# Placenta Previa & natural childbirth...?



## Annie37 (Mar 3, 2007)

I'm asking this here rather than in the Pregnant section,as whenever I have posted about my condition there, I get MAYBE 1 or 2 responses,if I'm lucky. Apparantly no one likes to talk about this condition..?
Anyway, I have had 3 bleeding episodes (2 really bad) and now they say the placenta is about a centimeter away from the cervix. I am coming into the
32nd week. What are the chances that I may get to have a natural childbirth? Is there a "magic number", such as X-centimeters from the cervix,or what? Any hope for me?
Anyone?


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## aylaanne (Mar 7, 2007)

I'm not sure about a magic number. I do know that your chances for hemmoraging or premature separation of the placenta during birth are higher than normal, and could mean a true emergency section. For your honest chances, I'd talk to your provider, and just hope that your placenta moves higher. As a patient, I wouldn't be comfortable with laboring intervention-free with my placenta that low. I'd still refuse drugs, but I'd probably ask for an epidural or spinal catheter to be in place and I'd want more frequent fetal monitoring.

Where are you laboring and birthing? I used to work at a hospital that handled a lot of high-risk cases. In your case, I could see them encouraging continuous fetal monitoring, perhaps internally if your water has broken, and possibly having you labor near to the operating room. If you do labor naturally and the placenta separates early, they're likely to put you under general anesthesia and possibly do a classical incision to get the baby out before it dies. If you have an epidural catheter in place, it might be possible to give you enough drugs through that so you might be able to stay awake in that case, but the chances are low.

Of course, I haven't seen many births, only around thirty or so, and most of those were low-risk and over-managed. Most of my research has been into normal childbirth without prenatal complications. I'm just sharing what my personal preferences would be if I were to be in your shoes, and what I expect might happen if you were to birth in the only Labor and Delivery floor I've worked on. Good luck and KUP.

eta: you might want to ask this question in the birth professionals forum. They're likely to have much more experience with this.


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## mendomidwife (Sep 6, 2006)

The doctor I refer women to would like the placenta to be at least 3cm's from the cervix. That is because I do homebirths......the last thing I want at home is a partial previa....
My midwife friend who works in a big hopsital practice says they do vaginal births on women with cervix's touching the os. BUT, they have a surgical suite up and ready to go.
BTW, the doc I work with is a research nut.....when he says 3cm's I AM SURE that it is because that is what the current literature supports. So....for me, 3cm's is the magic number.

Carla


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## jengacnm (Oct 26, 2006)

The "magic number" is 2 cms or more away from the cervix....I'll have to post the links later-but an article stated that 60% of women whose placentas were > or = to 2 cms away from the cervix delivered vaginally, while 90% of women whose placentas were < 2cms away had c sections for severe bleeding associated with previa.

Very important-the measurement should be done with a transvaginal ultrasound.

I had a client recently who had this. She had a scheduled c section because hers was 1.6 cms away from the cervix. Had it been > 2 cms, we would have had her labor and birth in the hospital, with continuous monitoring, a hep lock, and the OR team alerted.

Links later...

Jennifer


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## Annie37 (Mar 3, 2007)

Thank you all for your help! I had also found on a UK site about the 2 cm thing,but I am in Kansas. My OB seems optimistic that it will yet move,and so am I . The scary part was two of the 3 bleeds (last 2) I bled heavily,then passed a large blood clot (maybe 5 inches long,2 wide!) and then quit bleeding,both times! The drs couldn't really tell me what caused the blood clots. No contractions,baby was fine.
I am terrified of a C-section, w/ the epidural or spinal tap,as I have had a bad back ever since my epidural w/ my daughter's birth 12 years ago. Then again, I've always feared bleeding to death in childbirth! I go for biophysical profiles every Friday,and they do transvaginal u/s. My OB had said beforwe that they would give me a C/S 2 weeks before my due date if the placenta doesn't move up,I wonder if that is still truer now,as it has moved a bit since then(to a centimeter away).
This little boy must be a tough one, as I bled non-stop, very heavily,for the first 5-6 weeks of my pregnancy. I assumed I had miscarried,what w/ all the bleeding,and didn't know I was pregnant until the baby KICKED,at about 17-18 weeks!


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## RunningAway (Feb 24, 2005)

With my baby#3, my placenta was 3 mm (0.3cm) from the os at 31 weeks (marginal previa). After that point I was on pelvic rest and told that it was unlikely that my placenta would move further up because it was posterior and I was late in my pregnancy. I never had any bleeding. I had been planning a natural waterbirth in the hospital with a very hands off CNM. She said we could still go ahead with a vaginal birth, but if I had bleeding before labor or heavy bleeding during labor, it would be c/s. She also said that 90% of her marginal previa patients delivered vaginally. Repeat u/s at 35w showed the placenta had moved up to 3cm away from the os, now just a low lying placenta. I didn't end up with the waterbirth because we were concerned about being able to monitor blood loss, but I did have a natural intervention free birth at 41+1 weeks to a 9lbs. 9oz. baby, with no bleeding problems. I did have a hep lock, which otherwise would not have been required. Good luck.


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## Annie37 (Mar 3, 2007)

Quote:


Originally Posted by *RunningAway* 
With my baby#3, my placenta was 3 mm (0.3cm) from the os at 31 weeks (marginal previa). After that point I was on pelvic rest and told that it was unlikely that my placenta would move further up because it was posterior and I was late in my pregnancy. I never had any bleeding. I had been planning a natural waterbirth in the hospital with a very hands off CNM. She said we could still go ahead with a vaginal birth, but if I had bleeding before labor or heavy bleeding during labor, it would be c/s. She also said that 90% of her marginal previa patients delivered vaginally. Repeat u/s at 35w showed the placenta had moved up to 3cm away from the os, now just a low lying placenta. I didn't end up with the waterbirth because we were concerned about being able to monitor blood loss, but I did have a natural intervention free birth at 41+1 weeks to a 9lbs. 9oz. baby, with no bleeding problems. I did have a hep lock, which otherwise would not have been required. Good luck.

That is great news! I wonder,however,if the fact that I HAVE had bleeding (just had another bit of darkish,mucusy spotting just last night!) episodes is any indication of anything? Seems that most of the stories I have read where the placenta does move up, bleeding usually hasn't occurred.


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## jengacnm (Oct 26, 2006)

Here are the citations and abstracts I promised (bolding mine):

BJOG. 2003 Sep;110(9):860-4. Links
Placental edge to internal os distance in the late third trimester and
mode of delivery in placenta praevia.Bhide A, Prefumo F, Moore J,
Hollis
B, Thilaganathan B.
Fetal Medicine Unit, Academic Department of Obstetrics and Gynaecology,
St
George's Hospital Medical School, Cranmer Terrace, London SW17 0RE, UK.

OBJECTIVES: To correlate transvaginal ultrasound findings with mode of
delivery in cases of placenta praevia. DESIGN: Cohort study. SETTING: A
London Teaching Hospital. METHODS: Retrospective review of all cases of
placenta praevia diagnosed by transvaginal ultrasound between February
1997 and March 2002. MAIN OUTCOME MEASURES: Likelihood of vaginal
delivery
and major obstetric haemorrhage. RESULTS: A total of 121 pregnancies
were
studied with a mean scan-to-delivery interval of 10.5 days. In the 64
women who laboured, the likelihood of vaginal delivery rose
significantly
as the placental edge to internal os distance increased. *Caesarean
section
rate was 90% when the placental edge-internal os distance was 0.1 to
2.0
cm, falling to 37% when this measurement was over 2.0 cm* (P < 0.00045).
CONCLUSION: Trial of vaginal delivery is appropriate in cases with a
placental to internal os distance >2 cm. The term "praevia" should be
restricted to cases where the placental edge is < or =2 cm from the
internal os, as the likelihood of operative delivery and significant
postpartum haemorrhage is high. Cases where the placenta is more than 2
cm
from the internal os have a greater than 60% chance of vaginal delivery
and should be defined as "low lying" in order to reduce the clinician's
bias towards operative delivery.

Am J Obstet Gynecol. 1991 Oct;165(4 Pt 1):1036-8. Links
What is a low-lying placenta?Oppenheimer LW, Farine D, Ritchie JW,
Lewinsky RM, Telford J, Fairbanks LA.
Department of Obstetrics and Gynecology, Mount Sinai Hospital,
University
of Toronto, Ontario, Canada.

Transvaginal ultrasonography was performed in 127 women thought to have
placenta previa. In all cases of complete previa, placental location
was
confirmed at cesarean section. Where the placenta was situated in the
lower segment of the uterus but did not cover the cervical os the
distance
from the placental edge to the internal cervical os was measured. This
distance was analyzed in relation to the route of delivery. *No patient
with a placental edge greater than 2 cm from the internal cervical os
required cesarean section for the indication of placenta previa,
whereas
seven of eight patients with a distance of less than or equal to 2 cm
underwent cesarean section because of bleeding characteristic of a**placenta previa*. These preliminary results suggest that transvaginal
ultrasonography measurement may indicate the optimal delivery route and
make the traditional classification of placenta previa obsolete.


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## Annie37 (Mar 3, 2007)

Thanks for the info,Jen!! Am crossing fingers that the placenta will move and no more bad bleeds from now on!!


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## Kailey's mom (Apr 19, 2007)

There's still a small chance your placenta can move up hun







if it hasn't already. My ob said that if the placenta moved up, that could cause some bleeding also. Worst Case scenerio, and it doesn't move up I can tell you that the spinal block really isn't that bad/ I honestly did not feel it. I had a complete placenta previa, umb cord laying on my cervix and a breech preemi. I still, even though I had a c-section, had a wonderful birth. The most important thing is that you and your baby are safe. Things will be okay. HUGS!


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## hmbay (Sep 7, 2006)

My dr gave me the number of 2 cm which I see has already been posted. Mine didn't move with pg 2 until around 32 weeks. At 32 weeks I got told it was now 2 cm away and I could cancel my scheduled c/s and attempt a vbac if I wanted to (which I did). My dr did say it was common for the placenta to not move enough until weeks 32-36 in some cases. I also had a few episodes of bleeding--3 of them if I remember right. I really thought since i wanted to do a vbac my dr would want the placenta further away or take extra precautions but he felt 2 cm was sufficient and treated me like a "normal" vbac from that point in my pg forward.


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## Annie37 (Mar 3, 2007)

I go back to the OB on Friday,and they are going to check the position of the placenta & see how big the baby is now,so hopefully it has moved a bit. Yesterday,I had another bleed, pretty bad,lots of clots, like golf ball size & larger. No contractions,however,no cramping,baby was moving just fine. He has been rather quiet today,though,which has me a bit worried. I called the perinatologist's office that gave me a U/S when I was hospitalized last time,& only got his nurse. She didn't have any explanations for the clots either,other than "pooling" of blood that is pushed out w/ the BM. Frustrating.


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## Annie37 (Mar 3, 2007)

Well,the baby looks great,about 5lbs 1 oz according to the ultrasound ( I'm at 34 weeks today) . He is making breathing movements fine,heart rate great,etc! Problem is,the placenta is still only a tad over a cm away from the cervix. OB said they want it to get to 2-3cm considering the heavy bleeding I've experianced. Have to go to the perinatologist on the 27th to get a second opinion. Good news also , I haven't spotted in 2 days...trying to be optimistic here!!


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## westsidegirlygirl (May 27, 2007)

Hi all-

I was cruising along unassisted until 21 weeks, when I went in to the ER for bleeding and they found a marginal previa.

I went in for the second time today, and at 27 weeks it is still marginal, it does not appear to have moved.

This bothers me a great deal because I have had a previous unnecessary cesarean, extremely abusive, and I want absolutely nothing to do with any of those people. This is just about the only thing (besides transverse lie and a handful of extremely rare issues that aren't likely to occur) that would force me into the hospital and now here I am.

After everything I went through with the overmanagement of my son's birth, I just want a break. I had said repeatedly before I got pregnant that I wasn't going to let the risk of c/s stop me from having another child, but I also said that if I knew for sure I was going to have to go through that again, I would absolutely not get pregnant a second time.

I found a chart that estimates likelihood of persistence of previa based on gestational age at detection, type of previa, and history of c/s.

Hopefully its ok to post this link, I'm not used to the rules around here (I noticed no name calling of birth industry people allowed! I'm doing it in spirit, as this c/s history seems to dramatically increase my risk of persistence of the previa, from 12% without uterine scarring to 40% in my case and at this stage).

You have to scroll down to find the chart, in a green box.

http://www.aafp.org/afp/20070415/1199.html

I noticed someone said their OB thought with a posterior placenta it is less likely to stretch enough for the placenta to move away. The placenta is posterior in my case as well. I wonder if that changes the numbers, and if so in what way.

Anyway, I am really hoping that this goes away, really really hoping. Let someone who loves obstetricians and goes for elective cesareans have this, not me.


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## wifeandmom (Jun 28, 2005)

It is concerning to me that you are not in the hospital if you are experiencing bleeding episodes. From all of the research I did in my last pg on previa, once you had the first significant bleed, everything I found said the rest of the pg would need to be spent in the hospital. Delivery was routinely recommended in all that I read at 36 weeks with amnio prior to assure lung maturity.

It's just not something you mess around with if you're bleeding as much and as often as you indicate. I'd question your peri on the rationale behind allowing you to be at home at this point. Have you had steroids to speed lung maturity?

In the post above mine, the link given has a lot of very useful info and a decision tree type chart that lays out exactly what everything I found says is standard care for persistent previa.


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## wifeandmom (Jun 28, 2005)

Quote:


Originally Posted by *westsidegirlygirl* 

I noticed someone said their OB thought with a posterior placenta it is less likely to stretch enough for the placenta to move away. The placenta is posterior in my case as well. I wonder if that changes the numbers, and if so in what way.

Anyway, I am really hoping that this goes away, really really hoping. Let someone who loves obstetricians and goes for elective cesareans have this, not me.

I don't know that I read anything on a posterior placenta being less likely to move, but rather the opposite. If it is anterior, especially with a prior c-section, the chance that it has implanted over the scar area is obviously a great concern. An anterior placenta previa is also more likely to also involve accreta, and things get even uglier with that.

I had ERCS with my subsequent pg, but I wouldn't wish previa on *anyone*. It's scary, no matter HOW you plan to deliver. It's not just a matter of having to have a repeat section, it's a whole lot more complicated. The risk of bleeding prior to delivery, likely bedrest quite possibly while hospitalized, increased risk of abruption, likely pre-term birth, bleeding complications during delivery, etc etc etc are all things that simply having a repeat section isn't going to 'fix'.

So, even if mom was already planning to have an ERCS, things get a whole lot more complex and dangerous with a persistent previa at delivery. Saying that it might as well happen to someone who wants a repeat to begin with seems to ignore this fact, as I'm certain nobody would really wish complications during pg/birth on another woman no matter her birthing choices.

I say this not to be snarky or anything, just thought it should be addressed since I too had the same thought go through my head with my last pg when the doc pointed out a very low lying placenta. "What difference does it make?" is what I thought. "I'm already having a ERCS." It was one complication that I'd not researched extensively at that point, and all I'd ever heard/read/seen online about it centered around the fact that if it didn't resolve, c-section was the only option. I was already having a section, so imagine my surprise when I started reading and realized that delivery method is the LEAST of your worries with a previa at birth.

I was fortunate in that what was a very low lying placenta was at the very top of my uterus 6 weeks later. Actually, I guess it was called a marginal previa cause it covered about half of my cervix. It was a very long 6 weeks to wait and wonder if it was going to resolve or if I was going to need to come up with a plan for possible extended bed rest, pre-term delivery, NICU, etc etc etc.


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## westsidegirlygirl (May 27, 2007)

I have had two bleeds total so far, and there is no indication of any imminent danger. The first bleed yielded less than a half cup of blood, the second was more clots than blood. All indicators are that baby is fine, and while yes it is true that some women do need to be on complete bedrest with placenta previa, it does not seem that it is necessary with me.

Some women bleed daily or almost daily, and are not supposed to do so much as walk around. Mine situation has proven more stable, if that's the right word. Also, a complete previa is a different situation from a marginal one.

I think there is a wide range in terms of severity of risk prior to labor. So far, the placenta's position has not posed any day to day issues.


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## westsidegirlygirl (May 27, 2007)

Quote:


Originally Posted by *wifeandmom* 
I had ERCS with my subsequent pg, but I wouldn't wish previa on *anyone*. It's scary, no matter HOW you plan to deliver. It's not just a matter of having to have a repeat section, it's a whole lot more complicated. The risk of bleeding prior to delivery, likely bedrest quite possibly while hospitalized, increased risk of abruption, likely pre-term birth, bleeding complications during delivery, etc etc etc are all things that simply having a repeat section isn't going to 'fix'.

None of this applies in my case, except the bleeding which has been minimal and of no consequence. So the "package" I expressed a wish to give away includes none of these factors - at least no more than in a case without previa.

Quote:


Originally Posted by *wifeandmom* 
So, even if mom was already planning to have an ERCS, things get a whole lot more complex and dangerous with a persistent previa at delivery. Saying that it might as well happen to someone who wants a repeat to begin with seems to ignore this fact, as I'm certain nobody would really wish complications during pg/birth on another woman no matter her birthing choices.

If I ignore this fact, it is because, again, for me it is not a fact.

Quote:


Originally Posted by *wifeandmom* 
I say this not to be snarky or anything, just thought it should be addressed since I too had the same thought go through my head with my last pg when the doc pointed out a very low lying placenta. "What difference does it make?" is what I thought. "I'm already having a ERCS." It was one complication that I'd not researched extensively at that point, and all I'd ever heard/read/seen online about it centered around the fact that if it didn't resolve, c-section was the only option. I was already having a section, so imagine my surprise when I started reading and realized that delivery method is the LEAST of your worries with a previa at birth.

Again, there are varying levels of severity with this. I am not wishing birth complications on anyone, my situation does not seem to involve any risk factors other than cesarean section. It seems that you are talking about a complete previa, but you mention that yours was low-lying. I had low lying placenta last time too, but it was never a factor or an issue, and played no part in either my symptoms, my safety, the safety of the baby, or the considerations of the team of birth people who mismanaged my son's birth.

In my case, cesarean section was catastrophic. It (combined with another intervention I never should have had) led to a massive tumor in my abdominal wall, and the loss of my upper abdominal muscles. It also led to us being trapped in the hospital long enough for my son to get a hospital acquired infection, complete with dangerously high fever and land him in the NICU for an additional week. It was not something I chose freely (I was lied to at 10 cm, directly and by omission), it was not a risk that I wanted to take, especially not for zero reason at all, but I pay the price every day, regardless.

My point was not that I want other women to have problems with pregnancy. Who would ever want such a thing, or articulate such a wish? My point was that I want the cesareans to go not to me, but to the women who want cesareans. Some women can accept the risks, and prefer cesareans to vaginal delivery. Obstetricians, for example- I read that 3 out of 4 of them elect c/s for themselves. I don't know if that statistic is recent or not. I can not accept the risks under most circumstances, but there are a few cases where there is no choice, and I may be in one of them.


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## wifeandmom (Jun 28, 2005)

Quote:


Originally Posted by *westsidegirlygirl* 
None of this applies in my case, except the bleeding which has been minimal and of no consequence. So the "package" I expressed a wish to give away includes none of these factors - at least no more than in a case without previa.

If I ignore this fact, it is because, again, for me it is not a fact.


The diagnosis of previa that does not resolve by delivery automatically carries a statistically higher risk of all of the complications I listed. It is certainly not a *guarantee* that every woman with a previa at delivery will experience every single complication I listed.

But it *is* a fact that just by having a previa that does not resolve, the risks of certain complications are much greater than without a persistent previa.

And for *that* reason, I could never 'wish' a previa on another woman, regardless of whether or not she was already planning to have a section.
When I read your comment about wishing someone who already wanted a section would experience this instead of you, I thought you were coming from the standpoint of you would lose your chance at vaginal birth, whereas the other woman doesn't even want that chance. And if a diagnosis of previa at delivery was ONLY about how you delivered the baby, and it *didn't* involve all of the very real additional risk factors associated with such a diagnosis, I'd agree with you in a heartbeat.

Kind of like if you desperately wanted a hospital VBAC but none of your local hospitals did them anymore and Sally three states over had half a dozen hospitals that did VBACs but she wanted an ERCS anyway...it'd make sense to me to say 'Boy, I sure wish Sally had the hospital choices that I have and that I had the choices she has.'

But her ERCS isn't going to involve any greater risk if done in one place vs. the other, whereas wishing a woman who already wants a section to have a previa instead of someone who has a vaginal birth planned DOES mean you'd be wishing a whole multitude of additional possible complications on the section mom.

My point is that a woman with previa at delivery needs to be a whole lot more worried about the complications commonly associated with that previa instead of not being able to have the baby vaginally. There's a lot that can go wrong, way more so than with your typical c-section.


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## Annie37 (Mar 3, 2007)

Quote:

It is concerning to me that you are not in the hospital if you are experiencing bleeding episodes. From all of the research I did in my last pg on previa, once you had the first significant bleed, everything I found said the rest of the pg would need to be spent in the hospital. Delivery was routinely recommended in all that I read at 36 weeks with amnio prior to assure lung maturity.

It's just not something you mess around with if you're bleeding as much and as often as you indicate. I'd question your peri on the rationale behind allowing you to be at home at this point. Have you had steroids to speed lung maturity?

Yes,I had the steroid shots w/ the first hospitalization.

In my case,it was just not possible for me to stay in the hospital until I delivered. This pregnancy was NOT planned,in fact was the result of failed birth control, and we could not afford to have me there,as my husband is working 2 jobs and there is no one to keep our 2 kids. We literally would become homeless if he couldn't keep both jobs.
The bleeding seems to come in sudden spurts,always after a BM,and may be a bit of spotting afterwards. The 7 & 5 days I spent in the hospital was horribly stressful to me, as I am dealing w/ depression in this pregnancy, the stress of being there was making me a nervous wreck.


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## westsidegirlygirl (May 27, 2007)

Quote:


Originally Posted by *wifeandmom* 

And for *that* reason, I could never 'wish' a previa on another woman, regardless of whether or not she was already planning to have a section.


I think this conversation, like so many with regards to birth and birth choices, may be drifting towards that category of conversations that is about one thing on the surface, but is really about the subtext.

I don't have my finger on it exactly, but you are hearing something I am not saying, and suggesting that regardless of my explanation to the contrary I am still saying it.

If we go a level deeper, it is clear that I am extremely anti-cesarean based on my experiences, and you are relatively not so as you chose to ERC. Sometimes, when we explain or defend our choices and the conclusions we have drawn from our experiences, there is a perception of judgement that gets tacked on there and then becomes the undercurrent for the apparent conversation, as we continue to go back and forth over what would be a more appropriate analogy to better illustrate what one person or the other said, or what is wrong with the way each of us perceived the other's statements.

Unless I am way off base in my assessment of what is happening, I don't think we need to have a conversation about previa that is actually a conversation about the choices and/or conclusions we have made in the past and the defense of those choices and/or conclusions.

Suffice it to say that we each hold a piece of the truth, and our relative truths are probably much closer in line with each other than it appears in the emotional complexity of this exchange.


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## wifeandmom (Jun 28, 2005)

What you say makes a lot of sense.









When I was told during my last pg that the placenta was covering half of my cervix, I literally thought 'Oh, no big deal, right? I'm already having a section, and that's all having a previa is about.'

Yeah. Then I started doing some research. And I quickly realized that previa is a whole lot more than just 'automatic section'. Even though I *was* already having an ERCS, I cannot tell you how hard I prayed that the previa would resolve. The potential complications kept me awake at night to say the very least. I breathed the biggest sigh of relief when follow up u/s showed the placenta at the top of my uterus. I could go back to worrying about the risks of a 3rd section, but without the added risks of previa on top of it.

Previa and accreta risks are a part of why we won't be getting pg again. I've had three sections, all fabulous recoveries with zero complications. But I have no desire to push my luck, so to speak. I feel incredibly blessed to have had the experiences I have had thus far, given the circumstances that were before me at the time, but the previa scare during my last pg was enough to send me firmly into the 'four is enough' camp (we have a set of twins, so 3 pg/4 kids).

It's enough for lots of other reasons, but the stats on a fourth section just aren't good enough for me to purposefully get pg again. Not that this has a thing in the world to do with the OP.


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## Dido (Jan 7, 2006)

Oh, never mind.


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## Annie37 (Mar 3, 2007)

Thanks to those of you who were helpful, before the thread Hijack.


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