The Importance of the Placenta in Birth Injury Claims
by Mrs. Helen Stanley, Senior Midwife and Expert Witness
The placenta will play a part in many clinical negligence birth injury and stillbirth claims, this short article aims to explain a little bit more about this incredible organ, and how placenta histology reports will become an important document in any negligence claim.
It is now common practice for a placenta to be sent for histology if a baby is born in unexpectedly poor condition, along with recognised antenatal conditions, such as small for gestational age, or babies with a known abnormality. The reason for this is as although ultrasound scanning can tell us a lot about how a baby is developing and the placenta is functioning, it cannot tell us everything. Placenta histology can greatly assist with a baby’s ongoing treatment, but as it is a test that can only be performed post-delivery, it can also greatly assist a solicitor when trying to ascertain whether there has been a breach of duty and causation.
Histology reports can take a number of months to be completed fully. They are often checked by a second pathologist if the placenta is not obviously normal. This is worth knowing as you may not find the document amongst your original records request if the case is very new. If it is not there, then request it, and if the Trust reply that the placenta was not sent for histology ask them to explain why.
If a baby is stillborn and the family consent to a Post-Mortem, the placenta will go with baby and form part of the Post-Mortem report. Having the placenta histology report available will greatly assist your expert witness in writing their breach/causation report.
So, what is the placenta and why is it important?
The placenta is a unique temporary organ that grows and develops alongside the fetus in pregnancy and is sometimes called ‘afterbirth’ as it is delivered after the baby is born. It is an incredible organ as it is not only responsible for supplying the developing fetus with oxygen and nutrients, but also for waste elimination, hormone production to support the pregnancy, provides protection against internal infection and transfers protective antibodies to the baby.
The third stage of labour is when the placenta and membranes are delivered and haemostasis (control of maternal bleeding) is achieved. Following birth, the attending midwife will check the placenta is complete. This is to ensure there is nothing left behind within the woman’s uterus that may later cause an infection or a further haemorrhage.
The average full term placenta weighs around 500 grams and is shaped like a disc approximately 3cm thick. The fetal side is shiny and smooth as this also has the membranes attached, and the maternal side is dull and divided into lobes. There are two membranes, the amnion and the chorion, and an umbilical cord attached to the fetal side of approximately 50cm in length. This cord consists of two arteries and one vein.
According to MBRRACE-UK (2015) 27.1% of stillbirths were caused by placental insufficiencies/problems. Becher et al (BJOG 2006) found that intrapartum (during labour) stillborn babies did not have brain damage in 50% of cases, but at Post-Mortem in stillborn full-term infants 38% had placental inflammation and 13% a placenta below the 10th centile for gestational age.
What to look for on the Placenta Histology Report
Placenta histology can differentiate between an acute and chronic insult, it can assist with the timing of death [very important if a stillbirth is thought to be complicated by reduced fetal movements] and can assist with determining the nature of the insult to the fetus.
Placental findings indicating acute in utero compromise include a normal placental weight appropriate for fetal weight, acute villous oedema (chorioamnionitis), intravillous haemorrhage and/or acute retroplacental haemorrhage (indicative of placental abruption). Acute meconium staining (a sign of fetal distress in labour) may be present. In a more chronic in utero compromise the placenta may be an abnormal weight in relation to fetal weight. Acute or necrotising funisitis (infection) may be evident. The presence of significant chronic villitis is an important cause of intrauterine growth restriction (IUGR, SGA) and can be seen on placentas with fetal loss. Chronic fetal vascular obstruction/fetal thrombotic vasculopathy may be seen alongside other contributing factors such as maternal diabetes or fetal cardiac insufficiency. This can be helpful if mismanagement or undiagnosed gestational diabetes is a potential element of the claim (Redline 2007, Chang 2009).
In terms of causation, the placenta histology can assist with hypoxia, sepsis and fetal loss. There are many other findings that can help with diagnosis/causation but whilst this will be extremely helpful it is also important to remember that many stillbirths in particular have an unknown cause and placenta histology may be normal and unremarkable. Therefore, a normal placenta does not adversely affect the claim. However, having a little understanding of how valuable this incredible organ can be in supporting clinical negligence claims can go a long way.
About the Author:
Helen Stanley, BSc (hons) is a Senior Midwife with current experience in all areas of midwifery including antenatal, intrapartum and postnatal care in delivery suite, theatre and birth centre environments including community midwifery. Helen has been assessing clinical negligence cases since 2017 and can provide both Screening and Breach & Causation Reports.
To instruct Helen Stanley, and for a fee quote and terms, email firstname.lastname@example.org