A pathologist's perspective on placentas: About 1991 there was a lot of 
pressure to start examining placentas from high-risk births, purely to avert 
litigation by demonstrating that the baby was bad before the mother got to the 
hospital. Rules were quickly published about which placentas ought to be examined, 
and nothing has changed very much in the last twelve years.

Roughly a third of placentas (from 15% to 50% depending on the service) need 
examination. No authority seems to think that every placenta needs to be 
examined; in particular, cesarean section is not by itself an indication for 
placental examination. The obstetrical service must order the examination. 

All placentas must be held for a week before they are discarded, since some 
indications for examination do not become apparent until after the day of 
delivery. They do not need to be held in formalin if they can be refrigerated 
PROMPTLY after delivery - meaning that a separate refrigerator is needed in the 
delivery suite. I don't like to see large amounts of formalin handled in a 
delivery suite, since major spills seem to be alarmingly frequent.

Gross examination is critical, and should not be delegated to an untrained 
assistant. I've examined hundreds of placentas, and I am still uneasy about my 
grossing skills. A minimum of five blocks must be taken (membrane roll, cord 
sections, fetal surface, margin, and maternal surface). The person doing the 
gross examination needs to know whether delivery was vaginal or cesarean, and it 
is often helpful to know the indication for examination. The membrane roll in 
particular needs to be done right. The gross desk needs to be better lighted 
and more easily cleaned than is usually the case.

Paperwork needs to be made to work. A special form (separate from the 
ordinary surgical pathology form) needs to be filled out, and obstetrical nurses need 
to be taught how to fill the form out. The report must be sent both to the 
obstetrician and to the pediatrician (the placenta belongs to the baby, after 
all).

The CPT code is 88307, which in the case of twin placentas may be charged 
twice IF the cords are identified with their respective babies. It's one thing to 
bill and another to get paid. In most states about 80% of births are on 
Medicaid or its equivalent, and a payment of about US$45 is to be expected. I don't 
think anybody makes money on placentas, simply because they are so 
time-consuming both for the pathologist and the histotechnology - to say nothing of the 
mess.

The malpractice insurance companies say that placental examination definitely 
averts or wins litigation, and saves large amounts of money. Unfortunately 
it's the insurance companies that see the savings, not the hospitals or the 
pathology services.

I don't think there are any particular problems for the histotechnologist. 
Placental blocks fix rapidly (the cord may be an exception), and even cramming 
the cassette doesn't seem to matter much (though I avoid it). I always wash the 
cassettes briefly in a separate container of formalin, to avoid soiling the 
fixative in the holding pan or the processor.

The infuriating thing about placental examination is that it benefits neither 
the mother or the baby - it's done to benefit the #$&*@ing lawyers.

Bob Richmond
Samurai Pathologist
Knoxville TN