We often think of the physical risks and benefits when talking about VBAC versus repeat cesarean section, but what about the toll on mental health?

The stress of having a complication like placenta accreta is often not addressed and parents are left on their own trying to figure out how to cope with this serious diagnosis.

So I was thrilled to come across a study finally addressing this issue and to include it in our monthly Grand Rounds for VBAC Facts® Professional Members.

Join me for this Grand Rounds excerpt where we review Tol 2019, a study looking at the connection between abnormally invasive placenta and post traumatic stress disorder.

If you want to quickly get up to date on the VBAC evidence and easily stay current with the latest research, so you can increase VBAC access in your community, then join the VBAC Facts® Membership for Professionals.

Hi there! I’m Jen Kamel, VBAC Facts® Founder. Are you a perinatal professional who believes that every person should have access to vaginal birth after cesarean? If so, join me for this grand rounds excerpt where we review a study looking at the connection between abnormally invasive placenta and post traumatic stress disorder.

Abnormally invasive placenta & PTSD

The last and final article we will review in the July 2019 Grand Rounds is out of the UK and is entitled “Post traumatic stress disorder (PTSD): the psychological sequelae of abnormally invasive placenta (AIP)”. We talk a lot about abnormally invasive placenta, or AIP, in membership because of how closely tied it is with VBAC access. As the risk of AIP increases with each prior cesarean, and the repeat cesarean rate in the United States currently hovers around 90%, this topic is of deep interest to me and other maternal health advocates.

I discuss AIP at great length in “The Truth About VBAC for Professionals,” but briefly, AIP is so serious because it puts birthing parents at risk for high rates of postpartum hemorrhage, emergency hysterectomy, and death. To date, no research has been done examining the association between AIP and the incidence of post traumatic stress disorder, or PTSD. This study wishes to fill that gap of knowledge by measuring the psychological impact of having AIP versus an uncomplicated cesarean delivery versus an unexpected traumatic birth.

How often does abnormally invasive placenta occur

Let’s set the scene for AIP. In Europe, it affects about 1 to 3 out of every 10,000 births. But keep in mind that is the overall rate, not the rate among those with a prior cesarean which is the number one risk factor for AIP. In the United States, AIP rates are substantially higher, 1 in 533, per ACOG’s 2012 Committee Opinion on Accreta. And the rates soar even higher, to 1 in 322 after one prior cesarean per a 2006 study. (Silver, 2006)

Its 7% risk of maternal death (O’Brien 1996) is tied to excessive bleeding with an average blood loss of three to five liters. Sometimes, the only way to control this bleeding is through a cesarean hysterectomy. This is how AIP has became the number one reason for cesareans hysterectomies in high resource countries.

We know from existing research that those who have had a traumatic childbirth, including a severe postpartum hemorrhage or an emergency postpartum hysterectomy, have reported adverse psychological outcomes, including PTSD. One French study published in 2015 found that 76% of those who had a severe post-partum hemorrhage reported negative memories and 41% reported long-term challenges that affected their mental health and intimate relationships. Another study out of France published in 2011 found that 64% of birthing people who had an unplanned hysterectomy were diagnosed with PTSD.

How this study was conducted

Women were eligible to take part in this retrospective case-controlled questionnaire study in a UK Tertiary obstetric unit if they were over the age of 16, were fluent in English, and had given birth between September 2012 and September 2016. Hospital electronic records were reviewed to identify women potentially meeting this criteria then the full details of their delivery were checked from their hospital records to confirm that there had been no antenatal reason to anticipate an increased risk of a complicated or traumatic birth. All potential participants were sent an invitation letter. Participants were assigned to one of four groups. Once they joined the study, they were each assigned to one of four groups.

The study group one consisted of 17 women who were diagnosed with AIP. They either had a cesarean hysterectomy upon delivery or conservative management. Conservative management means that after the baby is delivered via cesarean, the uterus is closed leaving the placenta attached to the uterus. Two reasons why someone might opt for conservative treatment include the inability to remove the placenta without resulting in catastrophic blood loss and/or the strong desire to have future children. The birthing person is closely monitored during the post-partum period for infection and other complications while the placenta reabsorbs.

Group two consisted of 14 women who had a repeat cesarean because they had a prior cesarean. These were low risk surgeries as the repeat cesareans were occurring without medical indication. As a result, all women in this group had a routine uncomplicated surgery with minimal blood loss estimated at less than one liter.

The third study group consisted of 16 women with a prior cesarean who had an ultrasound scan due to the presence of AIP risk factors. However, AIP signs were not found on the ultrasound and so the women were cleared of the potential diagnosis. Everyone in this group had an uncomplicated repeat cesarean with minimal blood loss during the course of this study.

The fourth study group consisted of 22 women who did not have AIP but experienced either a severe postpartum hemorrhage of greater than three liters or an emergency post-partum hysterectomy. None of these women had risk factors for hemorrhage identified before delivery.

This study was based on a total of 69 women. Of the 17 women with AIP from group one, 16 had an immediate hysterectomy and one had successful conservative management. Of the 22 women from group four who had a severe hemorrhage, all were managed in the operating room and none had a hysterectomy at the time of delivery.

How they measured PTSD presence and severity

To identify those in the study suffering from PTSD, the researchers used a PTSD questionnaire that took about 5 minutes to complete. The researchers found, “The median PTSD screening scores for women with confirmed AIP and unexpected hemorrhage or emergency post-partum hysterectomy were significantly higher than those who had an uncomplicated cesarean (p=0.001).” Additionally, the median PTSD scores for those at risk for AIP but went on to have an uncomplicated cesarean were not significantly different than those without risk (p=0.726). No significant differences were seen between the median scores for women with AIP when compared to women who had an unexpected hemorrhage (p=0.89).

The number of women scoring above a 32 on the questionnaire was significantly greater in the AIP group (n=7) than in the uncomplicated cesarean group (n=1, p=0.045). However, a significant difference was not seen in the number of women with probable PTSD between the uncomplicated cesarean and unexpected hemorrhage group (n=7, p=0.12) or the women with AIP risks (n=0, p=0.47).

What can we do about AIP and PTSD?

This was the “first study to demonstrate that women who are antenatally diagnosed with AIP and are therefore anticipating a difficult, potentially traumatic delivery, are still at significantly increased risk of developing PTSD.” The authors state, “Currently there are no evidence based interventions available to prevent PTSD . Contemporary understanding of the condition indicates that post-event intervention should be the primary focus. Therefore, healthcare professionals, especially those involved in post-natal care of women, need to be educated about AIP and its potential negative psychological impact so that these women at high risk of developing PTSD can be identified early and access appropriate treatment.”

This is why I work so hard to highlight the connection between multiple repeat cesareans and abnormally invasive placentas. With its high maternal and neonatal mortality and morbidity rate, coupled with the mental health outcomes, it’s important that perinatal professionals educate their clients about AIP during the VBAC consult. Considering the future implications of current decisions is an important caveat that is often not covered. This is especially true among those who desire more children.

Action Steps: Educate, Screen, Refer

This study demonstrates that women who are diagnosed with AIP are still at a significantly increased risk of developing PTSD. The findings of this study indicate that being prepared for the possibility of a difficult childbirth does not necessarily mitigate the risk of developing PTSD. Early detection of the psychological sequelae of AIP through a systematic screening program might enable prompt intervention by facilitating access to psychological and mental health services for women developing PTSD.

Note that the sample sizes of the various groups in this study were very small. So we really do need further research on this important topic.

Nevertheless, I think being proactive is so important here and this is why all perinatal professionals should have a list of therapists and psychiatrists who you trust and are knowledgeable about birth trauma to whom you can refer your clients. So we really are talking about a sub-set of therapists who acknowledge the trauma that can come with birth rather than assuring the birthing person that all is well because they have a healthy baby.

I also wonder about bringing up the connection between AIP and PTSD with your clients prenatally so they can be prepared. I think for some, that could normalize the PTSD, possibly mitigate any shame they may feel, and result in them reaching out for help sooner. However, learning about the AIP/PTSD connection could result in additional anxiety in some birthing people, so this is an area to use your clinical judgement and work in conjunction with your local maternal mental health professional.

I hope you enjoyed this grand rounds excerpt. Every month, I present on recently published research relevant to perinatal professionals who want to increase VBAC access in their community. 

Access to this, and our library of grand rounds, is one of the many benefits of joining the VBAC Facts® Membership for Professionals.

If you want to increase VBAC access if your community, the first step is to learn the facts. 

Join membership now so you can easily stay current with the latest research.

Go to vbacfacts.com/membership to learn more. 

And until next time, I’m Jen Kamel.