Placenta Previa

PLACENTA PREVIA Definition: • •

Is an abnormal low implantation of the placenta in proximity to the internal cervical os. Placenta previa is a condition in which the placenta attaches to the uterine wall in the lower portion of the uterus and covers all or part of the cervix.

Classification of Placenta Previa 1. 2. 3.

Total Previa- the placenta completely covers the internal cervical os. Partial Previa- the placenta covers a part of the internal cervical os. Marginal Previa- the edge of the placenta lies at the margin of the internal cervical os and may be exposed during dilatation.

4.

Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to the internal os of the cervix.

Risk factors 1. 2. 3. 4. 5.

Advanced maternal age multiparity previous uterine surgery large placenta (multiple gestation, erythroblastosis) maternal smoking

True placenta previa at term is very serious. Complications for the baby include:

• • •

Problems for the baby, secondary to acute blood loss Intrauterine growth retardation due to poor placental perfusion Increased incidence of congenital anomalies

Signs and Symptoms Signs and symptoms of placenta previa vary, but the most common symptom is painless bleeding during the third trimester. Other reasons to suspect placenta previa would be:

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Premature contractions

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Baby is breech, or in transverse position

•

Uterus measures larger than it should according to gestational age

Management: 1. 2. 3.

may be given drugs that can prevent premature labor or birth example is progesterone. Ultrasound exams to determine migration of an early diagnosed previa or classification of the previa as total, partial, marginal, or low-lying. With a small first bleed, client may sent home on bed rest if she can return to hospital quickly.

4. 5. 6. 7. 8.

If bleeding is more profuse client is hospitalized on bed rest with BRP, IV access; labs: Hgb and Hct, urinalysis, blood group and type and cross match for 2 units of blood hold, possible transfusions; goal is to maintain the pregnancy fetal maturity. No vaginal exams are performed except under special conditions requiring a double set-up for immediate cesarean birth should hemorrhage result. Low lying or marginal previas may allowed to deliver vaginally if the fetal head acts as tamponade to prevent hemorrhage. Cesarean birth, often with vertical uterine incision, is used for total placenta previa. Steroid shots may be given to help mature the baby's lungs.

Anatomy and Physiology

Normal Placenta During Childbirth Process of placental growth and uterine wall changes during pregnancy 1. 2. 3.

The placenta grows with the placental site during pregnancy. During pregnancy and early labor the area of the placental site probably changes little, even during uterine contractions. The semirigid, noncontractile placenta cannot alter its surface area.

Anatomy of the uterine/placental compartment at the time of birth 1.

3.

The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area. The placental site is usually located on either the anterior or the posterior uterine wall.

4.

The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located

2.

Possible Nursing Diagnosis      

Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for Hemorrhage Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed Rest and Inactivity During Pregnancy

PATHOPHYSIOLOGY OF PLACENTA PREVIA

Painless Vaginal Bleeding

Ultrasound Risk Factors Advanced Maternal Age

Previous Uterine Multiparity

Surgery

Complete Previa Partial Previa

Large Placenta Maternal (Multiple Gestation, Smoking

Erythroblastosis)

Marginal Previa Low-lying placenta Bleeding Stops Fetus Stable

Bed Rest

↓ Urine Output

Observe

Hypotension (↓BP) Maternal Hemorrhage

Pale, cool skin ↑ Capillary refill

Bleeding continues Bleeding restarts

Tachycardia (↑ Pulse)

Complications: Congenital Anomalies Maternal Mortality (rare) Intrauterine Growth Retardation (IGR)

Cesarean Birth

Vaginal or Cesarean birth

Assessment S- “Dinudugo ako at tila marami nang lumalabas na dugo sa akin!” as verbalized by the Pt. OBleeding Episodes (amount, duration) Facial Grimace due of Pain or no complaint of pain Abdomen soft/hard when palpated Manifest Body Weakness Low BP Increased HR Decreased RR Fetal HR >120160 bpm Decreased Urine Out Increased Urine Concentration Pale, Cool Skin Increased Capillary Refill (specify) Lab. Results

Diagnosis Fluid Volume Deficient r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Scientific Rationale Fluid volume deficient is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death. Reference: Maternal and Child Health Nursing by Adele Piliteri Nursing Diagnosis Pocketbook by Mary Ellen Murray, R.N., Ph.D, Leslie D. Atkinson, R.N., M.S.N. Nurse’s Pocket Guide 9th Edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissier-Murr

Outcomes After rendering nursing intervention and medical assistance, Pt. will exhibit signs of adequate fluid balance during pregnancy.

Nursing Care Plan Nursing Intervention Diagnostic Assess color, odor, consistency and amount of vaginal bleeding; weigh pads Assess hourly intake and output.

Scientific Rationale Provides information about active bleeding versus old blood, tissue loss and degree of blood loss Provides information about maternal and fetal physiologic compensation to blood loss

Assess baseline data and note changes. Monitor FHR.

Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.

Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)

Detecting increased in measurement of abdominal girth suggests active abruption

Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)

Assessment provides information about blood vol., O2 saturation and peripheral perfusion

Assess for changes in LOC: note for complaints of thirst or apprehension

To detect signs of cerebral perfusion

Therapeutic Provide supplemental O2 as ordered via facemask or nasal cannula @ 10-12 L/min.

Intervention increases available O2 to saturate decreased hemoglobin

Initiate IV fluids as ordered (specify fluid type and rate).

For replacement of fluid vol. loss

Position Pt. in supine with hips elevated if ordered or left lateral position.

Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion

Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered.

Lab. Work provides information about degree of blood loss; prepares for possible transfusion. Ultra sound provides info about the cause of bleeding

Determine if Pt. has any objections to blood transfusions- inform physician.

Pt. may have religious beliefs related to accepting blood products

Administer blood transfusion as ordered with client consent.

To provides replacement of blood components and volume

Monitor closely for transfusions reaction

To prevent for Potentially life-threatening allergic reaction may result from incompatible blood

Provide emotional support; keep Pt. and family informed of findings and continuing plan of care. Administered prenatal vitamins and iron as ordered: provide a diet high in iron: lean meats, dark green leafy vegetables, eggs, and whole grains. Prepare Pt. for cesarean birth if ordered when severe hemorrhage, abruption, complete previa at term is already experience.

Support and information decrease anxiety and help Pt. and family to anticipate what might happen next. Proper diet and vitamins replace nutrient losses from active bleeding to prevent anemia- iron is a necessary component of hemoglobin Cesarean Birth may be necessary to resolve the hemorrhage or prevent fetal or maternal injury.

Evaluation Pt. has no further vaginal bleeding; Blood pressure is maintained at at least 100/60 mm Hg; PR <100 bpm; fetal HR is maintained at 120-160 bpm; UO >30ml/hr.