Placenta Previa
 It is abnormal implantation of the
placenta in proximity to the
internal cervical os.
 Is a condition in which the
placenta attaches to the uterine
wall in the lower position of the
uterus and covers all or part of
the cervix?
 One of the common cause of the
bleeding.
Classifications:
1. Total previa- placenta completely
covers the internal cervical os.
2. Partial previa- the placenta covers a
part of the internal cervical os.
3. Marginal previa- the cage 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.
Types of placenta previa:
1. Low marginal implantation
2. Partial placenta previa
3. Total placenta previa
Pathophysiology:
 Unknown
 May be linked to uterine fibroid
tumors or uterine scars from
surgery
 Factors that may affect the site of
the placenta’s attachment to the
uterine wall include:
 Defective vascularization
of the deciduas
 Multiple-gestations
 Previous uterine surgery
 Multiparity
 Advanced maternal age
 The lower uterine segment
of the uterus fails to
provide as much
nourishment as fundus
 Placenta lends to spread
out, seeking the blood
supply it needs, becoming
larger and thinner than
normal.
 Placenta villi are torn from
the uterine wall as the
lower uterine segment
contracts and dilates in the
3rd trimester.
 As the maternal cervical os
effaced and dilates, uterine
vessels are torn.
Assessment findings:
 Painless, bright red vaginal
bleeding after the 20th week of
gestation that starts without
warning and stops
spontaneously.
 Bleeding increase with each
successive incident.
 Soft, non-tender uterus.
Diagnostic findings:
 Pelvic examination under a
double set-up.
 Lab studies may reveal
decreased maternal high level.
 Transvaginal ultrasound scanning
is used to determine placental
position.
Management:
 Depending on where the first
episodic occurred and the
mount of bleeding.
 Limitation of maternal
activities.
 Monitoring of all relevant vital
sign.
 Emotional support
 No retrain from performing
rectal or vaginal exam.
 Vaginal delivery is considered
any when the bleeding is
minimal and the placenta
 previa is marginal or when the
labor is rapid.
 Immediate c/s delivery
performed as soon as the
fetus is sufficiently mature or
in the case of intervening
severe hemmorhage.
Nursing management:
 Teach the patient to immediately
identify and report s/s placenta
previa.
 If with active bleeding, monitorv/s,
I&O, and amount of vaginal
bleeding as well as FHT.
 Anticioate for the need for EFM
and assist with application as
indicated.
 Have oxygen readily available for
use should fetal distress occur.
 Rho (D) immunoglobulin for
bleeding in Rh-negative patients.
 Institute CBR
 Bethamethasone to enhance fetal
lung maturity
 Emotional support
 During the postpartum period,
monitor the patient for signs of
haemorrhage and stock.
 Tactfully discuss the possibility of
neonatal death.
Abruptio placenta
 Refers to the abnormal
separation after 20 to 24weeks of
gestation and prior to birth.
 Also a significant contributor to
maternal mortality.
 Common in multigravidas
(usualluy in women age 35 and
older, and is common cause of
bleeding during the 2nd half of
pregnancy)
 Dx is confirmed when there’s
heavy maternal bleeding, which
generally necessities termination
of pregnancy.
 Fteal prognosis depends on the
gestational age and amount of
blood loss.
 Maternal progress is good if
haemorrhage can be controlled.
Degrees of placental separation in
Abruptio placenta
1. Mild separation- begins with small
areas of separation and internal
bleeding (concealed haemorrhage)
between the placenta and uterine wall.
- Gradual onset, mild to moderate
bleeding, vague lower abdominal
tenderness and uterine irritability, strong
and regular fetal heart tones.
2. Moderate separation- may develop
abruptly or progress from mild to
extensive separation with external
haemorrhage.
- Gradual or abrupt onset, moderate,
dark red vaginal bleeding, continuous
abdominal pain, tender uterus that
remains firm between contractions,
barely audible or irregular and
bradycardia FHT, possible signs of
shock.
3. Severe separation- external
haemorrhage occurs, along with shock
and possible fetal cardiac distress.
- Abrupt onset of agonizing unremitting
uterine pain, boardlike, tender uterus,
moderate vaginal bleeding, rapidly
progressive stock, and absence of FHT.
Pathophysiology:
 Unknown
 Contributing factors: multiple
gestations, hydramnios. Cocaine
use, decreased blood flow to the
placenta, and trauma to the
abdomen, women with low serum
folic acid levels, vascular or renal
disease or PIH.
 Blood vessels at the placental
bed rupture spontaneously due to
lack of resilience or to abnormal
changes in uterine vasculature.
  An enlarged uterus which can’t
contract sufficiently to seal off the
torn vessels, and hypertension
complicate the situation.
 Consequently bleeding
continuous unchecked possibly
shearing off the placenta partially
or completely.
 As the blood enters the muscle
fibers, complete relaxation of the
uterus becomes impossible,
increasing the uterine tone and
irritability.
 If bleeding into the muscle fiber is
profuse, the uterus turns blue or
purple and the accumulated
blood prevents its normal
contractions after delivery.
Dx test findings:
 Pelvic exam under double set up
and ultrasonography rule out
placenta previa
 Decreased hgo levels and
platelet act
 Periodic assays for fibrin split
products to monitor progression
of abruption placenta and defect.
 DIC
Management:
 Monitoring maternal VS, uterine
contractions and vaginal bleeding
 Vaginal delivery depends on the
degree and timing of separation
in labor.
 CS indicated for moderate to
severe placental separation.
 Evaluation of maternal lab values.
 Fluid and electrolyte replacement
therapy, BT
 Emotional support
Possible complications:
 Maternal mortality rate is about
6%, dependent on the severity of
the bleeding, the presence of
coagulation defects,
hypofibronogenemia, and the
time lapse between placental
separation and delivery.
 Postpartum patients at risk for
vascular spasm, intravascular
clotting or haemorrhage and renal
failure from shock.
 Perinatal mortality dependent on
the degree of placental
separation and fetal level of
maturity.
 Most serious neonatal
complications stem from hypoxia,
prematurity and anemia.
Premature rupture of membranes
 Refers to membrane rupture 1 or
more hours before the onset of
labor. (preterm PROM refers to
rupture of the membranes before
the onset of labor in preterm
gestation)
 It is a spontaneous break in the
amniotic sac before onset of
regular contractions (resulting in
progression cervical dilation)
 The mothers is at risk for
chorioamnionitis if the time
between rupture of membranes
and onset of labor is longer than
24 hours.
 Signs include fetal tachycardia,
maternal fever, and foul-smelling
amniotic fluid and uterine
tenderness.
 Development of chorioamnionitis
can lead to sepsis and death.
 Risk of development increases
exponentially after 18 hours of
ROM without delivery.
 The risk of fetal infection, sepsis
and perinatal mortality increase
with every hour of ruptured of
membranes and labor, and every
vaginal examination or other
invasive procdure.
Causes:
 Unknown
  Malpresentation and a contracted
pelvis commonly accompany the
rupture
 Predisposing factors include poor
nutrition and hygiene and lack of
prenatal care, an incompetent
cervix, increased intrauterine
tension due to hydramnios or
multiple pregnancies, defects in
the amniotic membrane and
uterine, vaginal and cervical
infections (most commonly group
B streptococcal, gonococcal,
chlamydial, and anaerobic
organism)
Assessment findings:
 Typically, PROM causes blood-
tinged amniotic fluid containing
vernix-caseosa particles to gush
or leak from the vagina.
 Maternal fever, fetal tachycardia
and foul-smelling vaginal
discharge indicate infection.
 Alkaline PH of fluid collected from
the posterior fornix turns nitrazine
paper deep blue.
 A smear of fluid, placed on a slide
and allowed to dry takes on a
fern-like pattern (because of the
high sodium and protein content
of amniotic fluid) considered a
positive finding that confirms that
the substance is amniotic fluid.
Treatment:
 If these tests confirm infection,
labor must be induced, followed
by IV administration of an
antibiotic.
 A culture of gastric aspirate or a
swabbing from the neonate’s ear
may be done to determine the
need for antibiotic therapy
 With delivery, resuscitative
equipment must be readily
available to treat neonatal
distress.
Nursing intervention:
 Prepare the patient for vaginal
examination
 Before physically examining a
patient who is expected of having
PROM, explain all diagnostic test
and clarify any
misunderstandings.
 During the examination, stay with
the patient.
 Offer reassurance.
 Provide sterile gloves and sterile
lubricating jelly’
 Don’t use iodophor antiseptic
solution, discolorats nitrazine
paper and makes pH
determination impossible.
 Administer IV fluids as ordered
 If labor starts, observ the
mother’s contractions and
monitor her status
 Monitor VS q 2 hours.
 Watch for signs of maternal
infections, such as fever,
abdominal tenderness, and
changes in amniotic fluid
including purulence or foul odor
and fetal tachycardia (which may
precede maternal fever) report
such signs immediately.
 Stress that she must immediately
report premature rupture because
prompt treatment may prevent
dangerous infection.
 Warm the patient not to engage
in sexual intercourse, douche or
take tub baths after the
membrane rupture.
Placenta accrete
 Is an uncommon condition in
which the chorionic villi adhere to
the myometrium.
 This form of the condition
accounts for around 75-78% of all
cases.
Types:
1. Placenta accreta- the placental
chorionic will adhere to the superficial
layer of the uterine myometrium.
2. Placenta increta- the placental
chorionic will invade deeply into the
uterine myometrium.
3. Placenta pecreta- the placental
chorionic will go through the uterine
myometrium and often adhere to
abdominal structures such as the
bladder or intestine.