Placenta Previa

Occurs when the placenta implants in the lower uterine segment where

it encroaches on the internal cervical os - Low implantation the placenta implants in the lower uterine segment

- Partial placenta previa the placenta partially occludes the cervical os

- Total placenta previa the placenta totally occludes the cervical os One of the most common causes of bleeding during the second half of pregnancy

Increased parity (80% of affected clients are multiparous) Advanced maternal age (older than 35 years old in 33% of cases)

Past caesarean births

Past uterine curettage Multiple gestation

Prior placenta previa (incidence is 12 times greater in women with previous

placenta previa) Male fetus

Exact cause is unknown; may be linked to uterine fibroid tumors or

uterine scars from surgery

 Factors that may affect the site of the placentas attachment to the uterine wall include: - Defective vascularization of the deciduas

- Multiple gestations (the placenta requires a larger surface for

attachment) - Previous uterine surgery

- Multiparity
- Advanced maternal age The lower uterine segment of the uterus fails to provide as much nourishment as the fundus

 Placenta tends to spread out, seeking the blood supply it needs, becoming larger and thinner than normal

Placental villi are torn from the uterine wall as the lower uterine
segment contracts and dilates in the third trimester As the internal cervical os effaces and dilates, uterine vessels are torn Uterine sinuses are exposed at the placental site and bleeding occurs

Assessment Findings:
Painless, bright red vaginal bleeding is most common after the 20th week of

gestation, especially during the third trimester Initially, scant bleeding is noted, beginning before the onset of labor - Typically episodic, starting without warning and stopping spontaneously - Bleeding increases with each successive incident Palpation may reveal a soft, nontender uterus Abdominal examination using Leopolds maneuver reveals various malpresentations due to interference with the descent of the fetal head caused by the placentas abnormal location - Minimal descent of the fetal presenting part may indicate placenta previa - The fetus remains active, however, with good heart tones audible on auscultation

Diagnostic test findings:

Pelvic examination under a double setup (presentations for an emergency caesarean delivery) because of the likelihood of hemorrhage to confirm the diagnosis

- Performed only immediately before delivery

- In most cases, only the cervix is visualized Laboratory studies may reveal decreased maternal hemoglobin levels (due

to blood loss)
Transvaginal ultrasound scanning is used to determine placental position Radiologic tests, such as femoral arteriography, retrograde catheterization,

or radioisotope scanning or localization, may be done to locate the placenta

- These tests have limited value and are risky - Theyre usually performed only when ultrasound is unavailable

NURSING:

Dependent on when the first episode occurred and the amount of bleeding Limitation of maternal activities Monitoring of all relevant vital signs
MEDICAL:

Rectal or vaginal examinations, which could stimulate uterine activity, shouldnt be performed unless equipment is available for vaginal and caesarean delivery; the placenta can be located via ultrasound Vaginal delivery is considered only when the bleeding is minimal and the

placenta previa is marginal or when the labor is rapid

SURGICAL:

Immediate caesarean delivery performed as soon as the fetus is

sufficiently mature or in the case of intervening severe hemorrhage

PSYCHOLOGIC: Emotional support PHARMACOLOGIC: Betamethasone, a steroid that hastens fetal lung maturity, may be

prescribed for the mother to encourage the maturity of fetal lungs if the fetus is less than 34 weeks gestation.

 Teach the patient to immediately identify and report signs and

symptoms of placenta previa (bleeding, cramping) If the patient with placenta previa shows active bleeding, continuously monitor her blood pressure, pulse rate, respiration, central venous pressure, intake and output, and amount of vaginal bleeding, as well as the fetal heart rate and rhythm

Anticipate the need for electronic fetal monitoring and assist with
application as indicated Have oxygen readily available for use should fetal distress occur,

evidenced by bradycardia, tachycardia, or late or variable decelerations

 If the patient is Rh-negative, administer Rho(D) immune globulin (RhoGAM)

after every bleeding episode

Institute complete bed rest Prepare the patient and her family for a possible caesarean delivery and the birth of a preterm neonate, thoroughly explaining postpartum care so the patient and her family know what measures to expect If the fetus isnt mature, expect to administer an initial dose of betamethasone (Celestone Soluspan) to aid in promoting fetal lung maturity; explain that additional doses may be given again in 24 hours, and possibly in 1 to 2 weeks Provide emotional support during labor - Because of the neonates prematurity, the patient may not be given an analgesic and labor pain may be intense - Reassure her of her progress throughout labor - Keep her informed of the fetuss condition

 Anticipate the need for a referral for home care once the patients bleeding ceases and she has to return home on bed rest During the postpartum period, monitor the patient for signs of hemorrhage and shock caused by the uteruss diminished ability to contract

Tactfully discuss the possibility of neonatal death

- Tell the mother that the neonates survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive

disorders
- Assure her that frequent monitoring and prompt management greatly reduce the risk of death Encourage the patient and her family to verbalize their feelings, help them to develop effective coping strategies, and refer them for counselling, if necessary