Placental Probs

<<Placenta Previa & Placenta Abruption>>

Objectives
➔  Define the Normal; Abruptio;
Previa placentas
➔  Be able to identify and
differentiate between each.
➔  Be able to identify the nursing
considerations for all.
 What's the norm??
○  Structure that provides oxygen and nutrients

to the fetus

○  Removes waste products from your baby's blood

○  Most commonly attaches to top or side of uterus

○  Detachment happens during 3rd stage of labor

Placental Previa
Placenta Previa

Definition: placenta is improperly implanted in the lower uterine segment near or over the internal
cervical os. As the cervix softens, the placental sinuses are opened and may cause hemorrhages. It’s
painless and bright red vaginal bleeding may occur in the last half of pregnancy. There are three
classifications of placenta previa: low(Marginal), partial, and complete.
Placenta Previa

Causes: The exact cause of placenta previa is unknown. The

incident is higher with multiple gestation, history of uterine
surgery, and multiparity.
Placenta Previa complications:
Mother
●  Bleeding- which can then increase risk for premature rupture of
membranes>> premature labor
Baby
●  Reduction in fetal growth
PREVIA
diagnosis
-  Risk for actual deficient fluid volume
-  Risk for injury to both the mother and baby
-  Fear
-  Deficient knowledge

Assessment
-  Random painless vaginal bleeding after 20th week
-  Ultrasound identification of placental location
-  CBC to assess baseline anemia status
-  Assess fetal maturity for steroid treatment to help lungs develop
(betamethasone)
-  Continuous fetal monitoring
Placental Previa - Tx

GOAL: Identify the cause of bleeding and to ensure a birth of a mature newborn

Cause of bleeding: Determine if it is Placenta Previa or Advanced labor with bloody show (normal)
-  Tests: Transabdominal Ultrasound Scan or Abdominal/Transvaginal Sonography → identify if placental Previa
-  Direct Diagnosis: Feeling the placenta inside the cervical os → cause profuse bleeding

Pregnancy <37 weeks → delay birth until >37 weeks for fetus to mature
-  Bed Rest with Bathroom Privileges
-  NO vaginal examinations
-  Monitor Blood loss, Pain and Uterine contractility (have blood handy for transfusion)
-  FHR with External monitor and Mother’s VS
-  IV fluid (Lactated Ringers) and Betamethasone (fetal lung maturity)
-  Labs: Hgb; Hct; Rh factor; Urinalysis
If profuse bleeding persists or fetal well being is threatened → Cesarean birth performed ASAP
Placenta Previa: Nursing Considerations
NO VAGINAL EXAMS!
Bedrest
Monitor vitals
Assess blood loss
Monitor hemoglobin and hematocrit levels
Monitor fetal well-being
Maintain IV access for fluid administration when ordered
Provide emotional support
Promote adequate nutrition
Provide pre- and postoperative teaching and care
Placental Abruptio
Placenta Abruptio

Definition: premature separation of placenta from the uterine wall after the 20th week of gestation and
before the fetus is delivered. It’s painful and has dark red vaginal bleeding. Absence of visible blood if
bleeding is high in uterus or minimal. There are three classifications of abruptio placenta: marginal,
central, and complete.
Placenta Abruptio

Causes: Most common causes are maternal hypertension,

cocaine abuse, and abdominal trauma.
Abruptio- complications
For mother:
●  Excessive blood loss which may result in shock
●  Kidney or other organ failure
●  Blood clotting problems- due to disseminated intravascular coagulation
Baby
➔  Deprivation of oxygen and nutrients
➔  Premature or still birth

>>Bleeding from the site of the placental attachment is common and it can be
controlled. If bleeding can’t be controlled then hysterectomy may be
necessary.
ABRUPTIO
Diagnosis
-  Deficient fluid volume
-  Risk for injury to both mother and baby
-  Risk for impaired gas exchange
-  Deficient knowledge
Assessment
-  painful , rigid, boardlike abdomen with vaginal bleeding
-  Abdomen may increase in size due to continuous bleeding
-  Severe pain from bleeding
-  Uterus is irritable and shows consistent late decelerations
-  Uterus becomes bluish-purple
-  Outcome depends on degree of placental separation
-  Continuous fetal monitoring
-  Assess whether or not you can treat with betamethasone
Placental Abruptio - Tx

***Want an IV access and a Continuous electronic fetal monitoring (EFM)***

GOAL for Mother - Maintaining cardiovascular status
-  Hypovolemia from severe abruptio placentae = Life Threatening → Need to give Whole Blood and CVP to monitor fluid
- Tx to decrease risk of DIC (disseminated intravascular coagulation)
-  Typing and crossmatching for blood transfusions
-  Clotting mechanism evaluation
-  IV fluids
GOAL of Baby - Developing a plan for achieving the birth of the fetus
-  Birth method - depends on condition of mother and fetus
-  Vaginally:
-  Separation mild and gestation is close to term
-  Cesarean:
-  ROM and Oxytocin infusion do not initiate labor in a short time Longer delay → increase of hemorrhage
-  Severe hemorrhage - allowing an immediate hysterectomy to save both mom and fetus
-  Fetus alive but experiencing stress
-  Stillborn.
Abruptio Placenta: Nursing Considerations
Monitor mother’s vitals
Monitor fetus for signs of distress
Assess client for bleeding, uterine activity or abdominal pain
Measure mother’s abdominal girth at umbilicus for baseline and to evaluate occult bleeding
Review labs to estimate blood loss
Monitor client for signs of coagulation defects
Start and maintain IV fluids and monitor Is & Os
Provide oxygen as ordered
Monitor mother and fetus if vaginal delivery is attempted
Provide ongoing information and emotional support
QUIZ!
What are the two main functions of the
placenta??
A.  Provides thermoregulation & nutrients

B.  Provides oxygen and nutrients & removes waste products

from baby’s blood.

C.  It doesn’t do jack squat

D.  Helps to cushion the baby & gives the baby antibodies to
prevent infection
B- is correct!
The main functions like mentioned in the first slide are to remove waste products
from the baby’s blood and provide oxygen and nutrients to the baby. The amniotic
fluid helps to cushion the baby and contains antibodies to help prevent infection.
It also helps with thermoregulation.
What’s the best goal for a patient with Placenta
Previa that is less than <37 weeks?
A.  Deliver the baby ASAP vaginally.

B.  Deliver the baby ASAP through cesarean birth.

C.  Implement strategies to delay birth until patient is <37 weeks.

D.  Give them a candy bar to help the pain.

C - Is CORRECT!!!
Delay birth until >37 weeks for fetus to mature
-  Bed Rest with Bathroom Privileges
-  NO vaginal examinations
-  Monitor Blood loss, Pain and Uterine contractility (have blood handy for transfusion)
-  FHR with External monitor and Mother’s VS
-  IV fluid - Betamethasone to help fetal lung maturity

If profuse bleeding persists or fetal well being is threatened → Cesarean birth performed
The maternity nurse is preparing for the admission of
a client in the third trimester of pregnancy who is
experiencing vaginal bleeding and has a suspected
diagnosis of placenta previa. The nurse reviews the
health care provider’s prescriptions and should
question which prescription?
A. Prepare the patient for ultrasound.

B. Obtain equipment for a manual pelvic exam.

C. Prepare to draw a hemoglobin and hematocrit blood sample.

B- Is CORRECT!
Manual pelvic examinations are contraindicated when vaginal bleeding is apparent
until a diagnosis is made and placenta previa is ruled out. Manual exams can lead
to hemorrhage.

-  A diagnosis of placenta previa is made by ultrasound.

-  The hemoglobin and hematocrit levels are monitored.

-  Electronic fetal monitoring (external) is crucial in evaluating the status of the

fetus, who is at risk for severe hypoxia.
An ultrasound is performed on a client at term
gestation who is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate that
abruptio placenta is present. On the basis of these
findings, the nurse should prepare the client for
which anticipated prescription?
A. Delivery of the fetus.

B. Strict monitoring of intake and output.

C. Complete bed rest for the remainder of the pregnancy.

D. The need for weekly monitoring of coagulation studies until the time of
A - Is CORRECT!
The goal of abruptio placentae is to control the hemorrhage and deliver the fetus
as soon as possible. Delivery is treatment of choice if the fetus is at term gestation
or if the bleeding is moderate to severe and the client or fetus is in jeopardy.
The nurse in the postpartum unit is caring for a
patient who has just delivered a newborn infant
following a pregnancy with placenta previa. The
nurse reviews the plan of care and prepares to
monitor the client for which risk associated with
placenta previa?
A. Infection

B. Hemorrhage

C. Chronic Hypertension

D. Disseminated intravascular coagulation

B- Is CORRECT!
In placenta previa, the placenta is implanted in the lower uterine segment. The
lower uterine segment does not contain the same intertwining musculature as the
fundus of the uterus, and this site is more prone to bleeding.
The nurse is performing as assessment on a client
diagnosed with placenta previa. Which assessment
findings should the nurse expect to note? Select all
that apply.
1. Uterine rigidity

2. Uterine tenderness

3. Severe abdominal pain

4. Bright red vaginal bleeding

5. Soft, relaxed, nontender uterus

4,5, & 6- Are CORRECT!
Painless, bright red vaginal bleeding in the second or third trimester of pregnancy
is a sign of placenta previa. The patient has a soft, relaxed, nontender uterus, and
fundal height may be more than expected for gestational age.

In abruptio placentae, severe abdominal pain and tenderness is present. The

abdomen also feels hard and boardlike on palpation as the blood penetrates the
myometrium and causes uterine irritability.
A woman who's 36 week pregnant comes into L&D
with mild contractions. Which of the following
complications should the nurse watch for when the
client informs her that she has placenta previa?
A. sudden ROM
B. Vaginal bleeding
C. emesis
D. Fever
B- Is CORRECT!
Contractions may disrupt the microvascular network
in the placenta of the client with placenta previa and
result in bleeding.