placenta previa
Bedrest: What’s the Point?
May 5th, 2011This is podcast discusses the rationale for the bed rest prescription, indications for bed rest and new advances in the treatment of high risk pregnancy. Available as a download only.
Placenta Previa: Mamas on Bedrest, what it means when the placenta presents first.
January 3rd, 2011Recently a doula had a client who was placed on activity restriction for placenta previa. While aware of the diagnosis, she was unsure what it meant for hear management of her client. Mamas on Bedrest & Beyond was pleased to offer her this information and a few suggestions for management.
Placenta Previa: What is it and how common is it?
Placenta Previa occurs when the placenta develops within the uterus and covers the opening of the cervix. It occurs in about 1/200 pregnancies. If detected in the 1st or 2nd trimester of pregnancy and a patient is asymptomatic (i.e. not bleeding) often nothing is done and mama is carefully monitored. What often happens is that as the uterus grows, the placenta moves up and away from the opening of the cervix. However, if placenta previa is noted later in pregnancy and is accompanied by bleeding and/or contractions, mama is often placed on bed rest (if she is actively bleeding, in the hospital) and she is closely monitored.
Classification of Placenta Previa
Management of Placenta Previa depends on the degree of the previa.
Marginal Placenta Previa. If the previa is marginal, i.e. close to the cervical opening but not actually blocking it, then not much is done (especially if mama is not bleeding). At the time of delivery, the OB will have to determine if a c-section is necessary or if it is safe for mama to deliver vaginally.
Partial Placenta Previa. If the previa is partial, i.e. partially blocking the cervical opening, then mama may be placed on activity restriction or bed rest and watched closely. It is imperative that mama’s activities be limited so that the placenta is not torn resulting in bleeding. If Mama is bleeding, then the OB will try to stabliize the bleeding and then determine if immediate delivery is necessary.
Complete Placenta Previa. If the previa is complete, i.e. completely blocking the cervical opening, mama may be placed on activity restriction or on bed rest. In either case she will be closely monitored. If she begins to bleed, her OB will likely have to do an immediate c-section. However, if mama is not bleeding, the baby is stable and there are no other complications, mama will be monitored and the pregnancy allowed to continue to term. If mama and baby can make it to term and the placenta does not relocate itself away from the cervical opening, then the baby will be delivered via c-section. If mama is bleeding and that bleeding can’t be stopped, mama will be admitted to the hospital, given steroid shots to mature the baby’s lungs if needed (if she is not at term) and then delivered via c-section as soon as she and the baby are stable.
Discussion and Management
It was really nice to see that this doula’s client was placed on activity restriction, sitting with her feet elevated and avoiding any pelvic pressure or anything inserted vaginally, rather than placed on bed rest. Additionally, this woman should avoid sexual activity because an orgasm will cause uterine contractions which could lead to bleeding and/or preterm labor.
As with many of the “indications” for bed rest, bed rest has not been shown to be effective in prolonging pregnancy. In the case of this client, since she is not actively bleeding, and the assumption is that she is not in danger of imminently going into labor where rupture and hemorrhage of the placenta could be deadly for both mama and baby, then by all means restrict her activity. But putting her on bed rest is not likely going to alter the position of the placenta in this case. We also know that prolonged inactivity such as bed rest creates additional problems (physical and emotional) to mamas and often has no bearing on the pregnancy duration.
A caveat to this situation is that if mama is someone who can’t be trusted to limit her activity and would be likely to go into preterm labor, then yes, she may have to go on bed rest (but then again, would she stay put unless hospitalized???).
A doula or other pregnancy support professional will want to keep mama comfortable, but also provide a bit of movement and muscle stimulation to prevent complete deconditioning. Clients we’ve had in this situation have benefited from:
- Regular prenatal massage by a trained prenatal massage therapist to help maintain circulation and to avoid pooling of blood and lymph fluids in the extremities that can result in swelling.
- Careful positioning of mama when seated or reclining to avoid putting pressure on any one area causing pain and or sores.
- Passive and/or light resistance exercises for the upper body and passive exercises of the lower extremities. Examples can be found on the Bedrest Fitness DVD.
Placenta previa can become a medical emergency, but with proper management and support, mama and baby can safely go to term and do just fine. While bed rest may be indicated in many cases, it is not necessary in all cases and has to be determined on an individual basis.
For information on how to do passive/assisted exercise with mamas on bed rest, send an e-mail to info@mamasonbedrest.com.
Resources to Help Mamas on Bedrest & Beyond Quit Smoking
November 18th, 2010Today, November 18, 2010, marks the 35th anniversary of the American Cancer Society’s Great American Smokeout. It is a well known fact that smoking is the number one preventable/modifiable risk factor to heart disease and stroke as well as to many cancers. However, smoking is also very detrimental to pregnant women and their babies. The National Partnership to Help Pregnant Smokers Quit estimates that between 12 and 20% of pregnant women continue to smoke during their pregnancies.
According to the March of Dimes, Smoking during pregnancy can have the following consequences:
- Ectopic (tubal) pregnancy
- Vaginal Bleeding
- Placental Abruption (separation from the uterine wall)
- Placental Previa (The Placenta covering the entrance to the birth canal)
- Still Birth
- Premature Rupture of Membranes
- Preterm labor
The US Centers for Disease Control and Prevention report that 5-7% of infant deaths and 23-34% of infant deaths due to SIDS could have been prevented if the mother had not smoked during her pregnancy.
Babies born to mothers who smoke are at increased risk of:
- Birth Defects
- Low Birth Weight
- Prematurity
- Intrauterine Growth Retardation
Premature infants and low birth weight infants are at increased risk of having life long health problems such as asthma, colic and obesity. They also face numerous developmental problems such as Cerebral Palsy, metal retardation and learning disabilities. In a study published in the July 2010 edition of the American Journal of Preventive Medicine, researchers reported that if all women quit smoking during pregnancy, health care costs in the United States could be reduced by about $232 million a year and there would be improved overall health for mothers and babies.
People often ask, “With all the information available about the dangers of smoking, why would any woman smoke-especially while she is pregnant?” While this is a fair question, many people including many pregnant smokers don’t understand that smoking is a very serious addiction and addictions are very hard to break. What is interesting about smoking and addictions in general is that not everyone who smokes is addicted. We’ve all heard stories about people who one day decided to quit smoking and simply never picked up another cigarette. However, this is the exception rather than the norm. Most smokers have quite a bit of difficulty and need assistance to quit smoking.
Smoking cessation is even more difficult during pregnancy. Many people who decide to try to quite smoking will use nicotine replacements such as patches and gum. The efficacy and safety of these products is not established in the pregnant woman, so in order to avoid harm to the developing baby, they are not recommended for use during pregnancy. The same holds true for the various prescription medications used to help smokers quit. In the November 2010 issue of Obstetrics and Gynecology, a special review committee issued Opinion 471: Smoking Cessation During Pregnancy (Obstetrics & Gynecology: November 2010 – Volume 116 – Issue 5 – ppg 1241-1244), the review panel noted that medications such a buproprion, a common antidepressant and Varenicline, a drug that acts on brain nicotine receptors, are commonly prescribed for smoking cessation in non-pregnant patients. However, while neither medication has been shown to increase fetal anomalies or other adverse pregnancy side effects, they both have been linked to increased psychotic behaviors including suicide, so neither are recommended for use in the pregnant population. The panel found little or no evidence that meditation, hypnosis and acupuncture as effective strategies for smoking cessation, and although these techniques are often used successfully by smokers who wish to quit, no one has been able to that they are effective and safe in the pregnant population.
So what’s left? What is a pregnant smoker to do if she wishes to quit smoking? We already know that quitting greatly benefits mother and baby and that according to the ACOG review panel, the greatest benefits occur if a pregnant woman is able to quit smoking prior to the 15th week of pregnancy. But if a pregnant woman can’t use nicotine aids nor the available prescription medications, and if alternative therapies are supposedly ineffective, what is a pregnant mama to do?
The ACOG review panel recommends that obstetricians develop and carry out specific protocols in which they ask at each prenatal visit if a woman smokes or if she is exposed to second and/or third hand smoke. They find that OB intervention has a strong bearing on whether or not a pregnant woman quits smoking.The initial screen should be at the first prenatal appointment and the OB should have information readily available about the dangers of smoking during pregnancy and resources and referral sources for quitting (If the OB is unable to provide effective guidance and support for smoking cessation within his or her office). One of the best resources is The National Partnership to Help Pregnant Smokers Quit. The ACOG review panel also recommends that clinicians adopt The 5A’s, an office based smoking intervention designed to be used by trained practitioners. The 5A’s include:
The 5A’s of smoking cessation are as follows:
- ASK the patient about smoking status at the first prenatal visit, and continue to ask at subsequent visits. If the patient stopped smoking before or after she learned she was pregnant, the clinician should reinforce her decision to quit, congratulate her on success in quitting, and encourage her to stay smoke-free. If she is still smoking, the clinician should document this in her medical record and proceed with the remaining A’s.
- ADVISE the patient who smokes to stop, while offering information about the risks of continued smoking to the woman and her baby.
- ASSESS the patient’s motivation to attempt smoking cessation. At subsequent prenatal care visits, the clinician should offer quitting advice, evaluation, and motivational assistance.
- ASSIST the patient who wants to quit by offering pregnancy-specific, self-help smoking cessation materials, including a direct referral to the smoker’s quit line (1-800-QUIT NOW).
- ARRANGE follow-up visits to monitor the progress of the patient’s attempt to quit smoking.
Smoking is a very difficult habit to break. Pregnant women who smoke are faced with additional challenges because many smoking cessation aids should not be used during pregnancy. If you are a mama on bed rest and want help quitting smoking, talk to your obstetrician. Also, try the resources listed in this blog and in the resource section of our website. If you still need help, contact us directly at info@mamasonbedrest.com.
Image courtesy of The Ultimate Quite Smoking Guide-Smoking During pregnancy.
