Placenta abruptio is the separation of the placenta (the organ that nourishes the fetus) from its

attachment to the uterus wall before the baby is delivered.

Causes
The exact cause of a placental abruption may be hard to determine.

Direct causes are rare, but include:

 Injury to the belly area (abdomen) from a fall, hit to the abdomen, or automobile accident
 Sudden loss of uterine volume (can occur with rapid loss of amniotic fluid or after a first
twin is delivered)

Risk factors include:

 Blood clotting disorders (thrombophilias)

 Cigarette smoking
 Cocaine use
 Diabetes
 Drinking more than 14 alcoholic drinks per week during pregnancy
 High blood pressure during pregnancy (about half of placental abruptions that lead to the
baby's death are linked to high blood pressure)
 History of placenta abruptio
 Increased uterine distention (may occur with multiple pregnancies or very large volume
of amniotic fluid)
 Large number of past deliveries
 Older mother
 Premature rupture of membranes (the bag of water breaks before 37 weeks into the
pregnancy)
 Uterine fibroids

Placental abruption, which includes any amount of placental separation before delivery, occurs in
about 1 out of 150 deliveries. The severe form, which can cause the baby to die, occurs only in
about 1 out of 800 to 1,600 deliveries.

Symptoms
 Abdominal pain
 Back pain
 Frequent uterine contractions
 Uterine contractions with no relaxation in between
 Vaginal bleeding

Exams and Tests

Tests may include:

 Abdominal ultrasound
 Complete blood count
 Fetal monitoring
 Fibrinogen level
 Partial thromboplastin time
 Pelvic exam
 Prothrombin time
 Vaginal ultrasound

Treatment
Treatment may include fluids through a vein (IV) and blood transfusions. The mother will be
carefully monitored for symptoms of shock. The unborn baby will be watched for signs of
distress, which includes an abnormal heart rate.

An emergency cesarean section may be needed. If the baby is very premature and there is only a
small placental separation, the mother may be kept in the hospital for close observation. She may
be released after several days if the condition does not get worse.

If the fetus is developed enough, vaginal delivery may be done if it is safe for the mother and
child. Otherwise, a cesarean section may be done.

Outlook (Prognosis)
The mother does not usually die from this condition. However, all of the following increase the
risk for death in both the mother and baby:

 Closed cervix
 Delayed diagnosis and treatment of placental abruption
 Excessive blood loss, leading to shock
 Hidden (concealed) uterine bleeding in pregnancy
 No labor

Fetal distress occurs early in the condition in about half of all cases. Infants who live have a 40-
50% chance of complications, which range from mild to severe.

Possible Complications
Excess blood loss may lead to shock and possible death in the mother or baby. If bleeding occurs
after the delivery and blood loss cannot be controlled in other ways, the mother may need a
hysterectomy (removal of the uterus).
When to Contact a Medical Professional
Call your health care provider if you are in an auto accident, even if the accident is minor.

Call your doctor right away if you have bleeding during pregnancy. See your health care
provider right away, call your local emergency number (such as 911), or go to the emergency
room if you are pregnant and have vaginal bleeding and severe abdominal pain or contractions
during your pregnancy. Placental abruption can quickly become an emergency condition that
threatens the life of both the mother and baby.

Prevention
Avoid drinking, smoking, or using recreational drugs during pregnancy. Get early and regular
prenatal care.

Recognizing and managing conditions in the mother such as diabetes and high blood pressure
also decrease the risk of placental abruption.

Alternative Names
Premature separation of placenta; Ablatio placentae; Abruptio placentae; Placental abruption

References
Francois KE, Foley MR. Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR,
Simpson JL, eds. Obstetrics - Normal and Problem Pregnancies. 5th ed. Philadelphia, Pa:
Elsevier Churchill Livingstone; 2007:chap 18.

Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx J, Hockberger RS, Walls RM,
et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed.
Philadelphia, Pa: Mosby Elsevier; 2009:chap 176.

Cunningham FG, Leveno KL, Bloom SL, et al. Obstetrical hemorrhage. In: Cunningham FG,
Leveno KL, Bloom SL, et al., eds. Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill:
2010:chap 35.
Although cesarean (C-sections) are relatively safe surgical procedures, they should only be
performed in appropriate medical circumstances. Some of the most common reasons for a
cesarean are:

 If the baby is in a feet first (breech) position

 If the baby is in a shoulder first (transverse) position
 If the baby’s head is too large to fit through the birth canal
 If labor is prolonged and the mother’s cervix will not dilate to 10 centimeters
 If the mother has placenta previa, where the placenta is blocking the birth canal
 If there are signs of fetal distress which is when the fetus is in danger because of
decreased oxygen flow to the fetus

Some common causes of fetal distress are:

 Compression of the umbilical cord

 Compression of major blood vessels in the mother’s abdomen because of her birthing
position
 Maternal illness due to hypertension, anemia, or heart disease

Like many surgical procedures, cesarean sections require anesthesia. Usually, the mother is
given an epidural or a spinal block. Both of these will numb the lower body, but the mother will
remain awake. If the baby has to be delivered quickly, as in an emergency, the mother may be
given a general anesthetic, which will make her fall asleep.

During the surgery, an incision is made in the lower abdomen followed by an incision made in
the uterus. There is no pain associated with either of these incisions because of the anesthesia.
The doctor will open the uterus and the amniotic sac. Then the baby is carefully eased through
the incision and out into the world. The procedure usually lasts about 20 minutes.

Afterward, the physician delivers the placenta and stitches up the incisions in the uterus and
abdominal wall. Usually, the mother is allowed to leave the hospital within a few days, barring
complications like wound infections.

One concern that many women have is whether they’ll be able to have a normal delivery after
having a cesarean. The answer depends on what the reasons were for having the c-section in the
first place. If it was because of a one-time problem, like umbilical cord compression or breech
position, then the mother may be able to have a normal birth.

Therefore, as long as the mother has had one or two previous cesarean deliveries with a low-
transverse uterine incision, and there are no other indications for a cesarean, she is a candidate
for vaginal birth after cesarean, also called VBAC (say as "vee-back").

Cesarean sections are safe, and can even save the lives of both mother and baby during
emergency deliveries. Expectant mothers should be prepared for the possibility of having one.
Keep in mind, in childbirth, it’s not only the delivery method that matters, but the end result: a
healthy mother and baby.
Abuse History
Birth Emergencies
Breech Position
Discouraged Mother
Fast Labor
Fetal Distress
Gestational Diabetes
Group B Strep
Overdue
Previa
Postmaturity
Posterior Baby
Ruptured Membranes
Slow Progress
Transverse Position

Giving Birth

What is Normal Labor Like?

Making Decisions in Labor
Judging Progress in Labor
False Labor
Birth Challenges
Take the Birth Style Quiz
Using a Doula?
Fear of Labor
Birth in Other Cultures

Fetal Distress

Also called:non-reassuring heart tones or non-reassuring

fetal status
What is Fetal Distress?
The theory of fetal distress is this:
  Neurological damage occurs when the baby's brain is deprived of oxygen. Lack of
oxygen to the brain can be recognized by patterns in the baby's heart rate.

 When the baby's heart rate pattern demonstrates a lack of oxygen (fetal distress) it is
necessary for the baby to be born immediately.

 To recognize changes in oxygenation, the baby's heart rate will be monitored, probably
with an electronic fetal monitor (EFM) during labor for indications of fetal distress.

Why is a fetal distress a challenge?

Aside from the obvious concern that the baby is not handling labor well, the theory of fetal
distress causes a cascade of challenges for the mother who desires to have a natural birth, even if
she does not experience fetal distress during her labor.

To ensure your baby is safe during labor, his heart rate will be monitored. Your baby will be
considered safe as long as his heart rate stays below 160 and above 100-120, and it does not
become irregular. There are two ways to do this which operate equally well for the purposes of
keeping babies safe. One, called intermittent auscultation, is to listen to the babies heart with a
special stethoscope every 15 minutes. The other, called continuous monitoring, is to attach
devices to the mother which allow a continuous printout of information about the baby's heart
rate and mother's contractions.

Although the two methods do work equally well at keeping your baby safe, there are important
differences. The first difference is that the electronic fetal monitor gives more information than
the intermittent stethoscope method. But giving more information does not mean it gives better
information, and certainly does not translate to better outcomes. It is the interpretation of the
information that is open to the largest variation, which causes some problems. The biggest
problem being cesarean surgery and operative vaginal births increase when the electronic fetal
monitor is used, but the babies don't do any better than babies who had their heart rate measured
every 15 minutes with a stethoscope.

The first challenge to families then, is that the theory of fetal distress has not held up to scientific
scrutiny, despite the fact that it is a leading reason given for emergency cesarean surgery. Henci
Goer makes the following points about the theory of fetal distress:

1. The baby's heart rate during labor correlates poorly with measures of the baby's condition
at birth.

2. Measures of the baby's condition at birth correlate poorly with long-term outcomes.

3. Comparisons of EFM and intermittent listening show that EFM offers no long-term
benefits in either low or high-risk pregnancies (although it may have short-term benefits
especially when oxytocin is used).
 4. Comparisons of EFM and intermittent listening show that EFM increases the likelihood
of cesarean and vaginal instrumental delivery, infection and cerebral palsy in premature
babies.

The second challenge is that because the theory of fetal distress is so well accepted, mothers
giving birth in a hospital are almost always required to undergo monitoring with the electronic
fetal monitor. Being attached to the monitor can be uncomfortable, limits the mother's mobility
and as Henci Goer pointed out, increases the likelihood that the mother will "require" a cesarean.

Another challenge occurs if a caregiver feels the baby may be in fetal distress. Although studies
have indicated that the monitor has a high false positive rate (says the baby is in distress when he
is not), the mother who has been told her baby is in distress may be too concerned to remember
that it may not be real. If the mother becomes upset, frightened or anxious she runs the risk of
starting the fear-tension-pain cycle as well as being unable to be her own advocate. What is most
unsettling is that many of the heart rate abnormalities are easily resolved with simple measures
such as position changes, which the mother is hindered from doing while attached to the
electronic fetal monitor.

Coaching Solutions
Choose intermittent monitoring rather than continuous monitoring.

Avoid medications which can cause changes in the heart rate.

If the heart tones are non-reassuring, change position to see if the heart rate changes. You may
also have success at resolving abnormal heart tones by interrupting the administration of
oxytocin or by using oxygen for a few minutes. Double check the diagnosis with a more accurate
monitor or by stimulating the baby's scalp before having a cesarean.

Things to discuss with your caregiver:

 Since intermittent monitoring gives the same quality of information as continuous
monitoring, you may want to discuss whether intermittent monitoring will be safe in your
situation. If you expect to use medication for pain or to stimulate labor your caregiver
will require you use continuous monitoring.

 Having a doula with you in labor can help you stay calm and focused if fetal distress
becomes a concern. A doula can remind you of the high false positive rate for EFM and
help you to ask your caregiver about options for verifying the diagnosis (such as using an
internal monitor or stimulating the baby's scalp). Knowing if it is true fetal distress can
help you make informed decisions about how to proceed.

 If you wish to avoid the negative effects of an EFM you may want to consider your
options for giving birth in a birth center or at home.
  If you do use the EFM during labor, be sure to stay upright and mobile. Most monitor
leads will give you two to four feet of space to move around it, so change your position
regularly. Alternately, you may want to request the use of a telemetry unit which allows
your baby's heart rate to be monitored without being attached to a wire.

 Avoid the use of medications for pain and oxytocin. These drugs negatively affect the
baby's heart rate.

One further Note: This information was posted in the July 2003 Newsletter for the American
Society of Anesthesiologists:

"Fetal Distress" In 1988, ACOG recommended that the term "fetal distress" be abandoned (Committee
Opinion No. 197) and recently voiced its concern about the continued use of the term as an antepartum
or intrapartum diagnosis. The ACOG Committee on Obstetric Practice has reaffirmed that the term "fetal
distress" is imprecise and nonspecific and has asked that the anesthesiology community be made aware
that this term should not be used. The committee has suggested that the term be replaced with
"nonreassuring fetal status" followed by a further description of findings (e.g., due to fetal bradycardia,
late decelerations, etc.). Of note to anesthesiologists, the ACOG Committee Opinion No. 197 states that
"performing a cesarean delivery for a nonreassuring fetal heart rate pattern does not necessarily
preclude the use of regional anesthesia