an anterior placenta.

(24:10): Now, in the second half of pregnancy, the most common symptom of placenta previa is painless vaginal bleeding. And that is going to occur in up to 90% of persistent cases. So if your previa has not resolved, if it hangs around, about 90% of people may have some painless vaginal bleeding. All right? About one third will have that initial bleeding episode before 30 weeks. And that group, if it happens before 30 weeks, is more likely to have a blood transfusion, higher risk of preterm birth than if you have bleeding later in pregnancy. About a third will have a bleeding episode between 30 and 36 weeks, and then most will have a bleeding episode after 36 weeks, and then about 10% will get through the whole pregnancy with the placenta previa that lasts and not have any bleeding. So you can expect that if your previas is persistent at 28 weeks or 32 weeks, when you have a follow up ultrasound, if it's it's um, persistent in the third trimester, there's a good chance that you will have some vaginal bleeding at some point during your pregnancy.

(25:22): And bleeding, in fact, is the major risk factor with placenta previa. When that placenta is over the cervix, if you have contractions, if you have anything that stimulates or touches that placenta, it can increase the risk of bleeding, potentially significant bleeding that could affect either you and or your baby. So that is the bigger biggest risk of placenta previa is having significant bleeding and then that bleeding requiring delivery and leading to potentially a preterm birth. Okay, so how do we manage placenta previas? Well, the goal is really to watch the pregnancy, watch the previa, and see if it resolves with increasing gestational age. We also wanna make sure that it's not a placenta previa and accreta, and I'll talk about accreta in a minute, but that's when the placenta grows into the wall of the uterus. And then we wanna just reduce the risk of bleeding and then plan for the cesarean birth if the previa persists, because you cannot have a vaginal birth with a placenta previa if the placenta is covering the opening of the cervix as your cervix opens.

(26:38): Remember the placenta does all of the transfer back and forth of blood nutrients, things between you and your baby, like it filters your baby's blood. It's a complicated system where you and your baby's blood don't actually touch, but they run through the placenta and the placenta does all of the exchange between those. Okay? So that happens through the wall of your uterus, over your cervical opening. If your cervix opens and you have that raw surface of the placenta there and all of that blood flow going through it during a vaginal birth, you're just gonna potentially bleed to death. So you cannot have a vaginal birth with the placenta previa. That is completely and totally not safe. Okay? So that is why we need to plan for a cesarean birth if the previous persists. So as far as monitoring the placenta position, everybody does it a little bit differently, but, um, you'll get a repeat ultrasound around about 28 weeks.

(27:36): Another one at 32 weeks, potentially if at 28 weeks it's resolved then it's resolved, and then if at 28 weeks it hasn't resolved, then you may get a repeat ultrasound at 32 or 36 weeks. If you get a repeat ultrasound at 32 weeks and it's resolved, then it's resolved. If it hasn't resolved, then you're gonna get another ultrasound at 36 weeks. If you make it to 36 weeks and it's resolved, it's resolved. If it hasn't resolved, then at that point we plan for a cesarean birth. Okay? So twenty eight, thirty two, thirty six weeks. If it resolves, you're good. It can't come back. Once it's resolved, it's resolved. But if it's still there by 36 weeks, then we plan for cesarean birth.

(28:19): And that cesarean birth is going to be between 36 and 37 weeks. Typically, everybody's a little bit different, but between 36 and 37 weeks up to 37 weeks, and, um, and six days actually is considered reasonable by acog. Some other things that we do to reduce the risk of bleeding because we actually can't predict when or if bleeding is gonna occur. It's typically just random. We don't know what gestational age is gonna happen. It's not related to, um, most activities or anything, it's just kind of a random event. So some things that we know or that we recommend to reduce the risk of bleeding, we do not do su digital cervical exams. We don't put our fingers in there because if the placenta is right there and we touch it, we could stir up some bleeding, okay? If the cervix is partially open. So we don't wanna do that.

(29:14): We also recommend no sexual activity. Some say no sexual activity that even leads to orgasm because it may result in transient uterine contractions. But definitely no putting anything inside of the vagina that may touch the cervix or touch the placenta really and cause any problems. Also, we recommend just not strenuous activities. So no strenuous exercise, no heavy lifting more than 20 pounds, ideally no standing for prolonged periods of time, like more than than four hours. Those things have been shown to have a slightly increased risk of issues with placenta previa. They're not super strong, but those are some of the things that are sometimes recommended and you typically don't need to be in the hospital unless certain, uh, circumstances are met, and I'll talk about those in a minute.

(30:14): So what happens when you have a bleeding episode, which is almost certain to happen, if you have a placenta previa that persists? Well, an actively bleeding placenta previa is a potential emergency, like the bleeding can come up very quickly and it can progress pretty quickly. So if you have any bleeding at all with a placenta previa, then you need to come to labor and delivery, go to a hospital with a labor and delivery so that you can be monitored and the appropriate things can happen. And really, we're just looking to monitor the bleeding, making sure you're not losing so much blood that it is affecting you or your baby. Now the good news is that most patients who have a symptomatic previa with bleeding, most of the time you're, you're not gonna be delivered with that first bleeding episode, okay? Well over half are not delivered for at least four weeks, even if it's a large bleeding episode because if the baby looks okay, we don't have to necessarily deliver, all right?

(31:16): We only deliver if there's labor, if the baby's heart rate tracing doesn't look good, if you are not stable because you have lost so much blood. So really after that first bleeding episode, most people are fine, but we need to watch to be sure, okay? So if you have a bleeding episode, then you are monitored in the hospital and typically you can go home once you have no bleeding for 24 to 48 hours, okay? If you have a second episode, same thing. You come in, we monitor you, make sure things are okay, as long as things stay okay for 24 to 48 hours, then you can go home, okay? And be managed as an outpatient. Now, in those circumstances to be managed as an outpatient, we want you to be within a reasonable distance from the hospital. So 20, 25 minutes, um, want to be able to like maintain activity where you're not like doing a ton of stuff and then have somebody who can get you to the hospital or you're able to call an ambulance and get to the hospital quickly.

(32:20): If you have any issues with bleeding. Now once you have that third episode or more, then you are gonna be in the hospital until birth. All right? Because once it comes back, if it keeps coming back, it's unpredictable. We don't know how to tell if it's gonna be really severe. So typically if you have three or more bleeding episodes, you are going to stay in the hospital until delivery. All right? And then again, delivery, the goal is between 36, 37 weeks or 36 and 36 and seven weeks or um, sooner if there are any issues with you're a baby.

(33:00): Okay? Next thing I'm going to briefly touch on is placenta accreta, and then we'll do encapsulation and lotus birth. So placenta accreta is when the placenta literally grows into the wall of the uterus or through the wall of the uterus. Placenta accretaa is when it is just the myometrium or muscle layer of the uterus. Placenta inccreta is when it goes through the muscle layer. And placenta perccreta is when it goes through like to the outside and adjacent organs. I have, knock on wood, never seen that, hope to never see that because it is very, very serious. Now, fortunately, placenta accreta does not happen very frequently. The overall risk is very low, actually only 0.17%, all right? Now, even as low as that is, it's actually markedly higher than it was in the fifties. In the fifties it was 0.003%, very low. And the increase is the direct result of increasing rates of cesarean birth.

(34:14): Now, placenta accreta where its just to the muscle layer is the most common, that's 63%, placenta inccreta is 15%, and then going all the way through the wall of the uterus is 22%. Now, when we look at risk factors for placenta accreta, the most important risk factor is having a placenta previa after a prior cesarean birth. Okay? So you have a cesarean birth, and then in the next pregnancy you have a placenta previa that increases the risk of placenta accreta. So after a first cesarean birth, if you have a previa with the next one, your risk of placenta accreta is 3%, after a second cesarean birth 11%. Third cesarean birth 40%. Fourth cesarean birth 60%. Okay? That is if you have a previa after cesarean birth. Now, if you don't have a previa after a cesarean birth, then the frequency of placenta accreta is much lower.

(35:21): So it's only 0.03% after a first cesarean birth. If you have a first cesarean birth and then the next cesarean birth, the risk of placenta accreta is only 0.03% if you have, if you don't have a placenta previa, um, so much, much, much lower, that's compared to 3% if you do have a previa. And then really doesn't get any higher than 1% if you don't have a previa. So if you have a cesarean birth and then in another pregnancy have a previa, that is your strongest risk factor for having a placenta accreta. All right. Some other risk factors for placenta accreta that aren't related that we do need to keep an eye out for, cuz if we see it are having a myectomy or removal of fibroids where your uterine cavity was entered. If you have removal of adhesions or scar tissue from the inside of your uterus, that increases the risk of accreta.

(36:15): If you have had endometrial ablation where the inside of your uterus was burnt, then that increases the risk of accreta. You're not supposed to get pregnant after that. So that's not something that will happen frequently if you have a history of pelvic radiation, if you have a history of manual removal of the placenta at birth, if you have postpartum endometritis, so an infection of your uterus after birth, if you have infertility procedures that can also, these are all things that will slightly increase your risk of having placenta accreta. And the reason placenta accreta is so bad is because normally at a c-section or a a, a vaginal birth, the placenta just kind of comes off easily from the wall of the uterus. But in a placenta accreta, it does not separate well or easily at delivery. And when you attempt to remove it manually, it can result in massive bleeding, massive, massive life threatening bleeding.

(37:21): Usually a placenta accreta is going to necessitate a hysterectomy because the bleeding is so severe, but the bleeding is only severe at the time of delivery and trying to remove the placenta. Okay? So in fact, we don't see any bleeding before that. We only suspect placenta accreta typically by ultrasound examination. You can see or suspect it on ultrasound during pregnancy. And if you have risk factors that increase your risks, then we're certainly gonna look for it. But ultrasound ideally is when we see it during pregnancy. Now, occasionally it is not diagnosed until the time of a cesarean when you go to or a vaginal birth when you go to remove the placenta, and typically it's gonna be cesarean. I can't ever recall seeing a placenta accreta from a vaginal birth. Um, typically it's gonna be having had some tip type of surgery or something done to the uterus, like a cesarean birth, but you go to try to remove it and it doesn't come out and there's massive life threatening bleeding.

(38:28): So sometimes it can occur or not be diagnosed until the time of birth, but ideally you wanna see it before, um, before birth, so you can plan accordingly. Because when you have a placenta accreta or inccreta or perccreta, then we are generally going to try and deliver early. You need to be in a hospital that has blood services available that has specialists available. Typically, we're going to plan a cesarean hysterectomy, meaning c-section and hysterectomy at the same time and leaving the placenta in the uterus, and then just taking whole uterus out to reduce the risk of the massive bleeding that can occur when you try to remove a placenta accreta. All right, so let's finish up about briefly talking about placenta encapsulation. So placenta encapsulation is the process of steaming the placenta, dehydrating it, grounding it up and placing it in pills. And the reason that some women do this is they report consumption can help decrease postpartum depression, help them have less pain, reduces bleeding and increases milk production.

(39:39): There is no scientific evidence of the benefits from consuming the placenta. It's something that hasn't been studied very much. So it's possible that there may be a benefit, but there really haven't been many studies looking at consuming the placenta. Now, on the flip side, there's also little evidence of harm from consuming the placenta. There is reportedly, um, one, there is one report of a baby repeatedly getting ill shortly after birth related to placenta encapsulation, uh, and thought that the baby was being exposed to GBS as a result of the mom taking encapsulated placenta. She was a GBS carrier during her pregnancy. And the strain of the GBS bacteria from the encapsulated pills matched the bacteria in the baby's blood. Once mom stopped consuming the pills, the baby stopped getting sick. Now it's unclear how mom eating the bacteria and the pills led to the baby being infected.

(40:42): Maybe it somehow got in the breast milk. But there is one case report of that. So because of that, I recommend you don't consume your placenta if you have any problems with your pregnancy, because you are in a way consuming those problems as well. So if you have high blood pressure, uh, often the placenta has some issues with things like calcifications or things like that. Um, if you have an infection during labor, you don't wanna consume an infected placenta. Again, you'd be consuming those negative, um, things in the placenta. Now, if you decide to encapsulate your placenta, it can be anywhere, um, around $300 or so. Um, you want to be sure that you find someone who knows what they are doing. All right, inside of the Birth Preparation Course, I actually have a, a module, a lesson on placenta encapsulation. And there's a checklist of questions that you can ask if you're planning to do placenta encapsulation, so you know that it's being done safely, because remember, it's an organ, it's like raw meat.

(41:47): It needs to be stored, needs to be treated accordingly. There are actually no standards whatsoever for placenta encapsulation. Like anybody can say that they encapsulate the placenta. And there are like no standards or things that, or training or anything that, that someone has to go to go through. There are organizations that offer training, but you don't have to do any training. So you really wanna ask some questions about placenta encapsulation. And again, I I mentioned that inside the Birth Preparation Course. Now, if you do wanna encapsulate your placenta, hospitals have gotten better about this. They used to like really be nasty about you taking your placenta even though it came outta your own body. Um, you know, the, the fear or paranoia of something happening and baby getting sick, I don't know. But now these days, typically you have to, um, sign a release form.

(42:38): You also need to bring your own, your own storage cooler to transport it. It needs to be on ice. Cuz remember again, it's an organ, and then you should be able to take it with you fairly easily. I haven't heard too many hospitals these days not letting people take their placenta. Now, someone incidentally, like a few days before I recorded this episode, messaged me on Instagram and said she heard something like people were saying that hospitals make $50,000 per placenta to sell the placenta. That is, that, that's just not true. Like I, I'm not aware that hospitals make money and certainly not $50,000 per placenta selling the placenta. Um, it's, it's typically dis discarded as medical waste. The placenta is, it's, it's not sold to my knowledge. Um, it's certainly possible that they, they, they could sell the placenta, but it's not common. Typically, it is sold as it is, um, uh, discarded as medical waste.

(43:38): Okay, And last thing I wanna talk about is lotus birth, also known as non severance of the umbilical cord or umbilical non severance. And what that entails is that the umbilical cord is not clamped and cut the cord and the placenta remain attached to the baby until the cord naturally detaches. That typically happens between three to 10 days. Now, this isn't something that's done very commonly in hospital births. It may be done sometimes in home births. And people who are supporters of this practice believe that it is less stressful for the baby, that it leads to a more robust immune system and promotes bonding. But there isn't any proven benefit to that. There's no medical studies that have demonstrated a benefit. Granted, it has not been studied very much, but there also isn't necessarily really a biological plausible rationale for, for leaving it because the blood flow in the cord stops, um, at longest, typically 10 minutes after birth.

(44:54): And then once it's separated, once it's out, once the placenta is out, it's, it's not really doing anything. As a matter of fact, it's going to start to decay. Uh, if you don't treat it properly, it, it, it dies, okay? And it creates a terrible odor. There's hygienic issues, you have to, you know, be sure you keep it, um, clean because there's a risk of infection. So there have been two case reports showing babies getting sick from the practice. But again, it's not, not very common. Now, some people also say like, well, in nature, you know, nature, you wanna let it separate. Naturally, when we look in the animal world in general for mammals, animals that have a placenta, actually it's usually consumed by the mother. So in that regard, it may be a stronger argument for placenta encapsulation than, than lotus birth. But usually the placenta is consumed by the mother.

(45:59): Some primates, like some chimpanzees have been noted to not chew or cut the cords. Some monkeys, but some do. But the vast majority of mammals either consume the placenta or they sever it, like chew it, um, loose. But they do it after a period of bonding. So usually it's like a solid hour, if not longer, and then they chew it and, and, um, separate it from the baby. Okay. All right, So that is it for lotus birth, and that is it for this episode. So to recap, the placenta is a super important organ. It is responsible for healthy pregnancy, transporting nutrients, transporting waste. Healthy placenta is critical for a healthy pregnancy. Placenta abruption is when the placenta separates away from the wall of the uterus prematurely. Most often it's an acute event that is, um, heralded by onset of vaginal bleeding as well as uterine contractions and pain.

(47:09): Placenta previa is when the placenta covers the opening of the cervical os, it can lead to problems because of sudden onset of typically painless bleeding Most of the time. However, it will resolve. Placenta accreta as when the placenta grows through the wall of the uterus. The more it grows through, the more severe it is. Thankfully not very common. The most important risk factor for a placenta accreta is having a previous cesarean birth and then having a placenta previa in a subsequent pregnancy. Finally, placenta encapsulation is when you consume the placenta, typically in pills. Some people also have done placenta milkshakes or smoothies or things like that, but most people do encapsulation. There's no evidence that it is a benefit, but there's not a lot of strong evidence that it is of harm either. If it is something that you want to do, be sure that you have somebody doing it who is well trained to do so.

(48:03): Again, inside the Birth Preparation Course, I have a checklist of questions to ask if you want to encapsulate your placenta. And then finally, lotus birth is when you don't sever the umbilical cord from the placenta, and you have to be careful with that. It can't increase the risk of infection. There's also no biologic plausibility for it being a benefit that's unlike delayed core clamping. Like there is a benefit for delayed core clamping because blood flow is still going through the placenta, right? That's different than lotus birth when the placenta is completely out, there's nothing happening once it's completely out. And in either case, whether you do encapsulation or you decide to do a lotus birth, you need to have some ways to store the placenta. Keep it safe. Remember, it is an organ, it will decay. It will be a risk of infection just like anything else.

(48:55): All right. So there you have it. Do me a solid share this podcast with a friend, sharing hearing helps me to reach and serve more pregnant folks. And be sure to subscribe to the podcast and Apple Podcast or wherever you're listening to me right now, and leave me a review, an Apple Podcast. I read those reviews and I love to hear what you think about the show. Come follow me on Instagram on a, I'm on Instagram at Dr. Nicole Rankins, where I share more great pregnancy and birth tips there. So that is it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.

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