“Mailbag #12: What does the Fox say? “- with Dr. Nathan Fox

Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.

All right, welcome to Mailbag number 12, What does the Fox say? Our first question is from Mary.

“Hi. I have an epidural-related question. I had my first baby one year ago and really wanted to have an epidural. They inserted it, and it worked great for about an hour. It then slowly wore off until I could feel everything and had all use of my lower body. I advocated that it didn’t work, and the anesthesiologist came in and put more meds, and it did nothing. Is this common? Am I at risk of it happening again? I REALLY want an epidural next time. Ha ha. Thanks.”

All right, Mary, great question. So, again, just as a primer, an epidural in labor is a really good way to relieve pain. And the way it is done, and again, I’m not an anesthesiologist so I don’t place them myself, but again, I have knowledge of this, the way they’re placed is, essentially, they clean your back and they’re putting a needle sort of through your back, through your spine. And the goal of an epidural is to get the needle just before your spinal cord or your spinal column, which is essentially a very long, thin tube or bag that hangs on your back in your spine, and inside that is your spinal cord and all the nerves and whatnot. And so the goal of an epidural is to get the needle right before there, and then they thread a very thin plastic tube or catheter through the needle so that the tip of it is outside that bag, and then the outside of the catheter is connected to medication, an infusion that puts medicine through the catheter and sort of bathes the lower part of your spinal cord. And the goal is that fluid around it will sort of numb all of the nerves that are coming out of there going towards your uterus and your lower body.

Now, it’s a little bit less precise than what a spinal is. Now, a spinal is the same concept where the needle goes through your back, but instead of going into that space right outside of the spinal cord, actually, the spinal pierces the spinal cord, goes into it, which is, like, liquid in there, and then they inject liquid into there and then pull everything out. And that’s what we use for a C-section. So for C-section, you put the medication inside the spinal cord. It usually leads to a very quick and very, what we call, dense blocks that you don’t feel pain from somewhere above the uterus and below. With an epidural, since the needle doesn’t go into the spinal cord and just bathing around it, it definitely can happen that it is patchy for some people. Let’s say, some nerves are more numb than other nerves, or sometimes the catheter can be moved or dislodged, that it’s no longer bathing those nerves.

And so one of the possibilities for people who have an epidural and it’s not working well is that, all right, it’s in the right place, but we just have to inject more medicine to get sort of more fluid around the cord. So what sometimes happens when someone has an epidural in place, and they say, “You know what, it’s not working,” or the epidural has worn off, so to speak, and as they have more pain, is the anesthesiologist will come in and give you sort of what we call a bolus. It’s like an injection through that same catheter of a higher dose of medication. One of the medications is like a narcotic, which is more of a painkiller, and the other one is more of a numbing medicine. And whatever combination they use, it varies a little bit from place to place or from person to person or from situation to situation. But either way, they sort of give you some more, and sometimes that helps entirely or enough that at least you’re comfortable, meaning, even if it’s a little bit patchy, like, let’s say, you know, like, “My left side hurts a little, but my right side feels okay,” or “I have this one spot on my right that still hurts, but the rest feels okay,” sort of it’s manageable. So that’s one possibility.

The second possibility, since that catheter is sort of just sitting there, it could get dislodged, right? So either we can, for whatever reason, point in the wrong direction or pull back a little bit, or maybe it’s got blocked by some bone or ligament, or whatever it is, and that, in fact, it’s no longer a working epidural. And in that situation, sometimes the anesthesiologist will actually take it out and replace it entirely. Now, when an anesthesiologist decides to give you more medicine or to take it out and replace it entirely, certainly not my expertise, but both things happen not so uncommonly. Most people get an epidural, I get it, it works, they get a little bit more medicine, whatever. Occasionally, it has to be replaced, and that’s a bummer.

Obviously, you don’t want it to get replaced. You have to go through the procedure again. But it’s not considered dangerous to have to get it replaced. Again, it’s annoying, but it happens. And usually, it seems to be a matter of luck more than technique. Meaning, I haven’t seen any patterns that one anesthesiologist is better than another. Usually, just everyone does it sort of the same way, and every now and again, it doesn’t work and they have to replace it.

So I don’t know if I would say…it depends on how you define the word common when you asked, “Is it common?” It definitely happens. Most people, it’s not going to happen to, but on a busy labor floor, we see it all the time. So I guess it’s common from our end but maybe not as common from your end.

The question about if you’re at risk for it happening again, I don’t know is the short answer, but I would think not. It’s probably not related so much to you or your anatomy or your back or your spine or whatever it is. Again, since it’s probably mostly luck, I would think that you’re not very high risk for it happening again, or if you were, maybe slightly higher but not much. I think the exceptions are there are some people who may have had surgery on their spine or very difficult spines that they know from the outside that it might be a very difficult epidural placement. And for those people, from beginning, it’s a higher chance that it’s not going to work or they’re not going to get in the right place. But if everything is otherwise normal and it just happened to you sort of by chance, I would think it’s not something that’s likely to happen next time. Okay, good luck. Hope you have an epidural next time and it works really well.

Next question is from Sabrina. Sabrina asks, how many C-sections are safe to have for a relatively healthy woman?

So, Sabrina, I get that question all the time. People come to our practice either because they’ve had several C-sections, you know, one, two, three, four, five, or whatever it is, and they want to know, “Is it safe? Can I have another baby? Can I have another C-section?” Or potentially, they’re already pregnant, and their doctor said, “You know what, maybe you should see a high-risk doctor,” whatever it is, transfer their care to a practice that frequently does C-sections on people who’ve had multiple C-sections before. And the question comes up, “Okay, what is the number? What’s the magic number?” And this is one of those questions where I think, unfortunately, there’s been a lot of misinformation out there. A lot of people read, well, you can have up to three is safe, but four is not, or up to four is safe, but five is not. And it really doesn’t work like that.

Every time someone undergoes a C-section, there is some risk. That’s true on your first section, your second, your third, your fourth, and so on. I think the magnitude of the risk increases as you have more C-sections. Meaning, the risk on your first C-section is a certain amount, and on your second C-section, it’s slightly higher, and on your third C-section, it’s slightly higher than that, and on your fourth, it’s slightly higher than that, and so forth, and so forth. And the risks we’re talking about are predominantly bleeding, infection, and then rare things like needing a blood transfusion, needing a hysterectomy, damage to your other organs. So those are the big ones, right, if I’m going to need a hysterectomy when I have my C-section or if I have damage to my other organs.

So yes, they do go up numerically, but still, even with your fourth or fifth or sixth C-section, the absolute risk is not that high. Meaning, if I said to someone, “Your risk of one of those things happening is now,” let’s say, and this is not precise, but let’s say I said it’s 2% instead of 1%, or it’s 1.5% versus 0.25%, so yes, it’s higher, but still, the vast majority of people having that C-section are not going to have that complication. And so I don’t typically tell people that there’s a magic number, that, you know, four is too much or five is too much or six is too much or seven, or whatever it is.

We talk about, number one, the magnitude of the risk. Like, how high of a risk we’re talking is sort of point number one. Number two, a lot of it depends, how did the last C-section go? Meaning, if you have two people who are having their fifth C-section, one of whom, on their fourth C-section, everything was very, very straightforward, there was no scar tissue, it was really uncomplicated as far as C-sections go, whereas the other person, their fourth C-section was really difficult, there was a ton of scar tissue, it took many hours to do, there was a lot of complications. Clearly, it would be odd to counsel those people the exact same way for their fifth C-section. Presumably, the one who had the more easy fourth C-section surgically will probably have lower risk than the one who had a more complicated one. It’s hard to quantify that for people exactly. It’s hard to get a really good study that will tell you exactly how to sort of put that into numbers. It’s really just more of, surgically, what do I think is the likelihood it’s going to be a very tough C-section? And so, obviously, the one who had an easier time on the fourth C-section will have an easier time on their fifth compared to the other person.

The other thing is whether it’s your third, your fourth, your fifth, your sixth, your seventh, whatever C-section, the biggest impact on the risk of that C-section is not so much the number, whether it’s your third, fourth, fifth, sixth, or seventh. It’s really whether you happen to have, at the same time, a placenta previa where the placenta is covering the cervix. And the reason is if you have the combination of a placenta previa and two or more prior C-sections, the chance in this pregnancy that you have what we call a placenta accreta where the placenta is stuck to the uterus is very high, like 50% or more. So if I have someone who is having their seventh C-section without a placenta previa, the risk to her is probably much lower than someone having their fourth C-section with a placenta previa. And so it’s not so much the number of how many prior C-sections you had. It’s whether you happen to have a placenta previa that time. And it does not appear that the chance of having a placenta previa goes up with the number of prior C-sections. It seems to be, according to most data, it’s about, let’s say, a 3% to 5% chance, and that’s true on your first C-section, your second, your third, your fourth, your fifth, and so forth. So if you happen to have a placenta previa in this pregnancy and you’ve had multiple prior C-sections, then the chance of an accreta leading to things like transfusion, hysterectomy, and whatnot are definitely much higher.

So in our practice, when someone asks me that question, I generally will want to know the details of their last C-section, if I can. If we did it, obviously, we’ll know it intimately. If not, we’ll try to look at the operative report. If they’re already pregnant, it’ll matter whether they have a placenta previa or don’t have a placenta previa. And if they’re not yet pregnant, I’ll tell them that the risk, a lot of it will depend on whether they do or don’t develop a placenta previa and thereby a higher chance of placenta accreta. But we don’t cap it at a certain number. There are some people who have their fifth or sixth C-section was really, really, really tough. We’re going to have a different conversation about the next one versus if it was, I don’t want to say easy but not as difficult, let’s say. So I hope that answers your question. Yeah, I don’t put a hard number on it. The more you go, the higher the risk. But the absolute risk still tends to be pretty low if you’re, you know, getting operated on by someone who’s good. And if you are lucky enough to not have a placenta previa, meaning you’re in that…95% of people don’t have placenta previa.

All right, next question from Christine, also related to caesarean. “Hi. Do you cover the debate about single versus double-layer sutures during prior C-section and any differences and risk of uterine rupture? Thanks.”

Okay. So, Christine, I get your question 100%, but just for our listeners who might not know what you’re talking about, Christine’s question is related to when we do someone’s C-section, let’s say their first C-section, for whatever reason. They had a C-section because the baby was breech or because they’re having twins and they weren’t delivering vaginally, or there was some concern in labor, their labor was stalled, whatever it is. We’re doing their C-section, right? So the operative steps that we have to do, we obviously have to open everything up, including the uterus, take out the baby, take out the placenta, and then close everything up in the reverse order that we opened it. Fine, that makes a lot of sense.

And there are different ways to open things, and there’s different ways to close things. And that’s just surgical technique, and we don’t have to get into all the details of all the various steps, but one of the steps on the uterus is very, very critical. Number one, the most critical thing is how you open the uterus, meaning, if you open the uterus side to side, what we call low transverse incision, and we discuss this on VBAC podcast and whatnot, that type of incision, when you close it, in the next pregnancy, if they try to labor VBAC or TOLAC, the likelihood of it opening back up, right, that incision on the uterus reopening, called a uterine rupture, is approximately 1% or less if you do it side to side. Whereas if you opened the uterus up and down, top to bottom, what we call a vertical or a classical incision, then in the next pregnancy, if they try to labor, the chance of uterine rupture is much higher, like, at least 5% to 10%, and we do not recommend laboring in people like that. So how you open the uterus is one variable that’s critical in terms of the likelihood of being able to TOLAC or VBAC in the next pregnancy.

But there’s another variable. If you’re doing that low transverse incision and now you have to close that incision, there’s a question of whether closing it in one layer of sutures versus two-layer sutures has an impact on your next pregnancy. So surgically, what does that mean? If I close it in one layer, it’s basically the same way you would close, you would sew, I guess, a tear in a piece of clothing. You essentially just close it in one running layer and just, you know, put end-to-end suture together, and it heals, the sutures dissolve, and you’re done. The uterus is thicker than a piece of clothing, and so there is an option, instead of closing it in one thick layer, to actually close it in layers, two layers.

One of the ways to do it is to close the lower thickness first and then the upper thickness second. The other way is to close the full thickness first, and then you sort of put another layer, what’s called imbricating the second. I tend to prefer the former rather than the latter if you’re doing two layers. And the thought process behind two layers is that this will allow for a stronger closure of the uterus that is less susceptible to breaking down and opening up in the next labor. So that’s the premise.

And the question is, is it true? Number one, is it true that closing the uterus in two layers leads to less uterine ruptures if someone labors the next pregnancy compared to one layer? And I would say the data on that is a little bit confusing and mixed. There are some studies that suggest that a one-layer closure has a higher rate of uterine rupture than a two-layer closure, but the problem with those studies is they don’t tend to be randomized. Meaning, it’s not that we randomly assign one group of people to have one layer and one group to the other. And number two, not all of them are going to labor in the next pregnancy. Number three, uterine rupture is rare in both groups so it’s hard to have a study that’s big enough to necessarily find a difference. And number four, even in the studies that found a difference sort of retrospectively, it wasn’t a huge difference.

So for example, let’s say one study showed that, okay, we looked back, and the people who had a two-layer closure, their risk of rupture was 0.75%, and the people who had a one-layer closure, it was 1.5%. So you could say, “All right, that’s double,” right, 1.5% is double 0.75%, but still, it’s only 1.5%, right? It’s under 2%. And so, number one, it’s not entirely clear that…again, these numbers are not precise. They’re just meant to be an example. But it’s not entirely clear that that 1.5% versus 0.75% is true and real or precise. And number two, even if it were, does that mean that someone should be counseled much differently in the next pregnancy? Meaning, is there a big difference between about 1% and about 1.5% to 2%? And that sort of depends on the person.

So when I see people and they’ve had a single-layer closure, I might mention it to them that it’s possible that they have a slightly increased risk compared to if they have a double-layer closure. I’ll tell them I’m not certain of that, but it’s possible. But the magnitude of that risk seems to be relatively low. It’s very similar to sort of questions about if you’re going to induce someone with a prior C-section. There’s data similarly that’s retrospective, not entirely clear how precise or, you know, accurate it is, but that suggests that maybe there’s a slightly increased risk of uterine rupture if you induce labor compared to going into labor on your own, or if you’ve had two prior sections versus one prior section. And so it’s appropriate to talk about these things and to counsel them, but definitely, there’s a lot of differing opinions about how much weight to put into those statistics when counseling someone or making decisions about it.

And so I guess that’s the debate you’re talking about, and again, the way I go about it is, personally, in my practice, I usually will do a double-layer closure. I just sort of like how it is operatively. Even if someone is planning on not having another baby or planning on not having a VBAC or TOLAC, I usually prefer to close the uterus in two layers, not always but usually. And when I’m counseling someone about their risk of a uterine rupture in the next pregnancy, I will talk about if it was a single or double-layer closure, and I will mention that there are some data that might suggest a difference in risk. But I try to also quantify what that risk is, and for many people, it does not impact their decision. For some, it might, and that’s obviously fine. But for many people, it wouldn’t.

Okay. The next question is from my niece, Karen. Hey, Karen. How are you doing? Sorry, it took me so long to answer your question on the podcast. You could also text me. All right. “Hi, Naty.” Smiley face emoji. “Learned in a course about spina bifida and that, if you spot it early, there is an option to operate on the fetus. Was wondering about the process of detection and operation. Thanks. Best uncle and podcaster.” Thanks, Karen. I appreciate that.

Okay. So the short answer is yes. Spina bifida, which is also called a neural tube defect, is essentially a birth defect in the baby that happens early on in pregnancy and is usually recognized sometime in the second trimester, either initially by a blood test, which should be in the maternal serum AFP, which should be elevated, or, and then in our practice, more commonly, by an ultrasound where you actually can see the neural tube defect. What it is, essentially, is in the baby’s back, the baby’s spine, which forms by two things sort of coming together and closing, the lower portion of it does not close properly. And essentially, the baby has, in its back, like, a defect, like a hole, so to speak, in the back, and then part of the spinal cord sort of pouches out and balloons out into that hole. And it’s a condition that can have pretty severe effects on the baby after birth in terms of ability to walk, ability to have control over your bowel and bladder.

It can also sometimes, based on how it sort of pulls down on the brain, can affect sort of neurocognitive function. It can have something called hydrocephalus, there’s extra fluid in the brain that needs to be drained. So it can definitely have a lot of impacts on the babies, and their prognosis is variable, right? It’s not always exactly the same, but there’s definitely a high chance of certain complications.

After birth, when the baby is born, the treatment is, essentially, they sort of close up that hole, put everything in, and close up that hole. There is an idea, and this was born out in really good research, there’s an idea that the reason the baby gets harmed, so to speak, is that this is allowed to continue over the course of pregnancy, and the nerves get damaged by being exposed to the amniotic fluid and also on that sort of pulling on the brain throughout the course of pregnancy. So the thought is that we can fix this early, like, in the second or early third trimester, then the baby can grow and develop inside. And then, after birth, there’ll be a lower chance of complications. Not necessarily remove them entirely, but you can lower that chance. And so this has been studied, and it does seem to be the case that you can operate on a fetus in utero, meaning during pregnancy, and it will lower the chance of complications from this condition after birth.

Now, with that said, the operation is obviously very, very complex to operate on a fetus. You have to essentially put the mother under anesthesia. You have to either open up the uterus, like you’re doing a full C-section, pull the baby sort of up to the incision, operate on the baby’s spine, then put the baby back in, and close up the uterus and membranes, which clearly has risk to the mother because you’re doing surgery. It has risk to the baby, potentially, because when you do this, the water can break. It cannot reseal. They can have infection or labor afterward. So the operation itself is risky. But if it’s successful and the babies do not miscarry or not born prematurely and it sort of “works,” then it can lead to improved outcomes.

There’s another technique to do it where you don’t actually open up the mom like you’re doing a C-section, but you do it similar to how we would do laparoscopic surgery where you sort of put ports and cameras inside the uterus and try to operate on the baby that way. So there’s techniques to do it that way. The thought process is it’s a similar surgery on the baby, but there’s less risk of complications on the mother or of the water breaking and whatnot. And so it is possible. This is done in a few centers around the country. Obviously, this is very specialized stuff. Typically, the people who do the surgery aspect on the baby are pediatric surgeons, and the people who sort of start the process are maternal-fetal medicine specialists, usually with extra training in this particular fetal surgery. And so, usually, it’s a team of people who do it, and there are certain places around the country.

So when we see someone who we suspect spina bifida, there are certain criteria, exactly how far pregnant, how bad, this or this. We will typically discuss this as an option and refer them to one of the centers that does this and let them do their own evaluation, make the ultimate call if this patient, this fetus, is a good candidate for the surgery. And again, there’s risks and benefits to it. So that’s the process of detection and operation. Karen, hope you’re well.

Next question, from Maggie. “Hello. Love your content. I wondered if you could do a deep dive on implications of future pregnancies after postpartum hemorrhage, specifically to mention B-Lynch sutures. I had a PPH after a TOLAC, and subsequently, B-Lynch suture was used to attain hemostasis. Two weeks post-op, I actually developed a small bowel obstruction. And so I’ve been wondering about the implications of all this on future pregnancies. Appreciate your consideration. Thank you.”

All right, Maggie. So first of all, sorry you’ve had such a complicated delivery and then a rare but pretty complicated complication afterwards of a small bowel obstruction. I hope you are doing very, very well and have recovered and are enjoying time with your baby. In terms of your question, right, so a postpartum hemorrhage, which is where you’re bleeding, let’s just call it excessively after a delivery. There’s a certain amount that we consider normal, a certain amount that we consider abnormal. When you cross the line from one to the other is complex. We had a whole podcast on this. But let’s say, for whatever reason, we’re saying this is too much bleeding.

There are many reasons why that could happen. The most common reason, statistically, is something called uterine atony where, basically, that is where the uterus is atonic, meaning it does not have tone, meaning the uterus is sort of relaxed and not squeezing. In a typical pregnancy and delivery, after the baby and placenta comes out, the uterus is boggy, and there’s all this blood flow that’s coming into the uterus that was going to go to the placenta, and it’s going to go…if the placenta is not there, it’s going to go into the uterus and come out, and you have heavy bleeding. Now, the way the human body stops that is not the typical way that we stop bleeding in our body, you know, sending platelets and various fibroblasts and all these little factors to plug up the hole because these blood vessels are too thick for that.

So the way the body typically stops that is by the uterus contracting very, very tightly, and it sort of squeezes around those blood vessels. Think of it like stepping on a garden hose, right? The way you’re going to stop a garden hose, you either turn off the faucet or step on it. So when the uterus squeezes very tightly, it sort of compresses all those blood vessel garden hoses until the bleeding stops. And so, when people are having this, if we have to treat it, we first sort of massage the uterus because that sort of stimulates it to contract, we give medications, both routinely and as needed, sort of get the uterus to contract. We do all these things to get the uterus to contract if that is the problem.

One of the other options we have available to us if the uterus is not contracting is something called a B-Lynch suture. Now, B-Lynch suture is…you can sort of Google an image of it if you want to sort of see the mechanics, but basically, what it does is you’re using suture to sort of roll or fold the uterus on itself to sort of sew it into a tight ball. One way to think about it is if anyone’s ever done, like, tie-dying, right, and you take the shirts and you roll it into a ball, and you put the rubber bands around it so it stays into the ball. It’s essentially the same concept. You’re using sutures to take the uterus and squeeze it into a tight ball, and you use the sutures to sort of hold it in that way. And that sort of compresses the uterus to sort of stop the bleeding.

And then what happens over time, and this is, again, once the bleeding stops, you’re talking weeks to months later, all of those sutures dissolve, and then the uterus sort of re-forms its normal shape, because it’s no longer being squeezed. Meaning, you’re not actually sewing something to something else to sort of change its shape permanently. It’s just temporary. It’s almost as if you, like, put a hand in and squeezed it. And then, eventually, over time, when the sutures dissolve and it lets go, the uterus re-forms its prior shape.

So really, if someone’s had a postpartum hemorrhage and a B-Lynch suture was used to help compress the uterus, after time, the uterus will look normal, and it really shouldn’t impact future pregnancies because of that B-Lynch suture. Now, obviously, someone who’s had a postpartum hemorrhage, for whatever reason, is at risk for having it again in a future pregnancy. Again, it depends on the cause and why and this, but generally, and this is true for most things in medicine, if you’ve had something, you’re more likely to have it again in the next pregnancy compared to somebody else. It doesn’t mean you will have it, but it’s more likely. But the fact that a B-Lynch suture was used, as opposed to, let’s say, it correcting with just a medication, should not have any additional impact for the next pregnancy.

The small bowel obstruction where your intestines got blocked is an unusual complication from a delivery. It sort of depends on why that happened or what it was stuck to or what happened. But generally, fortunately, if it’s fixed and resolved, it usually also does not have a major impact on the next pregnancy. Okay, hope that answered your question.

All right, our last question for this Mailbag podcast is from Mallory. “Hi, Dr. Fox. I’m a loyal Toaster and found you and your podcast through Jackie and Claudia. Thanks for helping bring baby Charlie earthside. My question pertains to placenta accreta. My first pregnancy was in 2021 as a healthy 28-year-old. Overall, it was a normal healthy pregnancy without any complications. My placenta was posterior. I felt pretty good, and I was able to do Orangetheory throughout my whole pregnancy.” Good for you, Mallory. “I did have growth ultrasounds in my third trimester as I’m five-foot-one and I had concerns regarding my son’s size and possible shoulder dystocia. Labor and delivery was a bit more dicey, as we did encounter shoulder dystocia along with postpartum hemorrhage. About a month postpartum, we discovered that I had retained placenta, which was really resistant to removal and determined to be placenta accreta. I did not have a single risk factor for it, no prior pregnancy, no prior uterine surgeries, no previa, etc. I did end up having a couple of D&Cs to fully extract the retained portions of placenta. Fast forward to now, and I’m very fortunate to be pregnant with my second little boy.” Good luck to you. “This time, however, my placenta is anterior. Can you discuss whether placenta location has any impact on the likelihood of recurrence of placenta accreta and/or how to best advocate for yourself in this position? I did see a maternal-fetal medicine specialist for a different issue, but they did not seem concerned. My OB is awesome and will be monitoring closely, but of course, there’s no guarantee who I’ll get in delivery. Thanks.”

All right, Mallory, that was a detailed question. A lot has happened. I’m going to try to cover all this, but thank you. Good stuff. So again, some background, and we touched upon this earlier in this podcast, a placenta accreta is essentially where the placenta is unusually stuck to the uterus. Normally, after delivery, what happens is the baby is born, and this is true whether it’s a C-section or whether it’s a vaginal delivery. So normally, baby is born, we clamp and cut the cord, then the placenta comes out, and like we discussed in the last question, the uterus contracts, the bleeding stops, and all is well.

The problem is, every now and again, that placenta does not separate properly, and either the entire placenta is stuck to the uterus or a portion of the placenta is stuck to the uterus. Now, if the entire placenta is stuck to the uterus, that is a situation where basically you can’t proceed, right? The placenta is stuck, mom is bleeding, that’s a placenta accreta, it’s a very big deal, and not always but usually that’s going to lead to the need for a complete hysterectomy in order for the bleeding to stop. And that’s why placenta accreta is such a big deal. And again, the main risk factors for full placenta accreta are a placenta previa and prior uterine surgery, like a C-section. Again, not everybody has those risk factors, but some people do.

So you didn’t have that, obviously. There are definitely situations where people, they deliver the baby, they deliver the placenta, and it appears that the entire placenta has come out, both sort of, when we look at the placenta in sort of clinically, they may or may not have extra bleeding, but then it stops. But then we realize later, a day, a week, a month, two months that, in fact, a small portion of the placenta did not come out. It stayed inside. And the way you would find that out is either you can just…the most benign is you just see it on ultrasound. You know, you would have no symptoms whatsoever. We just see it on ultrasound. Number two, sometimes people have irregular bleeding after delivery, and everyone bleeds after delivery for X amount of weeks, but there’s a certain point where sometimes we think it’s unusual, and we do an ultrasound, and then we find it that way. And sometimes people have more profound bleeding, like within a day or two of delivery, they’re just really bleeding very heavy, and they have to go back in and try to remove that portion of the placenta.

Now, a lot of it depends on the size and location of the portion that remains, right? A very, very small piece is less likely to cause problems than a very, very large piece, which would make a lot of sense. And so this is something that we do see. And, Mallory, you’re correct. You did not have any risk factors for a retained placenta, and there are some, the same things that are risk factors for placenta accreta, things like prior surgery in your uterus, whether it’s a C-section, whether it’s a D&C. Sometimes if you have an abnormally shaped uterus, you can have this. But I would say, in my experience, for most people, it’s random, right? There’s people, whether they have a vaginal delivery, whether they have a C-section, a really tiny piece, you’re talking about the size of maybe a fingertip, like a centimeter, can, for whatever reason, not detach properly and then cause issues down the road, like bleeding and whatnot.

And then if we see it, the question is what to do about it, right? It’s usually not life-threatening, but it’s certainly going to be annoying, and it could cause on-and-off bleeding, rarely things like infection or more severe stuff, but usually, it’s just annoying. And then, what do you do about it? So you can wait and hope it comes out with one of your periods later. But if you’re nursing, you’re not going to have that. We can sometimes try to give medication, the same medications we give, I was talking about the last question, to sort of squeeze the uterus, to contract the uterus to maybe hope that’ll sort of squeeze the uterus enough that this thing comes out, or we can go in and try to do either a D&C or hysteroscopy to really get it and sort of take it out surgically. And eventually, it’s going to work, right? Something is going to work to take it out. And then, when they take it out, they say, “You know, this is really stuck.” It’s like a very small mini placenta accreta. Meaning, it’s not the entire placenta. It’s just a tiny portion.

And so someone who has that in a pregnancy, and it gets treated and they’re fine afterwards, definitely is at risk in the next pregnancy of either that happening again or potentially worse. Now, again, nothing could happen in the next pregnancy, and one of the questions you’re asking is, well, let’s say it happened in your first pregnancy when the placenta was posterior, on the backside of the uterus, and now the placenta is anterior, on the front side of the uterus. Presumably, whatever was making it stick to the backside of the uterus in the first pregnancy or if any sort of remaining “damages” there from removing it from the backside of the uterus, shouldn’t that not be applicable to this pregnancy where it’s on the anterior side of the uterus? And there’s a lot of logic to that, and it might be correct, but it’s sort of hard to prove that for a lot of reasons.

Number one, when we say the placenta is anterior, that means it’s predominantly anterior. There could be a tiny portion that’s also posterior. That’s number one. Number two, let’s say there’s, for whatever reason, some scar tissue going around the uterus. It may have only shown itself on the backside the first time and not the front side. So we sort of use it as, like, a gestalt. I would say yes, in general, it’s probably better that the placenta is anterior now versus posterior again, or sort of on the flip side, let’s say someone had a C-section on their first pregnancy, that’s on the anterior or the sort of higher upside of your uterus, and now the placenta on the next pregnancy on the backside, on the posterior. It’s probably a little bit less likely that it’s going to be an issue, but it’s not enough to sort of hold on to that as sort of proof or as a guarantee.

So what I would say is the likelihood, Mallory, for this upcoming pregnancy is your placenta is going to come out fine. No issues, whatsoever, like everybody else, and you’ll be fine. The second most likely possibility is it’ll be a little bit more difficult to take out the placenta, but the doctor at delivery will recognize that and sort of either take it out manually and get out all the portions or maybe do D&C at the time. The third most likely is sort of the same thing will happen to you as what happened to you this past time where it’ll come out, you’ll be fine, but then you realize, “Oh, man, there’s a little piece left that we have to take care of and do a D&C or hysteroscopy again.” And the least likely is that it’ll become much worse, and you’ll have, like, a placenta accreta, like, a severe one in this pregnancy. It’s not off the table as an impossibility, but it’s the least likely of all the options. I hope that answers your question.

All right, everyone. Thanks for sending in the podcast questions. This is a great week for our Mailbag. And we will be doing some more. Have a great one.

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