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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. Total Previa- the placenta completely covers the internal cervical os.
2. Partial Previa- the placenta covers a part of the internal cervical os.
3. 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. Advanced maternal age


2. multiparity
3. previous uterine surgery
4. large placenta (multiple gestation, erythroblastosis)
5. 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:

• Premature contractions

• Baby is breech, or in transverse position

• Uterus measures larger than it should according to gestational age

Management:

1. may be given drugs that can prevent premature labor or birth example is progesterone.
2. Ultrasound exams to determine migration of an early diagnosed previa or classification of the previa as total,
partial, marginal, or low-lying.
3. With a small first bleed, client may sent home on bed rest if she can return to hospital quickly.
4. 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.
5. No vaginal exams are performed except under special conditions requiring a double set-up for immediate
cesarean birth should hemorrhage result.
6. Low lying or marginal previas may allowed to deliver vaginally if the fetal head acts as tamponade to prevent
hemorrhage.
7. Cesarean birth, often with vertical uterine incision, is used for total placenta previa.
8. 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. The placenta grows with the placental site during pregnancy.


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

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

1. 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.
2. 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.
3. 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

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 Previous Uterine Large Placenta Maternal


Maternal Age Multiparity Surgery (Multiple Gestation, Smoking
Erythroblastosis)

Complete Previa Marginal Previa


Partial Previa Low-lying placenta

Bleeding Stops
Fetus Stable

Bed Rest

Observe
↓ Urine Output Pale, cool skin

Hypotension (↓BP) ↑ Capillary refill


Bleeding continues
Maternal Hemorrhage Bleeding restarts
Tachycardia (↑ Pulse)

Complications:

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

Cesarean Birth Vaginal or Cesarean


birth
Nursing Care Plan
Assessment Diagnosis Scientific Rationale Outcomes Nursing Intervention Scientific Rationale Evaluation
S- “Dinudugo ako Fluid Volume Fluid volume deficient After Pt. has no
at tila marami Deficient r/t is a state in which an rendering Diagnostic further vaginal
nang lumalabas Active Blood individual is nursing Provides information about active bleeding versus bleeding; Blood
na dugo sa akin!” Loss experiencing intervention Assess color, odor, consistency and amount of old blood, tissue loss and degree of blood loss pressure is
as verbalized by Secondary to decreased and medical vaginal bleeding; weigh pads maintained at
the Pt. Disrupted intravascular, assistance, Pt. Provides information about maternal and fetal at least 100/60
Placental interstitial and/or will exhibit Assess hourly intake and output. physiologic compensation to blood loss mm Hg; PR
O- Implantation intracellular fluid. signs of <100 bpm; fetal
Bleeding Episodes Active Blood Loss or adequate fluid Assess baseline data and note changes. Monitor Assessment provides information about possible HR is
(amount, duration) Hemorrhage due to balance FHR. infection, placenta previa or abruption. Warm, maintained at
Facial Grimace disrupted placental during moist, bloody environment is ideal for growth of 120-160 bpm;
due of Pain or no implantation during pregnancy. microorganisms. UO >30ml/hr.
complaint of pain pregnancy may
Abdomen manifest signs and Assess abdomen for tenderness or rigidity- if Detecting increased in measurement of abdominal
soft/hard when symptoms of fluid vol. present, measure abdomen at umbilicus (specify girth suggests active abruption
palpated deficient that may time interval)
Manifest Body later lead to
Weakness hypovolemic shock Assess SaO2, skin color, temp, moisture, turgor, Assessment provides information about blood vol.,
Low BP and cause maternal capillary refill (specify frequency) O2 saturation and peripheral perfusion
Increased HR and fetal death.
Decreased RR Assess for changes in LOC: note for complaints of To detect signs of cerebral perfusion
Fetal HR >120- Reference: thirst or apprehension
160 bpm Maternal and Child
Decreased Urine Health Nursing by
Therapeutic
Out Adele Piliteri
Increased Urine Provide supplemental O2 as ordered via Intervention increases available O2 to saturate
Concentration Nursing Diagnosis facemask or nasal cannula @ 10-12 L/min. decreased hemoglobin
Pale, Cool Skin Pocketbook by Mary
Increased Ellen Murray, R.N., Initiate IV fluids as ordered (specify fluid type and For replacement of fluid vol. loss
Capillary Refill Ph.D, Leslie D. rate).
(specify) Atkinson, R.N.,
Lab. Results M.S.N. Position Pt. in supine with hips elevated if ordered Position decreases pressure on placenta and
or left lateral position. cervical os. Left lateral position improves placental
Nurse’s Pocket Guide perfusion
9th Edition by Marilynn
E. Doenges, Mary Monitor lab. Work as obtained: Hgb & Hct, Rh and Lab. Work provides information about degree of
Frances Moorhouse, type, cross match for 2 units RBCs, urinalysis, blood loss; prepares for possible transfusion. Ultra
Alice C. Geissier-Murr etc. Scheduled for ultrasound as ordered. sound provides info about the cause of bleeding

Determine if Pt. has any objections to blood Pt. may have religious beliefs related to accepting
transfusions- inform physician. blood products

Administer blood transfusion as ordered with To provides replacement of blood components and
client consent. 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 Support and information decrease anxiety and help
of care. Pt. and family to anticipate what might happen next.

Proper diet and vitamins replace nutrient losses


Administered prenatal vitamins and iron as
from active bleeding to prevent anemia- iron is a
ordered: provide a diet high in iron: lean meats,
necessary component of hemoglobin
dark green leafy vegetables, eggs, and whole
grains.
Cesarean Birth may be necessary to resolve the
Prepare Pt. for cesarean birth if ordered when hemorrhage or prevent fetal or maternal injury.
severe hemorrhage, abruption, complete
previa at term is already experience.