PLACENTA PREVIA the placenta is

implanted in the lower uterine segment near or over the internal cervical os. > The patient is not in labor > Requires immediate evaluation because of the massive blood loss with resulting hypovolemic shock can occur if bleeding resumes > During the second trimester, the placenta may appear to cover the cervical os; however, at term, it does not cover the os > Occurs in 0.5% of births > Maternal morbidity rate is about 5% > Maternal mortality rate is <1% > Infants who are SGA or have intrauterine growth restriction have been associated with placental previa because of poor placental exchange or hypovolemia resulting from maternal blood loss and maternal anemia > If preterm gestation, it may be an indication for admission to a tertiary perinatal center because many community hospitals are not able to perform emergency CS birth 24/7 or provide neonatal intensive care *VBAC/VDAC: Vaginal birth/delivery after cesarean *Types of Placenta Previa: 1. Complete/Total/Central: If the internal os is entirely covered by the placenta when the cervix is fully dilated 2. Partial/Incomplete: Incomplete coverage of the internal os because it is partially covered

3. Marginal: Only an edge of the placenta extends to the internal os, but it may extend onto the os during dilation of the cervix during labor. The distance of the placenta is 2 to 3 cm from the internal os and does not cover it 4. Low-lying: When the placenta is implanted in the lower uterine segment, but does not reach the os. The internal os is still open. When the exact relationship of the os to the placenta has not been determined or in cases of apparent placenta previa in the second trimester. *Important risk factors: 1. Previous placenta previa 2. Previous cesarean birth 3. suction curettage for miscarriage/induced abortion (endometrial scarring) 4. Multiple gestation (larger placenta area) 5. Closely spaced pregnancies 6. Maternal age > 35 years 7. African/Asian ethnicity 8. Male fetal gender 9. Smoking 10. Cocaine use

*Clinical Manifestations - About 70% of women have painless uterine bleeding - 20% of women have vaginal bleeding associated with uterine activity - It should be suspected whenever vaginal bleeding occurs after 20 wks AOG - Associated with the stretching and thinning of the lower uterine segment (3rd trimester)

- Placental attachment is gradually disrupted: Bleeding occurs when the uterus is not able to contract adequately and stop blood flow form open vessels - Initial bleeding is usually a small amound and stops as clots form, but it can recur at any time - Bright red blood - Vital signs may be normal - Soft, relaxed, non-tender uterus with a normal tone - The fundal height is usually greater than expected for gestational age because the low placenta hinders descent of the presenting fetal part (If fetus is in lying longitudinally) - Commonly in an oblique, breech or transverse position *Associated complications: 1. PROM 2. Preterm labor/birth 3. Surgery-related trauma to structures adjacent to he uterus 4. Anesthesia complications 5. Blood transfusion reactions 6. Over-infusion of fluids 7. Abnormal placental attachments 8. Postpartum hemorrhage 9. Anemia 10. 11. Thrombophlebitis Infection

1. Patient History - GPTPALM, EDC, general status, bleeding (quantity, precipitating event, associated pain) 2. Laboratory studies - CBC, blood typing, Rh factor, coagulation profile, type/crossmatch 3. Bleeding - checking/weighing the amount of bleeding on perineal pads, bed pans, linens (1g=1ml of blood) *Diagnosis: 1. Transabdominal ultrasound examination > 93-97% accurate > Also is used for placental location 2. Speculum Examination > E.g. cervisitis, polyps, carcinoma of the cervix 3. Coagulation Profile > To rule out other causes of bleeding *Nursing Diagnosis: 1. Decreased cardiac output related to excessive blood loss secondary to placenta previa 2. Deficient fluid volume related to excessive blood loss secondary to placenta previa 3. Ineffective peripheral perfusion related to hypovolemia and shunting of blood to central circulation 4. Anxiety/fear related to maternal condition and pregnancy outcome 5. Anticipatory grieving related to actual/perceived threat to self, pregnancy, or infant

*Assessment: *Management:

- Depends on the gestational age, condition of the fetus, and amount of blood present - Double set-up procedure (IE: If needed before 34 weeks, women is taken to DR/OR set up for CS because of profound hemorrhage can occur) - If at term and in labor/bleeding, immediate CS (Nurse will assess maternal/fetal status while preparing for surgery) - Assess maternal VS (dec. BP, inc. PR, changes in levels of consciousness and oliguria) - Fetal assessment by continuous electronic fetal monitoring (signs of hypoxia) - Postpartum hemorrhage may occur even if the fundus is contracted firmly - Ultrasound examination (every 2-3 weeks) - Fetal surveillance (NST, BPPs 1-2 weekly) - No sexual contact until involution takes place *Nursing Interventions: 1. Emotional support 2. Patient education - All procedures should be explained 3. Support person should be present 4. Control/stop bleeding to save pregnancy 5. Bed rest and observation when fetus is not mature 6. May give anterpartum steroids (betamethasone) to promote fetal lung maturity if <34 wks AOG 7. No vaginal/rectal examinations

> Separation occurs in the area of the decidua basalis after 20 weeks of pregnancy and before birth of the baby > Most likely to occur in twin gestations > Significant 5-17% recurrence risk > Occurs in 3rd stage of labor > Cant save pregnancy > Placenta is normal (upper posterior fundal region; possible at upper anterior fundal region and corpus luteum, but never at cervix/isthmus) > Clotting defects (DIC) ub 19-30% if women (usually within 8 hours of hospital admission) > 1% Mortality rate: leading cause of maternal death > Perinatal mortality rate ranges from 15-30% > Women are usually not managed out of the hospital because the placenta can separate at any time and immediate intervention or birth may be necessary *Types: 1. Marginal: Duncans mechanism, maternal side out 2. Central: Schults mechanism, fetal side out *Risk factors: 1. Maternal hypertension 2. Cocaine use (associated with the development of hypertension) 3. Blunt external abdominal trauma (motor vehicle accidents/maternal battering) 4. Maternal smoking 5. Pressure by enlarging uterus 6. PROM causing sudden release of pressure

ABRUPTIO PLACENTAE premature

seperation/detachment of part or all of the placenta from its implantation site

7. High parity 8. Malnutrition 9. Previous placental apoplexy *Clinical manifestations: - Dark red blood - Sharp, stabbing pain - Separation may be partial, complete or only the margin of the placenta may be involved - Bleeding from placenal site may separte membranes from the decidua basalis and flow through the vagina (may remain concealed retroplacental hemorrhage or may do both) - Vaginal bleeding and abdominal pain - Uterine tenderness and contractions - Silent abruption (uterine tenderness and abdominal pain may be absent) - Bleeding may result to maternal hypovolemia and coagulopathy - Mild to severe uterine hypertonicity - Pain is mild to severe and localized over one region of the uterus or diffuse over the uterus with a boardlike abdomen - Extensive myometrial bleeding damages the uterine muscle - Couvelaire uterus/uteroplacental apoplexy (if blood accumulates between the separated placenta and the uterine wall/retroplacental blood may penetrate through the thickness of the wall of the uterus into the peritoneal cavity) - Uterus appears purplish and copper colored, ecchymotic, and contractility is lost - Shock may occur and is out of proportion to blood loss

- (+) Apt test (for blood in amniotic fluid) - Hemoglobin/hematocrit levels drop - Coagulation factor levels drop - Kleihauer-Betke stain (to determine the presence of fetal to maternal bleeding - transplacental hemorrhage) *Maternal, Fetal, Neonatal outcomes: 1. Mothers prognosis depends on the extent of placental detachment, overall blood loss, degree of DIC, and time between placental detachment/birth 2. Complications include hemorrhage, hypovolemic shock, hypofibrinogenemia and thrombocytopenia 3. Couvelaire uterus, DIC, infection occurs 4. Renal failure and pituitary necrosis (Sheenans syndrome) may result from ischemia 5. Rare cases: Rh (-) women can become sensitized if fetal-to-maternal hemorrhage occurs and fetal blood type is Rh (+) 6. Death occurs from fetal hypoxia, preterm birth, SGA status 7. Increased risks for neurologic defects and fetal complications (congenital anomalies) *Collaborative Care: - Fundic height may be measured due to concealed bleeding - 60% of fetuses exhibit non-reassuring signs on the electronic fetal heart monitor (loss of variability, late decelerations, uterine hyper stimulation, increased resting tone

- Many women demonstrate coagulopathy by abnormal clotting studies (fibrinogen, platelet count, prothrombin time, partial thromboplastin time, fibrin split products) - Sonographic examination: rule out placenta previa; (-) findings do not rule out abruption *Hospital care: - Treatment depends on severity of blood loss and fetal maturity/status - Woman is hospitalized and closely observed for signs of bleeding/labor - Fetal status is monitored with intermittent FHR monitoring and NST/BPP until fetal maturity is achieved or until the womans condition deteriorates and immediate birth is indicated - Corticosteroids to accelerate fetal lung maturity - Rh (-) women may be given Rh(D) immune globulin if fetal-to-maternal hemorrhage occurs and the fetal blood is (+) - Vaginal birth for hemodynamically stable women - Fetal comprise, severe hemorrhage, coagulopathy, poor labor progress, increasing uterine resting tone - CS delivery - 16 gauge IV line should be started - Serial laboratory studies (hematocrit or hemoglobin determinations and clotting studies) - Continuous fetal monitoring - Indwelling Foley catheter is inserted for continuous assessment of urine output - Blood and fluid replacement (goals: maintain UO @ 30 ml/hr+ and hematocrit @ 30%+) - If goals not met, hemodynamic monitoring

- Fresh frozen plasma/cryoprecipitate given to maintain fibrinogen level at a min. of 100-150 mg/dl *Nursing Interventions: 1. Emotional support 2. Patient education - All procedures should be explained 3. Monitor VS frequently q15 4. Bed rest and close observation 5. Give oxygen in left lateral position 6. Monitor bleeding