Introduction: The placenta is implanted in the lower uterine segment near or over the internal cervical os.

The degree to which the internal cervical os is covered by the placenta has been used to classify four types of placenta previa; total, partial, marginal and low–lying. In total previa the internal os is entirely covered by the placenta. Partial placenta previa implies incomplete coverage of the internal os. Marginal placenta previa indicates that only an edge of the placenta extends to the margin of the internal os. And the last is the low – lying placenta has been used when the placenta is implanted in the lower uterine segment but not reach the os. The more descriptive classification that includes placenta previa is in the third trimester. The incidence of placenta previa is approximately 0.5% of births. The most important risk factors are previous placenta previa, previous cesarean birth, and suction curettage for miscarriage or induced abortion, possible related to endometrial scarring. The risk also increases with multiple gestations because of the larger placental area, closely spaced pregnancies, advanced maternal age older than 34 years, African or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and tobacco use. Classification of Placenta Previa: 1. 2. 3. 4. 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. Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to the internal os of the cervix.

Predisposing Factors: 1. 2. 3. 4. 5. Multiparity (80% of affected clients are multiparous) Advanced maternal age (older than 35 years old in 33% of cases Multiple gestation Previous Cesarean birth Uterine Incisions

6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa) 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 Clinical Manifestations: Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated with the stretching and thinning of the lower uterine segment that occurs in third trimester. Adequately contract and stop blood flow from open vessels. Stop blood flow from open vessels

Decreasing urinary output Normal Placenta During Childbirth

. If the woman is not bleeding severely she can be managed non-operatively until the 36th week.[3] In parts of the world where ultrasound is unavailable. Leopold’s Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position of the placenta. By this time the baby’s chance of survival is as good as at full term. 3. In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. The placental site is usually located on either the anterior or the posterior uterine wall. it is not uncommon to confirm the diagnosis with an examination in the surgical theatre. 3. Abdominalexamination usually finds the uterus non-tender and relaxed. 2. 2. Praevia can be confirmed with an ultrasound. bright red vaginal bleeding. The placenta grows with the placental site during pregnancy. it may shear off and a small section may bleed. noncontractile placenta cannot alter its surface area. consisting of tiny myofibrils. The cotyledons of the maternal surface of the placenta extend into the decidua basalis. 4. Anatomy of the uterine/placental compartment at the time of birth 1. surgery. even during uterine contractions. which forms a natural cleavage plane between the placenta and the uterine wall. The proper timing of an examination in theatre is important. Women with placenta previa often present with painless.Process of placental growth and uterine wall changes during pregnancy 1. so there is no bleeding. The semirigid. During pregnancy and early labor the area of the placental site probably changes little. In a normal pregnancy the placenta does not overlie it. If the placenta does overlie the lower segment. This bleeding often starts mildly and may increase as the area of placental separation increases. around the branches of the uterine arteries that run through the wall of the uterus to the placental area. or infection. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is located Anatomy of Female Reproductive System Physiology of Female Reproductive System Anatomy and Physiology of Male Reproductive System Pathophysiology No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma. There are interlacing uterine muscle bundles. Praevia should be suspected if there is bleeding after 24 weeks of gestation.

Diagnostic Evaluation: Placenta previa is diagnosed using transabdominal ultrasound.transabdominal scans with fewer false positive results Transvaginal ultrasound  If a woman is bleeding she is usually placed in the labor and birth unit or for cesarean birth because profound hemorrhage can occur during the examination. Complete blood count (CBC)  To monitor mother’s blood volume .setup procedure Ultrasonographic scan  If ultrasonographic scanning reveals a normally implanted placenta. . This type of vaginalexamination knows as the double. an examination may be performed to rule out local causes of bleeding and a coagulation profile is obtained to rule out other causes of bleeding management of placenta previa depends of the gestational age and condition of the fetus and the amount and cesarean birth.

pulse. Request consultation with a neontologist or pediatrician to discuss a treatment plan with the patient and her family.Fetoscope        To monitor fetal heart rate and conditions Medical Management: Maternal stabilization and fetal monitoring Control of blood loss. central venous pressure. Provide or teach perineal hygiene to decrease the risk of ascending infection. Anticipate the need for a referral for home care if the patient bleeding ceases and she’s to return home in bed rest. continuously monitor her blood pressure. and amount of vaginal bleeding as well as the fetal heart rate and rhythm Assist with application of intermittent or continuous electronic fetal monitoring as indicated by maternal and fetal status. differential shift. 9. or loss of variability. Teach woman to monitor fetal movement to evaluate well being . Observe for abnormal fetal heart rate patterns such as loss of variability. check for urine tenderness and malodorous vaginal discharge to detect early signs of infection resulting from exposure of placental tissue. monitor the patient for signs of early and late postpartum hemorrhage and shock. tachycardia. 3. as indicated by bradycardia. 10. 11. and refer them for counseling. respiration. 5. decelerations tachycardia to identify fetal distress. 4. late or available decelerations. 15. 19. 12. 16. Assure the patient that frequent monitoring and prompt management greatly reduce the risk of neonatal death. During the postpartum period. If the patient is Rh-negative and not sensitized. 6. Monitor VS for elevated temperature. 17. pulse rate. and provide thorough instructions for postpartum care. 13. 8. administer Rh (D) immune globulin (RhoGAM) after every bleeding episode. if necessary. Have oxygen readily available for use should fetal distress occur. pathologic sinusoidal pattern. unstable baseline. Prepare the patient and her family for a possible caesarian delivery and the birth of a preterm neonate. 22. 1. 2. Assess fetal movement to evaluate for possible fetal hypoxia. monitor laboratory results for elevated WBC count. 7. If the fetus less than 36 weeks gestation expect to administer an initial dose of betamethasone: explain that additional doses may be given again in 24 hours and possibly for the next 2 weeks to help mature the neonates lungs. 21. 20. intake and output. 18. Explain that the fetus survival depends on gestational age and amount of maternal blood loss. Position the patient in side lying position and wedge for support to maximize placental perfusion. and blood pressure. careful observation to determine safety of continuing pregnancy or need for preterm delivery Hospitalization with complete bed rest until 36 weeks gestation with complete placenta previa Possible vaginal delivery with minimal bleeding or rapidly progressing labor Nursing Interventions: If continuation of the pregnancy is deemed safe for patient and fetus administer magnesium sulfate as ordered for premature labor Obtain blood samples for complete blood count and blood type and cross matching Institute complete bed rest If the patient and placenta previa is experiencing active bleeding. Administer prescribed IV fluids and blood products. blood replacement Delivery of viable neonate With fetus of less than 36 weeks gestation. Provide information about labor progress and the condition of the fetus. Encourage the patient and her family to verbalize their feelings helps them to develop effective coping strategies. 14.

chapter 23. Administer oxygen as ordered to increase oxygenation to mother and fetus. Maternal Neonatial Nursing Lippincott manual of Nursing Practice http://wikipedia. Diet She might to begin to neglect her diet or her supplementary vitamins because “It doesn’t matter anymore”. page 751. Assess for contraindications of Betamethasone administration. to the presence of a support person can offer additional comfort to a client. Exercise        Needs to adequate her time with her child to be certain he or she is all right. Possible Nursing Diagnosis for Placenta Previa: 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 View Nursing Care Plan – Placenta Previa References: Maternal & Child Nursing Seventh Edition Vol. seventh edition. Administer oral dose and home monitoring requires professional supervision. and nurse can states hearing fetal heart beat helps to reassure her about baby’s health. Lowdermilk Pregnancy care      . Maternity nursing. Spiritual Assess anxiety level of client over preterm labor possible feelings. Discharge Plan: Medication   Betamethasone (Celestone) is a corticosteroid that acts as an anti-inflammatory and immunosuppressive agent.23. Determine whether client wants a support person to be wit her. 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. Obtain reports of urine and cervical cultures and fibronectin. Attach contraction and fetal heart rate monitoring for continuous evaluation of contractions of fetal response.1 page 413.

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