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Archive for February 27th, 2008

In today’s Telegraph was a piece written by Rowan Pelling who was commenting on the ‘golden hello’ to midwives who have left the profession. I feel that this article explains succintly most of the causes for midwives leaving the profession and then goes on to be realistic about what Alan Johnson is really offering – ‘He offers them a miserly £1,500 (plus up to the same amount in childcare, training days and travel) to re-engage with an even more demoralised and disaster-struck maternity service than the one they left several years earlier.’ The author is employing an Independent Midwife for the birth of her next child and suggests that the problems within the maternity services is her reason. I have no problem with this, it is her choice.

The article invites responses and the first one is from Emily, expecting her second baby in August, who says  – ‘I’ve seen the midwife twice and she seems more interested in ticking boxes and moving on to the next mum than taking time to answer my concerns. The NHS has become a conveyour belt where primary care providers are only interested in treating the issue at hand. Ask anything of them and it is treated like an inconvienence.’  So, Emily is at most 18 weeks pregnant, that’s if baby is due on the 1st August, if it’s due at the end of the month she is 14 weeks, according to the NICE guidelines for Antenatal Care she should be seen prior to 12 weeks and then again at 16 weeks, so twice. Right so far then. At these sessions the midwife will have been ‘booking’ Emily, lots of asking of questions and ticking of boxes, filling in of multiple forms to book scans, have the appropriate blood tests performed, basically attempting to ensure that the pathway is laid for Emily’s progression through her pregnancy. So yes, the midwife is really ‘ticking all the boxes’ at the moment and, unfortunately Emily has it right, the midwife is moving on to the next Mum, and the next, and the next because the way the service is at the moment a midwife’s priority is to give safe care and if she has time to do anything more then wonderful, but becoming increasingly unlikely. If Emily had read Rowans article properly she would have read that one reason midwives leave is that ‘maternity services are so overstretched that a rewarding job has turned into crisis management’ so my message to Emily would be ‘ Your midwife is probably as unhappy with the care she is providing as you are with the care you are receiving. It’s not her fault’.

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Vasa Previa – a midwives dictionary definition is ‘Vessels in front of the presenting part. A rare condition of velamentous insertion of the umbilical cord, usually with a degree of placenta previa, in which the vessels in the membranes are lying in front of the presenting part. When the membranes rupture there is a risk of compression of, or even haemorrhage from these vessels leading to hypoxia or haemorrhage to the child.I would add to this ‘where there is a succenturiate lobe to the placenta’.

Quite a lot of medical jargon here so I’m going to get that out of the way first and explaining all these should go a long way to explaining vasa previa.

Vessels – blood vessels of the umbilical cord.

Presenting part – here they are talking about what part of the baby is coming first, generally the head.

Velamentous – In a normal placenta the cord and the vessels go right up to the surface of the placenta before branching off, with a velamentous insertion the blood vessels branch off before reaching the placenta so are therefore exposed within the membranes.

Placenta previa Placenta previa is when the placenta attaches to the wall of the uterus in the lower portion of the uterus and covers all or part of the cervix. It is found in about 1:200 pregnancies at term ( 37 – 42 weeks). It is observed far more frequently on 20 week scans but on re-scan at 34 – 36 weeks the placenta has moved away from the cervix.

previa.gif

Different types of placenta previa

Membranes rupture – Waters break, either by themselves or with a little help.

Hypoxia – Baby does not receive enough oxygen due to the pressure on the blood vessels.

Haemorrhage – The blood carried within the umbilical cord is the baby’s. Think of the cord as an extension of baby, rather like the tubes in a dialysis machine or a heart-bypass, and you can understand why a breaking of these would lead to the baby having a huge blood loss, but whilst still inside it’s Mother’s womb.

Succenturiate – the placenta has an extra, separate piece to it. Often this is immediately adjacent,, so is not as much of a concern for vasa previa, but it can be some distance away and so have blood vessels which cross over the membranes connecting it to the main body of the placenta.

Photo of Vasa Previa

good-velam.jpg

So what  is the incidence of vasa previa? Stats vary, as usual, but there seems to be a consensus of around 1: 2,000 – 1:3,000 pregnancies.

How is it discovered? It can be detected on a 20 week scan, but  it can be easy to miss, if the woman is overweight, has a bladder that is obscuring the view or the problem blood vessels are in a position where they can not be seen, so unfortunately some cases are not detected until the waters break and there is blood. When I say blood I don’t mean a very slight pinky tinge, that is normal, I mean when the fluid looks like fresh blood. There are clues though that there may be vasa previa,  a low-lying placenta, a placenta that has an extra lobe (succenturiate), the incidence appears to be higher in IVF pregnancies, women who smoke, multiple pregnancies, and have a previous history of the condition so these cases would be thoroughly investigated

What can be done? Diagnosis is the most important step. Once diagnosed then decisions can be made about time and mode of birth which, studies have shown leads to a good outcome. Recently a surgeon has reported success with treating this problem by laser surgery to the blood vessels. However, this case was where there was an extra lobe to the placenta, not where the problem was a velamentous insertion. Good article to read though for more information.

How dangerous is it? Well, if it’s not detected then the death rate for baby can be as high as 95% but, if it’s found antenatally then, as long as there are not any other problems, the survival rate is 100%.

Wonderful website here, UK Vasa Previa Awareness.

Thank you to Mother of the Bride for suggesting this topic. If anyone else has any ideas for a post please let me know.

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