6.hemorrhagic disorder(late term)


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6.hemorrhagic disorder(late term)

  1. 1. Complication of pregnancy Hemorrhagic disorder Late term
  2. 2. PLACENTA PREVIA • Placenta previa is the development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os.
  3. 3. Placental Abnormalities Placenta previa • Complete – Placenta completely covers the cervical opening after 27 weeks of pregnancy • Marginal – Placenta is within 2 to 3 cm of the cervical opening after 27 weeks of pregnancy
  4. 4. Pathophysiology/Etiology 1. The cause is unknown. 2. One possible theory states that the embryo will implant in the lower uterine segment if the decidua in the uterine fundus is not favorable. 3. About 80% of placenta previa episodes occur in multiparas. 4. Seen more often with history of abortion, cesarean section, uterine scarring
  5. 5. Clinical Manifestations 1. Characteristic sign is painless vaginal bleeding, which usually appears near the end of the second trimester or later. 2. Bleeding from placenta previa may not occur until cervical dilation occurs and the placenta is loosened from the uterus. 3. With a complete placenta previa the bleeding will occur earlier in the pregnancy and be more profuse.
  6. 6. Diagnostic Evaluation 1. Ultrasound is the method of choice to show location of the placenta.
  7. 7. Management 1. Bed rest and hospitalization until delivery are usual. 2. IV access and at least 2 units of blood should be available at all times. 3. Continuous maternal and fetal monitoring 4. Amniocentesis may be done to determine fetal lung maturity for possible delivery. 5. Cesarean section is often indicated and may be performed immediately depending on the degree of placenta previa. 6. Vaginal delivery may sometimes be attempted in a marginal previa without active bleeding. 7. A pediatric specialty team may be needed at delivery due to prematurity and other neonatal complications.
  8. 8. Complications 1. Immediate hemorrhage, with possible shock and maternal death 2. Fetal mortality resulting from hypoxia in utero and prematurity 3. Postpartum hemorrhage resulting from decreased contractility of uterine muscle
  9. 9. Nursing Assessment 1. Determine the amount and type of bleeding; also, review any history of bleeding throughout this pregnancy. 2. Inquire as to the presence or absence of pain in association with the bleeding. 3. Record maternal and fetal vital signs. 4. Palpate for the presence of uterine contractions. 5. Evaluate laboratory data on hemoglobin and hematocrit status. 6. Never perform a vaginal examination on anyone who is bleeding. This may puncture the placenta
  10. 10. Nursing Diagnoses A. Altered Tissue Perfusion, Placental, related to excessive bleeding B. Fluid Volume Deficit related to excessive bleeding C. Risk for Infection related to excessive blood loss and open vessels near cervix D. Anxiety related to excessive bleeding, procedures, and possible maternal-fetal complications
  11. 11. Nursing Interventions A. Promoting Tissue Perfusion 1. Frequently monitor mother and fetus. 2. Administer IV fluids, as prescribed 3. Position on side to promote placental perfusion. 4. Administer oxygen by face mask, as indicated.
  12. 12. B. Maintaining Fluid Volume 1. Establish and maintain a large-bore IV line, as prescribed, and draw blood for type and screen for blood replacement. 2. Position in a sitting position to allow the weight of fetus to compress the placenta and decrease bleeding. 3. Maintain strict bed rest during any bleeding episode. 4. If bleeding is profuse and delivery cannot be delayed, prepare the woman physically and emotionally for a cesarean delivery.
  13. 13. C. Preventing Infection 1. Use aseptic technique when providing care. 2. Evaluate temperature every 4 hours unless elevated; then, evaluate every 2 hours. 3. Evaluate white blood cell (WBC) and differential count. 4. Teach perineal care and handwashing. 5. Assess odor of all vaginal bleeding or lochia. 6. Instruct on perineal care and handwashing techniques.
  14. 14. D. Decreasing Anxiety 1. Explain all treatments and procedures and answer all related questions. 2. Encourage verbalization of feelings by patient and family. 3. Provide information on a cesarean delivery and prepare patient emotionally. 4. Discuss the effects of long-term hospitalization or prolonged bed rest.
  15. 15. Patient Education/Health Maintenance 1. Educate the woman and her family about the etiology and treatment of placenta previa. 2. Educate the woman to inform medical personnel about her diagnosis and not to have vaginal examinations. 3. Educate the woman who is discharged from the hospital with a placenta previa to avoid intercourse or anything per vagina, to limit physical activity, to have an accessible person in the event of an emergency, and to go to the hospital immediately for repeat bleeding.
  16. 16. Evaluation A. Fetal condition stable B. Absence of shock, stable vital signs, absence of bleeding C. Does not develop any symptoms of an infection D. Verbalizes concerns and understanding of procedures and treatments
  17. 17. ABRUPTIO PLACENTAE • Abruptio placentae is premature separation of the normally implanted placenta. • There are two types of abruptio palcentae: concealed hemorrhage and external hemorrhare. • With a concealed hemorrhage the placenta separates centrally, and a large amount of blood is accumulated under the placenta. • When an external hemorrhage is present, the separation is along the placental margin, and blood flows under the membranes and through the cervix.
  18. 18. Placental Abruption • Usually occurs after the 20th week of pregnancy • About 15% of all newborn deaths is due to abruption: 50% of these deaths is because of premature delivery.
  19. 19. Placental Abruption • Possible Symptoms 1. Sudden intense stomach pain 2. Premature contractions 3. May see bleeding or may not see bleeding
  20. 20. Placental Abnormalities Placenta accreta, increta, percreta: Rare conditions where the placenta grows into the wall of the uterus or surrounding organs.
  21. 21. Pathophysiology/Etiology 1. Etiology is unknown. 2. Women at risk for developing abruptio placentae include those with history of hypertension or previous abruptio placentae, or those who have rapid decompression of the uterine cavity, short umbilical cord, or presence of a uterine anomaly or tumor. 3. Additional risk occurs in existing pregnancies complicated by trauma, hypertension, alcohol, cigarette smoking, and cocaine abuse. 4. Hemorrhage occurs into the decidua basalis. 5. The decidua basalis then forms a hematoma. 6. This hematoma can expand as the bleeding increases, causing the hematoma to increase in size and further detach the placenta from the uterine wall.
  22. 22. Clinical Manifestations 1. Concealed hemorrhage—results in a change in maternal vital signs, but no visible signs of hemorrhage are present. 2. External hemorrhage—hemorrhage is evident along with a change in maternal vital signs. 3. Fetal heart rate may change, depending on the degree of hemorrhage. 4. Abdominal pain is often present. concealed hemorrhage>external hemorrhage
  23. 23. Diagnostic Evaluation 1. Based on signs and symptoms, including vaginal bleeding, abdominal pain, uterine contractions, uterine tenderness, fetal distress. Not all may be seen in every case. 2. Ultrasound is done but is not always sensitive enough to rule out the diagnosis.
  24. 24. Complications 1. Maternal shock 2. DIC(disseminated intravenous coagulation) 3. Amniotic fluid embolism 4. Postpartum hemorrhage 5. Prematurity 6. Maternal/fetal death
  25. 25. Management 1. Hospitalization, bed rest, and continuous fetal monitoring 2. Management of hemorrhagic shock 3. Severe abruptions and fetal distress necessitate immediate delivery by cesarean section. 4. If the woman's status is stable, and there is no fetal distress, then a vaginal delivery may be considered. 5. A pediatric specialty team may be necessary at delivery due to prematurity and neonatal complications
  26. 26. Nursing Assessment 1. Determine the amount and type of bleeding and the presence or absence of pain. 2. Monitor maternal and fetal vital signs. 3. Palpate the abdomen. a. Note the presence of contractions and relaxation between contractions (if contractions are present). b. If contractions are not present, assess the abdomen for firmness. 4. Measure and record fundal height to evaluate the presence of concealed bleeding.
  27. 27. Nursing Diagnoses A. Altered Tissue Perfusion, Placental, related to excessive bleeding B. Fluid Volume Deficit related to excessive bleeding C. Fear related to excessive bleeding, procedures, and unknown outcome
  28. 28. Nursing Interventions A. Maintaining Tissue Perfusion 1. Evaluate amount of bleeding by weighing all pads. Monitor CBC results and vital signs. 2. Position in the left lateral position, with the head elevated to enhance placental perfusion. 3. Administer oxygen through a face mask. 4. Evaluate fetal status with continuous external fetal monitoring. 5. Encourage relaxation techniques.
  29. 29. B. Maintaining Fluid Volume 1. Establish and maintain large-bore IV line for fluids and blood products as prescribed. 2. Evaluate coagulation studies. 3. Monitor maternal vital signs and contractions. 4. Monitor vaginal bleeding and evaluate fundal height to detect an increase in bleeding.
  30. 30. C. Decreasing Fear 1. Inform the woman and her family about the status of both herself and the fetus. 2. Explain all procedures in advance when possible or as they are performed. 3. Answer questions in a calm manner, using simple terms. 4. Encourage the presence of a support person.
  31. 31. Patient Education/Health Maintenance 1. Provide information to the woman and her family regarding etiology and treatment for abruptio placentae. 2. Encourage involvement from the neonatal team regarding education related to fetal/neonatal outcome.
  32. 32. Evaluation A. Fetal heart rate within normal range, without a loss of variability B. Absence of shock, demonstrated by stable maternal vital signs C. Demonstrates concern; asks questions
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