EGERTON UNIVERSITY

COLLEGE OF OPEN AND DISTANCE LEARNING

E-CAMPUS

NURS 220: INTRODUCTION TO MIDWIFERY AND PREGNANCY

Topic 4 Handout

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Published 2020
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Topic 4 – The placenta

Early development

• Zygote develops into a blastocyte which is a spherical structure

composed of the inner cell mass which develops into the fetus and the
outer ring of the trophoblast cells which will develop into the placenta
and the membranes.

• By 8th day the trophoblasts begin to make human chorionic

gonadotrophin (hCG), a hormone that that ensures that the
endometrium will be receptive to the implanting embryo.

Implantation

• Once the blastocyst is in contact with the endometrium, the

trophoblastic layer adheres to the endometrial surface and the
process of placentation begins.

• The blastocyst is completely buried by day 10 into the endometrium

and its now called the decidua.

• The decidua secretes cytokines and protease inhibitors which

modulate trophoblast invasion.

• Draw and label a diagram showing the chorionic villi

Chorionic villi

• Initially the blastocyt is covered with fine downy hair consisting of the
projections from the trophoblastic layer.

• After three weeks they proliferate and branch forming the chorionic
villi. The villi become more profuse in the area where blood supply is
richest the decidua basalis

• The chorion frondosum develops and becomes the placenta. The

portion of the decidua the project to the uterine cavity is known as
the decidua capsularis.

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• The decidua under the capsularis degenerates forming the chorion
leave which is the origin of the chorionic membrane.

• The remaining decidua is known as the decidua parietalis. As the fetus

grows and enlarges the capsularies thins and disappears and the
chorion meets the decidua parietalis on the opposite wall of the
uterus.

• The villi erode the walls of the maternal blood vessels as they
penetrate the decidua forming a lake of maternal blood which the
float.

• The opened blood vessels are called sinuses while the area
surrounding the villi is called blood spaces.

• Maternal blood flows slowly to enable absorption of all the nutrient by

the villi which are known as the nutritive villi.

• The ones that are deeply attached are known as the anchoring villi

• The chorionic villus is covered by a single layer of cytotrophoblast

cells and the external layer of the syncytiotrophoblast. These layers of
tissue separate the maternal blood from the fetal blood making it
impossible for the two circulation to mix unless any villi is damaged.

THE MATURE PLACENTA

• Originates from the trophoblastic layer of the fertilized ovum

• It preforms the functions the fetus is unable to carry out during the
intrauterine life.

• The survival of the fetus depends on its integrity and efficiency.

• Placenta is fully formed and functional by the 10 week

• Between 12-20 weeks the placenta weighs more than the fetus

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 Functions of the placenta

1. Respiration

• During intrauterine life, no pulmonary exchange of gases can take

place. The fetus obtain oxygen and excrete carbon dioxide through
the placenta.

• Oxygen from the mother`s blood passes to fetal blood through simple
diffusion, similarly the fetus give out e carbon dioxide to the mothers
blood.

• The rate of diffusion depends on

• maternal /fetal gases gradient

• Maternal fetal placental blood flow

• Placental permeability

• Placental surface area

2. Nutrition

• The fetus require nutrients for growth and development.

Amino acids –body building

Glucose-Energy and growth

Calcium and phosphorus- Bones and teeth

Iron – Blood development

These nutrients are actively transferred from the mother through the walls
of the chorionic villi.

Water, vitamins and minerals also pass to the fetus. Fats and fat soluble
vitamins (A, D and E) also cross the placenta

3. Protection

Provides a limited barrier for infection

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Few bacteria can penetrate except treponema of syphilis and tubercle
bacillus.

Alcohol, some chemicals associated with cigarette, certain viruses e, g

human cytomegalovirus and rubella are never filtered the easily cross the
placental barrier and likely to cause congenital abnormalities.

Certain drugs cross the placental barrier to the fetus which may be
harmless e.g. tertracycline, aminoglycosides, chlrophenicol, nitrofurantoin
and quinolones while certain antibiotics may be beneficial especially for
women with syphilis

Immunoglobulin G (IgG) conferring passive immunity to the baby for three

months after birth

NB. Only the antibodies that the mother has can be passed to the fetus.

4. Endocrine

Human chorionic gonadotrophin (hCG) produced by the cytotrophoblastic

layer of the chorionic villi.

• It’s at the peak levels by the 7th -10th week and it form the basis of a
pregnancy test.

• It’s excreted in the mothers urine and it stimulates the growth and
activity if the corpus luteum.

• Estrogens -the amount of Estrogen produced is an index of

fetoplacental wellbeing. Measured in serum oestriol.

• Progestrone – Made in the syncytial layer of the placenta until

immediately before the onset of labour when the levels fall. It’s
measured in urine as pregnanediol. It acts on tissues that are already
receptive to estrogen.

• Human placental lactogen(hPL) Has a role in glucose metabolism in

pregnancy.

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• As hCG falls, it rises throughout in pregnancy.

• 5. Storage

• Placenta metabolizes glucose, stores it in the form of glycogen and

reconverts it to glucose as required.

• It also stores iron and fat soluble vitamins.

6. Excretion

• Mainly its carbon dioxide and bilirubin.

Placental circulation

• Maternal blood is discharged in a pulsatile fashion into the intervillous

space by 80-100spiral arteries in the decidua basalis.

• It spurts into the chorionic plate and flows slowly around the the villi
eventually returning to the endometrial veins and the maternal
circulation.

• 150 mls of maternal blood in the intervillous spaces, which is

exchanged 3-4 times /minute.

• Fetal blood low in oxygen content is pumped towards the placenta

along the umbilical arteries and transported along the capillaries of
the chorionic villi where exchange of the nutrients takes place. Blood
is returned to the fetus via the umbilical vein

The Membranes

• Outer membrane - Chorion

• Inner membrane – Amnion

Characteristics of the chorion

• Thick and opaque

• Derived from the trophoblast

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• Continuous with the chorionic plate which forms the base of the
placenta and adheres closely to the uterine wall.

Characteristics of the Amnion

• Smooth, tough and translucent

• Derived from the inner cell mass

• It lines the chorion and the surface of the placenta continuing over to
the surface of the umbilical cord.

• It in contact with the surface of the fetus initially but 4-5 weeks after
conception amniotic fluid starts to accumulate within it.

Amniotic fluid

• Clear, alkaline and slightly yellowish liquid contained within the

amniotic sac

Origin

• Maternal vessels in the decidua

• Fetal blood vessels in the placenta

• Secreted from the amnion especially the part covering the umbilical
cord and the placenta

• From the 10th week of gestation the fetal urine adds to the volume.

• The amniotic fluid is exchanged every 3 hourly.

Composition

• 99% water

• 1% dissolved food nutrients and waste products

• Skin cells, vernix caseosa and lanugo

• Abnormal constituents- Meconium

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 Volume

It measures about 50 mL at 12 weeks, 400 mL at 20 weeks and

reaches its peak of 1000ml at 36–38 weeks. Thereafter the amount
diminishes, till at term it measures about 600–800 mL.

As the pregnancy continues post term, further reduction occurs to

the extent of about 200 mL at 43 weeks

• 1500mls -Polyhydromnious

• 300mls – Oligohydromnious

• An osmolarity of 250 mOsmol/L is suggestive of fetal maturity. The

amniotic fluid’s osmolality falls with advancing gestation

Functions of amniotic fluid

During pregnancy

1) It acts as a shock absorber, protecting the fetus from possible

extraneous injury

(2) Maintains an even temperature

(3) The fluid distends the amniotic sac and thereby allows for growth
and free movement of the fetus and prevents adhesion between the
fetal parts and amniotic sac

(4) Its nutritive value is negligible because of small amount of protein

and salt content; however, water supply to the fetus is quite
adequate.

During labor

1. Aids effacement of the cervix and the dilatation of the uterine os

especially when the presenting part is poorly applied.

The amnion and chorion are combined to form a hydrostatic wedge which
helps in dilatation of the cervix

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(2) During uterine contraction, it prevents marked interference with the
placental circulation so long as the membranes remain intact

(3) It guards against umbilical cord compression

(4) It flushes the birth canal at the end of first stage of labor and by its
aseptic and bactericidal action protects the fetus and prevents ascending
infection to the uterine cavity

The umbilical cord

• It extends from the fetal surface of the placenta to the umbilical area
of the fetus which is formed by the 5 th week of pregnancy.

• Originates from the ducts that forms between the amniotic sac and
the yolk sac and spreads the umbilical blood vessels.

FUNCTIONS

1. Transport nutrients to the developing fetus

2. Removes waste product from the fetus

Structure

• Contains two arteries and one vein

• Blood vessels are protected by wharthon`s jerry

• Covered with amnion that is continuous with the placenta

• Has no nerve nor nerve supply

Measurements

• 1-2 cm in diameter

• 40-50 cm in length short if its <40cm >50 cm is considered long

The placenta at term

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• It is round flat mass about 20 cm in diameter and 2.5 cm thick at the
center

• It weighs one-sixth of the babies weight

Characteristics of the maternal surface

1. It is dark red due to blood

2. The surface is arranged in about 18-20 cotyledons (lobes separated

by sulci (furrows)

3. Deposits of lime salt may be present making it gritty

4. Each lobe is made of lobules containing a single villi with its branches

Characteristics of the fetal surface

1. It has a shiny appearance because of the amnion covering it

2. Branches of the umbilical vein and arteries are visible

3. The amnion can be peeled off the surface of the chorion to the
umbilical cord

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Anatomical variations of the placenta and the cord

1. A succenturiate lobe

 There is a small extra lobe is present, separate from the main

placenta and joined to it by blood vessels that run through the
membrane to reach it

 The lobe may be retained in the uterus after delivery of the placenta

 It is not removed , it may cause hemorrhage and infection

 Every placenta must be examined for a hole in the membranes with

vessels running to it

2. Circumvallate placenta

 An opaque ring is seen on the fetal surface of the placenta

 It is due to doubling back of the chorion and amnion

 May result to membranes leaving the placenta near the center than at
the edge

 It is associated with prematurity, prenatal bleeding, abruption,

multiparty and early fluid loss

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 3. Bipartite placenta

There are two complete and separate parts, each with a cord leaving
from it but joins short distance from the two parts of the placenta

4. Tripartite placenta

Similar with bipartite but it has three different parts

5. Battledore insertion of the cord

 The cord is inserted at the edge of the placenta like a table tennis bat

 Not significant unless the attachment is fragile

6. velamentous insertion of the cord

 The cord is inserted into the membranes some distance from the edge
of the placenta

 Umbilical veins run through the membranes from the cord to the
placenta

 The cord is likely to detach upon applying traction during active

management of third stage of labor

 It the placenta is low lying, the vessels may pass across the uterine
os (vasa praevia)

 Rupture of membranes may lead to rapid exsanguination of the fetus

SUMMARY

The topic has covered on the development of the placenta, its functions and
the two membranes available at the placenta, the functions of amniotic fluid
and the anatomical variations of the placenta and their significance to
midwifery practice.

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