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. 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.
5.
6.
7. 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
8. 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.
10. 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.
11. 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
12. 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
13. 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
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
19. 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
20. 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.
21.
22.
23. 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.
24. Placental Abruption
• Possible Symptoms
1. Sudden intense stomach pain
2. Premature contractions
3. May see bleeding or may not see bleeding
27. 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.
28. 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
29. 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.
31. 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
32. 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.
33. 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
34. 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.
35. 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.
36. 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.
37. 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.
38. 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
