Ateneo de Naga University Collge of Nursing

CASE STUDY OF ABRUPTIO PLACENTA

Submitted by: Jovan Conde Mary Joy Luistro Glaiza Quintana Lily Tadeo Keran Toledo

Submitted to: CHRISTY MARISSA AGUILAR, RN Clinical Instructor

July 1, 2011

I.

INTRODUCTION

Placental abruption (also known as abruptio placentae) is an obstetric catastrophe (complication of pregnancy), wherein the placental lining has separated from the uterus of the mother. It is the most common cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. Many women can die from this type of abnormality. The heart rate of the fetus can be associated with the severity. Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.

II.

OBJECTIVES

General This case study aims that the students and reader will gain more knowledge and further understanding about Abruptio Placenta Specific The students should be able to: 1. Study the anatomy and physiology of female reproductive system 2. Trace the pathophysiology of Abruptio Placenta

3. Determine the diagnostic test needed for a client including their implications and nursing responsibilities 4. Identify the possible drugs to be prescribed, their actions, indications, contraindications and nursing responsibilities. 5. Formulate a possible nursing care plan based from the prioritized nursing diagnosis.

III.

Patient s Profile A. 1. Initial Name of Patient 2. Age 3. Occupation 4. Address B. 1. Admission Complaints 2. Admission Diagnosis 3. Final/Discharge Diagnosis 4. Clinical Impression

IV.

Assessment A. Observation of Patient B. Physical Examination

V.

Assessment from Chart A. Patient s Health History B. Admission Sheet C. Laboratory Results The following laboratory tests are necessary for the patient with Placenta Previa condition: 1. Urinalysis Purpose: Urinalysis will examine the patient s urines for signs of renal or urinary tract disease, to help discover diseases that are not related with renal disorders. Alterations in the following components will have some implications: a. Abnormal color: Liver problems or jaundice may occur b. Specific Gravity: To demonstrate the concentrating and diluting ability of the kidneys.

c. Sugar: Presence of sugar may indicate diabetes and chronic kidney disease d. Pus cells: May be a sign of swelling in the kidney and pelvic region, urethral ulceration and chronic inflammatory of the bladder. e. RBS: Blood in the urine may sometimes a serious urinary tract problem Nursing Responsibilities: a. Tell the patient that the test is for the detection of renal and urinary tract disorders and assessment of body function. b. Notify the patient that the procedure requires a urine sample. Urine must be acquired most likely on the first void in the morning. 2. Blood Typing Purpose: To check compatibility of the donor and patient before blood transfusion Nursing Responsibilities: 1. Inform the patient that test determines her blood group. 2. Notify the patient that the test requires blood sample thus venipuncture is done. 3. Check the patient s history for recent administration of blood , dextran or IV. 4. After the procedure apply direct pressure to the venipuncture site until bleeding stops. 5. Refer if venipuncture develops hematoma and monitor the pulse distal to the site. 3. Ultrasound Purposes: 1. To know fetal an pregnancy abnormalities and measurement of organ size and strucutre. Obtain a consent from signed by a patient. Explain that the procedure is painless and safe and no radiation is involved. 2. To identify and differentiate cyst and solid tumor. Emphasized the importance of remaining still during the scan and to prevent distorted image. 3. To ensure the presentation and identify complications of the fetus the detect if there is a risk for pregnancy. Assist the patient into a supine position; possible use of pillow to support the area to be examined.

VI.

Assessment from Textbooks A. Anatomy and Physiology

External Structures A. Visible Organs of the Vulva

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Mons pubis covered with pubic hair located over pubic bones, serves a protective function Labia major and labia minora two pairs of tissue surrounding the outer part of the vulva. Vestibule surrounded by the labia it contains the vaginal opening and urethra. Vaginal opening Clitoris erectile tissue analagous to the penis Urethral orifice Perineum the region of the genital area between the vulva and the anus. This is the location of an episiotomy if performed during birth.

B. Breasts mammary glands

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Function is to secrete milk for infant lactation. After delivery, the withdrawal of estrogen and progesterone due to the expulsion of the placenta cause prolactin to be produced, which stimulates milk formation. Oxytocin is a hormone that stimulates the release of milk.

Internal Reproductive Organs A. Located in the Pelvic Cavity

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Ovaries female gonads located on each side of the uterus. Functions include (1) Development and release of the ovum (egg) (2) Secretion of the hormones estrogen and progesterone Fallopian tubes (1) Carry the ovum from the ovary to the uterus. (2) Fimbriae sweep ovum into the tube. Uterus (1) Hollow pear-shaped organ that stretches and enlarges during pregnancy to support the fetus. (2) Other functions include menstruation and expelling of the fetus during labor. (3) Divisions of the uterus are: fundus uppermost portion; corpus the body; cervix lower third that exits into the vagina through the cervical os. Vagina (1) Curved tube leading from the uterus to the vestibule. (2) Functions as a passageway for menstrual flow, organ of copulation, and birth canal.

Pelvis A. Bones support and protect pelvic contents

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Sacrum wedge-shaped bone formed by the fusion of five vertebrae Coccyx small triangular bone at bottom of the vertebral column. Innominate bones (1) Ilium upper prominence of the hip (2) Ischium L-shaped bone below the ischium. Distance between the

ischial spines is the shortest diameter of the pelvic cavity. (3) Pubis slightly bowed front portion of the innominate bone. The pubis meet at the front of the pelvis to make up the joint called the symphysis pubis. Below the symphysis is a triangular space called the pubic arch, under which the fetal head passes during birth. B. Pelvic floor muscular floor of bony pelvis, supports pelvic contents
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Levator ani major portion, made up of four muscles (1) Ileococcygeus (2) Puboccygeus (3) Puborectalis (4) Pubovaginalis Coccygeal muscle underlies sacrospinous ligament a thin muscular sheet which helps the levator ani support the pelvic contents

C. Pelvic shapes vaginal birth is never ruled out because of pelvic type without a trial of labor.
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Android narrow, heart shaped, similar to shape of male pelvis not favorable for vaginal birth Anthropoid widest from front to back usually adequate for vaginal birth Platypelloid widest from side to side not favorable for vaginal birth Gynecoid classic female pelvis approximately 50 percent of women and it s the best for vaginal birth

Functions of the Female Reproductive System 1.External Genitalia The mons pubic protects the pubic bone from trauma. The clitoris provides for sexual arousal and orgasm. The labia majora and minora protect the external genitalia, urethra, and distal vagina. Secretions from Bartholin s glands lubricate the external vulva during coitus and improve sperm survival. Secretions from Skene s glands lubricate the external genitalia during coitus. The urethral meatus is the external opening of the female urethra. The perineal muscle expands during childbirth to enlarge the vagina, allowing for passage of the fetal head. 2.Internal genitalia The vagina aids in conception by conveying sperm to the cervix and helps in childbirth by serving as a passageway for the fetus. The uterus receives the fertilized egg, provides for implantation, nourishes and

protects the growing fetus, and contacts to expel the fetus during childbirth. The ovaries produce and release mature ova and regulate the menstrual cycle through the production of estrogen and progesterone. The fallopian tubes move the sperm toward the ova and the ova toward the uterus, thereby aiding in fertilization. 3.The pelvis supports and protects the reproductive and other pelvic organs. During the late months of pregnancy, the false pelvis supports the uterus and helps direct the fetus into the true pelvis for birth. 4.The breasts serve to produce and secrete (Lactate) milk for the infant. B. Pathophysiology
Trauma/hypertension/coagulopathy

Bleeding into the decidua basalis/hematoma

Separation of the placenta from the uterine wall (compression, blood supply to the fetus is

Overt/External vaginal bleeding or pooling of blood behind the placenta (concealed/internal abruption placenta)

Mother may experience abdominal/back pain, abnormal or premature contractions

Fetal distress/death

Classification of abruptions according to severity:

   

Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

C. DESCRIPTION OF THE DISEASE Abruptio placenta is premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage. Two types of abruption placentae: Concealed hemorrhage - the placenta separation centrally, and a large amount of blood is accumulated under the placenta. External hemorrhage the separation is along the placental margin, and blood flows under the membranes and through cervix. Risk Factors: 1. 2. 3. 4. 5. 6. 7. 8. 9. Uterine anomalies Multiparity Preeclampsia Previous cesarean delivery Renal or vascular disease Trauma to the abdomen Previous third semester bleeding Abnormally large placenta Short umbilical cord

Common Clinical Manifestations: 1. 2. 3. 4. 5. 6. Intense, localized uterine pain, with or without vaginal bleeding Concealed or external dark red bleeding Uterus firm to boardlike, with severe continuous pain Uterine contractions Uterine outline possibly enlarged or changing shape FHR present or absent

7. Fetal presenting part may be engaged Nursing Management: 1. Continuous evaluate maternal and fetal physiologic status, particularly: o Vital Signs o Bleeding o Electronic fetal and maternal monitoring tracings o Signs of shock rapid pulse, cold and moist skin, decrease in blood pressure o Decreasing urine output o Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity. 2. Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated. 3. Provide appropriate management. o On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava. o Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level. o Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask. o Prepare for cesarean section, which is the method of choice for the birth 4. Provide client and family teaching. 5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the separation, amount of fetal hypoxia and amount of bleeding. NURSING CARE PLAN

Assessment

Diagnosis Ineffective Tissue Perfusion related to Excessive blood loss secondary to premature placental separation

Planning Goal: Client will maintain adequate tissue perfusion by (date/time). Outcome: 1. Client will maintain BP and pulse (specify: BP >100/60

Intervention y Assess patients condition especially the SaO2, BP, PR and RR. y Monitor for restlessness, anxiety, air hunger and changes in LOC.

Rationale y Assessment provides baseline information about clients present condition. y S/Sx of the said condition provides information

Evaluation Patients blood pressure was maintained(100/60) Patients pulse was at least 60 beats per minute.

and pulse between 60-90 beats per minute), warm skin and dry. 2. Urine output not less than 30cc/hour. 3. Client will remain alert and oriented, FHR pattern remains reassuring.

y Monitor accurately input and output. Evaluate also blood loss by weighing pads. y Continuously monitor FHR pattern compare to baseline data from prenatal record. Inform other health care team for any signs of non reassuring changes. y Assess for uterine irritability, abdominal pain, rigidity and increase abdominal girth.

y Assess clients skin color, temperature, moisture, turgor and capillary refill.

of developing indications of inadequate cerebral tissue perfusion. y Monitoring provides data about renal perfusion and function and the extent of blood loss. y The fetus may initially respond reassuring to decrease placental perfusion by raising the FHR above the normal baseline. Non reassuring FHR is an indication for delivery. y Assessment gives information about the severity of placental abruption. Bleeding may be occult causing abdominal rigidity and pain.

y Initiate IV access with gauge 18 catheter and provide fluids, blood products, or blood as ordered. y Monitor laboratory results (Hgb, Hct, Clotting studies).

y Observe client for signs of spontaneous bleeding.

y Keep client and significant others informed of the condition and plan of care.

y Assessment provides information about peripheral tissue perfusion. Hypovolem ia results in shunting of blood away from peripheral circulation to the brain and vital organs. y Intervention provides venous access to replace fluids.

y Laboratory studies provide information on extent of blood loss y Notify and signs of caregivers and impeding prepare for DIC. immediate y This delivery and provides neonatal information resuscitation about the for maternal depletion of and fetal. clotting factors and developmen t of DIC. y Information of the condition of the client will promote

understandi ng and cooperation. y Continued blood loss or developmen t of DIC may lead to maternal or fetal injury or death.

DRUG STUDY DRUG NAME ACTION INDICATION SIDE EFFECTS and ADVERSE EFFECTS Nausea; vomiting; more intense or abrupt contractions of the uterus. NURSING CONSIDERATIONS & RESPONSIBILITIES

Generic Name: Oxytocin

Inducing labor in women with Rh problems, diabetes, preeclampsia, or when it is in the best interest of the mother or fetus. It is also used to help abort the fetus in cases of incomplete abortion or miscarriage, produce contractions during the third stage of labor, and control bleeding after childbirth.

Oxytocin is a uterine stimulant. It works by causing uterine contractions by changing calcium concentrations in the uterine muscle cells.

Do NOT use Oxytocin if:

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you are allergic to any ingredient in Oxytocin your birth canal is too small compared with the fetus's head the fetus is in a difficult position within the womb or is in distress and delivery is not progressing you have other complications that require medical intervention for birth you have bacteria in the blood

VII. DISCHARGE PLANNING Medication Emphasized the importance of medication compliance. Exercise Needs to adequate her time with her child to be certain he or she is all right, and nurse c an states hearing fetal heart beat helps to reassure her about baby s health. Attach contraction and fetal heart rate monitoring for continuous evaluation of contractions of fetal response. Treatment Used of drugs Catheterization Health Teaching Maintain a bed rest Maintain a 8 glasses of water Ongoing Assessment Assess client s home surrounding to determine whether they are appropriate for bed rest and continuing monitoring at home. Administer oral dose and home monitoring requires professional supervision. Diet She might to begin to neglect her diet or her supplementary vitamins because It doesn t matter anymore . Spiritual Assess anxiety level of client over preterm labor possible feelings. Determine whether client wants a support person to be wit her, to the presence of a support person can offer additional comfort to a client. References:
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Maternal & Child Nursing Seventh Edition Vol.1 Maternity nursing, Lowdermilk Perry, seventh edition. Maternal Neonatal Nursing Lippincott manual of Nursing Practice