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Home Birth: Case Analysis and Crucial Points Case Study

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Updated: Jul 30th, 2021

Your patient, Joanne Jones, is a 32 y/o G4P2012. She has no significant past medical or surgical history.

Past OB Hx

  • G1: Uncomplicated, un-medicated NSVD of a baby boy at 38 weeks gestation weighing 6lb14oz in the hospital in 2011 – small vaginal laceration, unrepaired
  • G2: Uncomplicated SAB in 2011
  • G3: Uncomplicated, un-medicated NSVD of a baby girl at 38 weeks gestation weighing 7lb14oz at home in 2013

Hx of Current Pregnancy

Labs
O+ antibodies neg
GC/CT neg
Rubella immune
Varicella immune
RPR non-reactive
HBsAg neg
HIV neg
H&H 12.5 & 37.4
Platelets 292
Diabetes Screening- Glucose 74
GBS neg

Pre-pregnancy BMI 18.6, BMI at time of delivery 22.6

At 39 weeks gestation, the patient began spontaneous labour in 1730. CNM arrived at the patient’s home at 2145. Fetal heart tones and maternal vital signs are done. House set up for delivery. The second CNM arrived at 2230. Maternal and Fetal vitals monitored pre-ACNM protocol and remained within normal limits. The patient entered the birth tub at 2305. The patient began spontaneously bearing down at 2340. SROM occurred in 2350. Head was visible at 2355, and a viable baby girl born over intact perineum at 2356. APGARs 9/9. Weight 7lb 3oz.

Placenta failed to delivery by 30 minutes PP.

  1. Is this normal?

This is not normal.

  1. How much blood loss would be acceptable?

Up to an average maximum of 500cc.

  1. What would be your current management of this patient?

Administration of oxytocin10 IU intramuscular.

The cord was clamped and cut at this time (30 min) and the patient and infant removed from the tub. The patient began to have heavier bleeding at 45 minutes postpartum, and the decision was made to call 911 and transfer to a higher level of care.

  1. Once you decided to transfer this patient, what is your management?

Administration of additional oxytocin 20 IU as an infusion. Controlled cord traction can be tried afterwards whose failure indicates manual removal of placenta. Removal of the uterus (hysterectomy) comes as the last option (Evensen, Anderson, & Fontaine, 2017).

  1. Other than your patient, what else do you need to manage at this point?

The fetus ensuring it is well dried up and kept warm.

Further Investigation – Placental Concerns & Abnormalities

Please discuss the pathology and maternal/fetal implications of :

Placenta Previa

The placenta partially or completely covers the cervix of the mother. Risk factors associated with the condition include smoking, cocaine use, a previous scar on the uterus, age of more than 35 years, more than one fetus (Bukowski et al., 2017). The condition can cause premature birth and excessive bleeding during delivery.

Placenta Accreta, Increte, Percreta

In the placenta accreta, the placenta attaches too deeply into the uterine walls but does not invade the uterine muscle. In the placenta increta, the placenta attaches to the uterine muscle while in placenta per cent, the placenta goes beyond the uterus to other surrounding organs (Bukowski et al., 2017). Placenta previa and previous scars on the uterus are identified as risk factors. The conditions can lead to premature birth and severe intrapartum hemorrhage posing a risk to both fetus and mother, respectively.

Placental Hematoma

Placental Hematoma occurs due to premature detachment of the placenta. Blood clots accumulate in the space between the placenta and uterus, leading to more bleeding. Implications include preterm labour, placenta abruption and even premature rupture of the membranes.

Placental infarction

This condition results from interrupted blood supply to part of the placenta leading to cell death. Small infarcts, especially at the edges, are considered normal towards term (Bukowski et al., 2017). The size of infarcts determines severity clinically. If a large area of the placenta is affected, it can lead to placental insufficiency hence restricting fetal growth. It can also cause perinatal death.

Placental Calcification

The condition occurs due to the deposition of calcium-phosphate in the placental tissues. Some of the associated risk factors include smoking, a bacterial infection of the placenta, hypertension, exposure to radiations or low-frequency sounds, and even reaction to the medication. Implications include low birth weight, preterm labour, stillbirth, and postpartum hemorrhage.

Discuss the etiology of the following and their fetal implications:

Vasa Previa

Vasa Previa is associated with the presence of previous scars on the uterus, multiple pregnancies, low lying placenta, and the placenta consisting of more than one part (Vintzileos, Ananth, & Smulian, 2015). The condition causes decreased blood flow to fetuses hence growth retardation, fetal distress, miscarriage or stillbirth.

Velamentous cord insertion

Some of the identified precipitating factors include age above 35 years old, smoking, several miscarriages and multiple (Bukowski et al., 2017). To the fetus, it has serious implications such as fetal bradycardia, small for gestation age, intrauterine growth retardation, congenital abnormalities, and prematurity.

Marginal cord insertion

Multiple pregnancies and abnormal development of placental tissues are among the identified causes. Usually, there is insufficient blood flow to the fetus leading to fetal distress, prematurity, fetal retardation, and even stillbirth.

Succenturiate lobe

Usually, the condition comes about due to abnormal differentiation of the placental tissue. Blood supply to the fetus is divided hence can lead to growth retardation, small for gestation age and stillbirth.

Case Wrap-up

This patient was found to have a Placenta Accreta. What does this mean? Discuss what might make you suspicious that there was a placenta accreta during the third stage of labour. How would you counsel the patient in regards to her future pregnancies?

Placenta accrete means the placenta is too deeply embedded into the uterine layers but does not reach the muscular layer. This makes it difficult for the placenta to detach easily to be expelled during delivery. Usually, in the placenta Accreta, there is a prolonged third stage of labour, more than thirty minutes. In the subsequent pregnancies, the patient ought to ensure the extent of the placental implantation is determined by attending physicians during prenatal clinic visits through CT scan or MRI (Vintzileos, Ananth, & Smulian, 2015).

References

Bukowski, R., Hansen, N. I., Pinar, H., Willinger, M., Reddy, U. M., Parker, C. B., Koch, M. A. (2017). Altered fetal growth, placental abnormalities, and stillbirth. PloS one, 12(8), e0182874.

Evensen, A., Anderson, J., & Fontaine, P. (2017). Postpartum hemorrhage. Prevention and treatment, 95, 442-9.

Vintzileos, A. M., Ananth, C. V., & Smulian, J. C. (2015). Using ultrasound in the clinical management of placental implantation abnormalities. American Journal of Obstetrics and Gynecology, 213(4), S70-S77.

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