#06: Placenta previa

Placenta previa

* Is a condition wherein the placenta of a pregnant woman is implanted abnormally in the uterus. It accounts for the most incidents of bleeding in the third trimester of pregnancy.
* low implantation of the placenta
* It is the inevitable event of hemorrhage caused by separation of an abnormal attached placenta in the uterus.

Degrees

* low lying placenta
* marginal previa
* partial previa
* complete previa

Low lying placenta

placenta is in the lower segment of the uterus but does not reach the opening of the cervix.

Marginal previa

placenta is next to the cervix but does not cover the opening.

Partial previa

placenta covers part of the cervical opening.

Complete previa

placenta covers the entire cervical opening. This type is also known as type IV placenta previa.

Precipitating factors

* smoking
* cocaine use
* gestatinal diabetes mellitus

Predisposing factors

● Advanced maternal age

● Multiple pregnancy

● Multiparity

● Race

● Endometritis

● Abortion

● Had placenta previa with previous pregnancy

● Present scars in the uterus, from previous surgery such as cesarean section.

● Previous manual removal of placenta

Clinical Manifestations

● Uterine contraction soft upon palpitations

● Ultrasound shows malpositioned placental

● Soft, non-tender abdomen, relaxes between contractions, if present

● Fetal Heart Rate is stable and within normal limits

● Episodic painless vaginal bleed after 20 weeks of gestation

● Bright red bleeding after 20 weeks of gestation without pain

Laboratory exams

* Hematocrit or complete blood count
* Blood type and Rh
* Coagulation test

Hematocrit or Complete blood count

to monitor mother's blood volume

Coagulation test

used to find out if you have a problem with any of your clotting factors that may cause too little or too much blood clotting.

Diagnostic exams

* Ultrasound
* Fetoscope

Ultrasound

which shows whether the position of the placenta is correct or not. Normal ultrasound results show that the placenta is not less than 2 cm or near in contact with internal cervical os. FIndings where the placenta is less than 2 cm or nearly with internal cervical os may indicate a malpositioned placenta.

Fetoscope

to monitor fetal heart rate and conditions.

Tocolytic drugs

* magnesium sulfate
* terbutaline
* corticosteroids

Magnesium Sulfate

to inhibit contractions in patients with symptomatic placenta previa whose bleeding is mild or moderate.

Terbutaline (Brethine)

to prevent massive bleeding while at the same time prolonging the pregnancy. It acts directly on beta2-receptors to relax uterine contractions.

Corticosteroids

may be given to enhance lung development in the fetus prior to Cesarean delivery.

Intravenous therapy

would be prescribed by the physician to replace the blood that was lost during bleeding

External monitoring equipment

to monitor uterine contractions and record fetal heart sounds, and external equipment is preferred than the internal monitoring equipment

Cesarean delivery

if the placenta has obstructed more than 30% of the cervical os, it would be hard for the fetus to get past the placenta through normal delivery. Cesarean birth is recommended by a physician

Independent nursing interventions

● Monitor the client’s vital signs.

○ Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. The physician would order monitoring of the blood pressure every 5-15 minutes

● Weigh perineal pads to estimate blood loss.

○ Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss.

● Position the client supine with hips elevated if ordered or in a left side-lying position

○ To ensure an adequate blood supply to the client and fetus, place the client immediately on bed rest in a left side-lying position. The left side-lying position decreases pressure on the placenta and cervical os and improves placental perfusion.

● Monitor uterine contractions and fetal heart rate continuously

○ Attach external monitoring equipment to record fetal heart sounds and uterine contractions; however, avoid the use of an internal monitor for either fetal or uterine assessment to prevent hemorrhage. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.

● Assess hourly intake and output.

○ Monitor urine output frequently, as often as every hour, as an indicator that the client’s blood volume is remaining adequate to perfuse her kidneys.

● Assess color, odor, consistency, and amount of vaginal bleeding.

○ Inspect the perineum for bleeding and estimate the present rate of blood loss. The bleeding with placenta previa is usually abrupt, painless, bright red, and sudden. The bleeding may be provoked by intercourse, vaginal examinations, or labor, and at times there may be no identifiable cause.

● Provide client and family teaching

○ Explain the condition and management options. To ensure an adequate blood supply to the mother and fetus, place the woman at bed rest in a side-lying position. Anticipate the order for a sonogram to localize the placenta. If the condition of the mother or fetus deteriorates, a cesarean birth will be required.

Dependent nursing interventions

● Intravenous therapy

○ Administer as prescribed by the physician for replacement of blood loss during bleeding

● Attach external monitoring equipment

○ External monitoring equipment monitors uterine contractions and records fetal heart sounds, which is preferred than using internal monitoring equipment

● Cesarean Delivery

○ Cesarean birth is recommended by a physician if the placenta has obstructed more than 30% of the cervical os, it would be hard for the fetus to get past the placenta through normal delivery.

● Avoid vaginal examination

○ This may initiate hemorrhage that is fatal or both the mother and the baby

● Blood transfusion of whole blood if shock with hemorrhage occurs

● Tocolytic drug therapy

○ to slow down labor as prescribed to mothers preterm, early labor, progressive contractions and premature ROM

● Amniocentesis

○ This is done to to test the amniotic fluid around the fetus to see if the lungs are fully developed

● Blood typing and crossmatching

○ To check compatibility

Collaborative nursing interventions

● Collaborate with other healthcare providers in giving further information to the client

○ Assist clients with learning methods to compensate for disruption of cognitive skills. Addresses problems in concentration, memory and judgment.

Possible nursing diagnosis (1)

● Deficient fluid volume related to active blood loss secondary to disrupted Placental implantation

○ 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.

Possible nursing diagnosis (2)

● Decreased cardiac output related to altered contractility

○ Placenta Previa is the development of placenta in the lower uterine segment partially or completely covering the internal cervical os. Placenta Previa causes bleeding. Due to large amounts of blood lost, the heart tries to pump faster in order to compensate for blood loss. As a result, the heart pumps faster with less blood pumped.

Possible nursing diagnosis (3)

● Ineffective tissue perfusion related to decreased HgB concentration in blood & hypovolemia

○ Placenta Previa causes painless and continuous bleeding. With bleeding, there is decreased Hemoglobin. Hemoglobin carries oxygen to different parts of the body. If there is decreased hemoglobin there is a failure to nourish the tissues at the capillary level..

Nursing considerations

● WOF

○ Major hemorrhage (bleeding) for the mother

○ Shock from loss of blood

○ Fetal distress from lack of oxygen

○ Premature l abor or delivery

○ Health risks to the baby, if born prematurely

○ Emergency cesarean delivery

○ Hysterectomy, if the placenta fails to come away from the uterine lining

○ Blood loss for the baby

○ Death.

● Assessment

○ Profuse hemorrhage.

○ Hypotension.

○ Tachycardia.

○ Soft and nontender uterus.

○ Normal fetal heart tones (usually)

● Prevent vaginal examinations

● No Abdominal manipulation