GRACIOUS COLLEGE OF NURSING,

ABHANPUR, RAIPUR (C.G.)

Subject: Obstetrics & Gyneacological Nursing
CASE PRESENTATION ON
PLACENTA PREVIA

Submitted To Submitted By
Mrs. ARIMA WALTER NETAM, CHHAYA YADAV
MSC (N), ASSISTANT PROFESSOR OF MSC (N) 1ST YEAR
DEPARTMENT OF OBG, GCN
 CASE PRESENTATION
INTRODUCTION-My client Mrs. Rani W/O Mr.Omprakash was admitted in Dr.
B.R.A.M. Hospital, Raipur having the case of 27 weeks pregnancy with placenta previa on
08/06/2019 at 09 A.M.

BASELINE DATA OF THE PATIENT

1. Name - Mrs. Rani
2. Husband’s Name - Mr. Omprakash
3. Age - 28 years
4. Sex - Female
5. Address - Bhatapara Raipur, C.G.
6. Registration no - I/168
7. Date of Admission -
8. LMP
9. EDD -
10. Obstetric score - G1P1L1A0S0
11. Gestational age - 39 Weeks + 1 day
12. Unit - I
13. Ward no - 05 ( obstetrics Ward)
14. Bed no - 07
15. Religion - Hindu
16. Marital status - Married
17. Educational status -. 10th passed
18. Occupation - House wife

19 diagnosis - puerperal sepsis

19. Consultant - Dr. Abha Singh

CLIENT COMPLAINTS-(document in patient’s own word)

 Pain in lower abdomen since last night
 Vaginal bleeding
 Weakness since 3-4 days
 Dizziness since 3-4 days
 Other complains- Not able to do routine work, decreased appetite and nausea since one week.

HISTORY OF THE CLIENT

 1. FAMILY HISTORY-
 Type of family- Nuclear
 No. of family members- 02
 Any disease- no any history of any disease in the family.


FAMILY COMPOSITION:-
S.No Name of the Person Age/sex Relationship Health Specify
with client status disease(if
any)
1. Mr Rakesh 28 yr/M Husband Good No
2. Mrs. Sunita 25yr/F Self Average Puerperal
sepsis

FAMILY TREE-(INDEX)
Male Female Female Client

2. SOCIO ECONOMIC HISTORY-

 Family Income - Rs. 15000/month
 No of Earning Member - One (01)
 Education - graduation passed
 Social Support - Satisfactory
 Relationship With Neighbors - Good

3. SANITARY HISTORY-
 Housing - Puccaa House (Rented)
 Ventilation - Well ventilated
 Electricity - Available
 Drainage System - Open Drainage system
 Water facility - tape water (Municipal)

4. PERSONNAL HEALTH HISTORY

 Oral hygiene - Good
 Bathing habit - Once Daily
 Grooming - Maintained
 Health facility nearby home - Community Health Center
available at home
5. SLEEP PATTERN
 Type of sleep - Irregular
  Duration of Sleep - 5 hours with 1 hour of afternoon
Nap
 Any Abnormality - Interrupted sleep with difficulty in
falling asleep

6. BLADDER AND BOWEL HABITS

 Regularity - Regular

 Frequency - 3-4 times a day

 Time Interval- - 7-8 hour
 Amount - 20ml/hr

7. ALLERGIES - No any significant history of allergies

8. HEALTH HABITS
 Smoking
 Tobacco None of these
 Alcohol
 Drugs

9. RELIGIOUS HISTORY
 Religion - Hindu
10.EXERCISE
Remark- Patient is not aware of any exercises in pregnancy

11.NUTRITIONAL HISTORY
 Type of Diet - Vegetarian
 Daily menu - Rice, Pulses, Vegetables,
Chapatis
 Special Preferences - Tea

12.PRESENT MEDICAL HISTORY

Patient was having weakness and nausea since15 days . Joints pain and early fatigue
fever with chills headache insomnia anxiety etc.

13.PAST MEDICAL HISTORY

 Childhood illness - Not significant
 Adult illness - Not significant
 Hospitalization - No
 Accident - No
 Hyperlipidemia - No
 Hypertension - No
 Diabetes mellitus - No
 Chronic obstructive
 pulmonary disease - No
 Other chronic illness - No
 Trauma to chest - No
 Throat and dental extraction- No
 Rheumatic fever - No
 Thrombo embolism - No
 Any other disease - No

14.PRESENT SURGICAL HISTORY

No any significant present surgical history.

15.PAST SURGICAL HISTORY

No any significant past surgical history.

16.MENSTRUAL HISTORY-
 Type of Cycle - Regular
 Duration of menstrual cycle - 28 days
 Duration of menstruation - 4-5 days
 Amount of Blood Loss -
 No of Pads Used - 3-4/day

17.OBSTETRICAL HISTORY
 No of living children Nil
 Health status of the baby- Nil
 Last issues child age- Nil
 Last menstrual period- 10/09/2018
 Expected date of delivery- 17/06/2019
 Gravida- 1st (First)
 Para- Nil
 Abortion- Nil
 Stillbirth- Nil

18.PAST OBSTETRICAL HISTORY-

S.no Gravida Abort. Preterm Fullterm Type of Sex Alive Wt. Stillbirt Rema
Delivery h rks
1. 1st - - 01 Normal F -live 3.2 -
kg

19.ANTENATAL ATTENDANCE-
Date Wt. Urine, B.P. F.H.R. Weeks Of Fundal T/t and
Albumin, Gestation Height Remarks
 Sugar
16-07-2013 47 kg Nil 120/8Pof 140beats/min 12 weeks 16 cm Tab.
hg Calcium
and Tab.
Frida
07-09-2013 48kg Nil 120/80 140beats/min 16 weeks 18 cm Tab.
mm of hg Neogest
200mg,
Tab. Sup

PHYSICAL EXAMINATION OF CLIENT

1. GENERAL APPEARANCE
a) Body positions- normal
b) Nourishment - Undernutritioned
c) Health - Healthy
d) Activity - Dull
e) General built - Thin

2. MENTAL STATUS
a) Consciousness - Conscious
b) Look - Anxious

3. SKIN CONDITION
a) Color - faifair in colour
b) Texture - good
c) Skin turgor - Dehydrated
d) Temperature - normal
e) Lesions - Absent
f) Scars - Absent
g) Edema - Absent

4. HEAD AND FACE

a) Scalp - Normal and Clean
b) Hair distribution -Normal
c) Hair Color - Black
d) Face - normal

5. EYES
a) Globe - Normal
b) Eye Brow - Present
c) Eye Lashes - Distribution
d) Conjunctiva - normal
 e) Sclera - White
f) Cornea and iris - Regular
g) Pupils - Reacted to light
h) Vision - Normal

6. EARS
a) External Ear -No Obstruction and no discharges
b) Hearing - Normal

7. NOSE
a) External nose -No Crust & No discharges
b) Nostril - No inflammation and No septal deviations

8. MOUTH AND PHARYNX

a) Lips - Normal in colour
b) Mouth No Foul smell
c) Teeth - No discoloration and no dental carries
d) Tongue - Dry
e) Gum - Normal
f) Uvula - Symmetrical
g) Tonsils - Normal
h) Voice - Normal

9. NECK
a) Lymph nodes - No Enlargement
b) Thyroid gland- No Enlargement
c) Masses - Absent
d) Swelling Absent
e) Neck Range of Motion- Normal

10.THORAX AND LUNGS

a) Shape - Normal
b) Expansion - Adequate
c) Tenderness - Not Present
d) Breath sounds- No any abnormal sound

BREAST EXAMINATION

I. Consistency Tenderness,
II. Engorgement engorged
III. Lactation Present
IV. Nipple cracked neepal

11.HEART
a) Rate - 78 beats/min.
 b) Rhythm - Regular
c) Size - Normal
d) Location - Appropriate
e) Apical pulse - Palpable
f) Heart sound - S1 and S2 audible

12.ABDOMEN-
a) Shape - Normal
b) Bowel sound - Present
c) Liver - Palpable
d) Spleen - Palpable
e) Tenderness - Present

Abdominal Examination :-

1.Inspection

 Tone :Tonic
 Scar :Absent
 Herniation :Absent
 Skin condition :Silver appearance
 2.Palpation – no organomegaly

3.Auscultation :bowel sound present

Vaginal Examination :-

 Vaginal discharge present

 Foul smelling present

13.EXTREMITIES-
a) Upper limb - Normal
b) Lower limb - Normal

c) Movement - Present
d) Tremors - Absent
e) Edema - Absent
f) Varicose vein - Absent
g) Reflexes - Present

14.GENITALIA(FEMALE)
a) Hair distribution - Equal
b) Discharge - present
c) Bleeding -. Present
 d) Urethral meatus - Normal
e) Vaginal Opening - Normal
f) Clitoris - Normal
g) Foul smell - Present
h) Mass - Not present

15.RECTUM
a) Inflammation - Normal
b) Scars - Not Present
c) Lesions - Not Present
d) Ulceration - Not Present
e) Rashes - Not Present
f) Pain - Not Significant
g) Bleeding - Nil
h) Sphincter control - Present

16.VITAL SIGNS
a) Temperature - febrile (100.4° F)
 Route for monitoring temperature – Axillary
b) Pulse
 Monitoring site - Radial
 Rate - 104beats/min
 Rhythm - Regular

Remarks – body temperature is high.

c) Respiration
 Rate - 24 beats/min
 Rhythm - Regular
 Easiness of breath - Easy breathing in fowlers position
 Position of client while - Semi-Fowlers position
breathing

Remarks- No any significant abnormality observed

d) Blood pressure
 Lying down position - 140/85 mm of Hg
 Orthostatic hypotension - Absent

17. HEIGHT - 152 cm

18. WEIGHT - 48 kg
19. PERINEAL EXAMINATION
1. Perineal area - redness and swelling
2. Any bleeding/ discharge present
 3. Episiotomy suture -present
4. Any wound gaping - Nil

VAGINAL EXAMINATION

1. Odour - Foul
2. Colour - Bloody
3. Amount mild

20.EXTREMITIES
1. Edema - absent
2. Varicosities - Not present

INVESTIGATION

S.NO. PARAMETER PATIENTS NORMAL REMARK

VALUE VALUE

1. Hematology
Hb 12.1 gm% 11.5-13.5 gm% No abnormality
WBC count 25 4.5-11 10/mm3 Increased
Blood group O+ve No Abnormality
HIV I & II -ve - No Abnormality
HbsAg -ve - No Abnormality
HCV -ve - No Abnormality
VDRL -ve - No Abnormality
Malaria Parasite -ve - No Abnormality
Sicking test -ve - No Abnormality

2. Urinalysis

Albumin nil Normal

Sugar -ve Normal
Pus cell 2-3 cells Normal

 ULTRASONOGRAPHY- (Done by Dr. Atul Tiwari) :- ultrasound

scan is done to assist diagnosis of retained product of conception.

OTHER INVESTIGATIONS-
No any other investigation performed.
DIAGNOSIS: puerperal sepsis

DISEASE CONDITION
DEFINITION:- It is defined as the implantation of placenta in
the lower uterine segment near or at internal cervical OS.
Based on this patient's clinical presentation, placenta previa
was suspected and further confirmed by Transabdominal
ultrasound. Placenta previa is defined as the presence of
placental tissue over or adjacent to the cervical os.

Epidemiology :
 1:300livebirths
 0.3-5% of total APH cases
 1.5-5% of cases with pervious caesarean section
 Complete placenta previa prevalence rate :20-45%
 Partial placenta previa prevalence rate:30%
 Marginal placenta previa prevalence rate:25-50 %

Classification of placenta previa:

1. Type I Placenta previa (Low lying placenta previa): Only the lower margin
of placenta reaches into upper portion of uterine segment. vaginal delivery is
possible. There is the low risk of antepartum haemorrhage and maternal and
fetal condition is good.
2. II. Type 11 Placenta previa (Low lying Marginal placenta previa):
Marginal placenta extends upto lower uterine segment neat the internal Os of
the cervix. Vaginal delivery is particularly possible if placenta is anterior.
Blood loss is usually moderate although maternal and fetal condition vary; fetal
hypoxia is more likely to be present than maternal shock.
3. III. Type III placenta previa (incomplete central placenta previa/partial
placenta previa): Placenta is located over the internal Os but not centrally.
Bleeding is likely to be severe, particularly when lower uterine segment stretch
and cervix begin to efface and dilate in late pregnancy. Vaginal delivery is
inappropriate because the placenta precedes the fetus.
4. IV. Type IV placenta previa (complete central placenta previa/ total
placenta previa ) Placenta is centrally located over the internal Os and
 torrential haemorrhage is more likely. Caesarean section is essential in order to
save the lives of both mother and fetus.
ETIOLOGY

S.NO IN BOOK IN PATIENT

.
1 Grand multiparity Not present
2 History of abortion Present
3 Infertility treatment Not present
4 Previous uterine surgery/ caesarean Present Present
5 section Not present
6 Fetal Malpresentation Not present
7 Uterine anomalies Interpregnency interval is about
Sort Interpregnancy interval 1 year
8 Smoking Present in non smoker

SIGNS AND SYMPTOMS:-

Sings

Sr According to book According to patient

no

1. General condition and anemia are Patient general condition is

proportionate to the visible blood loss. pale and anaemic.
2. On abdominal examination; On abdominal examination3;
-The size of the uterus is proportional to the - Present
period of gestation.
-The uterus feels relaxed, soft and elastic - Present
without any localized area of tenderness
3. -Persistence of Malpresentation - Not present
Blood loss is often bright red. - Present
Symptoms:-

S.N. According to book According to patient

1. Sudden onset of vaginal Bleeding present spontaneously 5 days back
bleeding.
2. Painless bleeding. Presence of painless bleeding
3. Apparently causeless and No any history of trauma or injury or previous
recurrent placenta previa

INVESTIGATION

S.N. In book In patients

1 USG and CTG Done in patient.
2 Tests, such as blood group, HB Done in patient.
3 level. Done in patient.
4 VDRL Done in patient.
5 CBC, BT CT Done in patient
HBSAG

COMPLICATIONS

S.N. Book picture Patient condition

1 Antepartum haemorrhage Present
2 Malpresentation Not present
3 Premature labour Present
4 Premature rupture of membrane Present
5 Cord prolapse Not present
6 Slow dilation of cervix Not present
7 Intrapartum haemorrhage . Not present
8 Increase rate for sepsis. Not present
9 Intrauterine death . Not present

TREATMENT AND MANAGEMENT:- According to Johnson and Macafee

protocol: the first step of management of the patients is hospitalization.

Immediate treatment:-

According to book In my patient

 Assessment
 History taking for the conformation of
diagnosis
 Maternal condition(stable /unstable)
 If patient is in shock:
 The initial treatment should be
restorative consisting of resuscitation,
Rest, warmth sedation,
 and transfusion of blood to overcome
Done
Done
Pale, anaemic maternal state, prone
to shock
Patient was kept in complete bed
rest.
Blood arranged and transfused to
maintain blood circulation.
Patient instructed well about the
 shock and re establishment of blood disability condition and encouraged
circulation with minimal delay. to express feelings regarding the
situation.
Differential diagnosis via Investigations:-
 Ultrasonography (allocate the placenta) USG done(low lying placenta
previa identified)
 Haematological reports (complete All these haematological
blood counts haematocrits, blood group investigations done
and cross match, bleeding time,
clotting time).

Further examination:-
 Avoid vaginal examination Vaginal examination avoided
 Speculum examination to rule out local Speculum examination not done

MEDICATION

S.N Drug name Indication Dose Nurses responsibility

o and
route
01. Tab Iron and Iron deficiency anemia 100ug Assess vital signs.
Folic Acid Prophylactically given in and Provides teaching regarding
pregnancy Megaloblastic oral intake of iron
02. INJ anemia For fetal lung maturity. 9mg Encourages to take
Dexamethasone /day medications along with food
(IV) rich in vitamin C
Advises not to take medicine
with tea or milk Provides
instructions regarding color
change of stool and urine. –
Monitors intake output of
patients.
-assessed patients level of
consciousness and headache
during the therapy.
educated to take missed doses
as soon as remembered.
NURSING CARE PLAN:-

S. Assessment Nursing Goal Planning Implementa Evaluatio

N. diagnosis tion n
01 Subjective Imbalanc Client To encourage Citrus fruit progressi
Client e will choice of food and leafy ve weight
reports- nutrition demonstra high in protein vegetables gain.
* Less food less than te iron and vit-C rich in iron Client
intake than body progressiv when oral suggested maintains
the requirem e weight intake is in diet. .
recommend ents gain or permitted. Also
ed daily related to stable To promote pulses,
allowance. anorexia weight intake of supe grams,
• Feeling of as with juices, and jaggery and
inability to manifeste normalisa other milk
chew food d by tion of nutritious emphasized
• Reluctance decrease laboratory fluids. for
in food in body values. To monitor inclusion
Objective weight, the weight diet.
On reported changes and Intake of
observation- lack of other atleast
• Weight food laboratory 2000 ml
reduction intake value levels. per day of
below the etc. To encourage fruit juices,
jdeal. adequate rest vegetables
• and sleep. sous and
Hyperactive To other
bowel recommend available
sounds small frequent seasonal
meals. nutritious
fluids were
suggested
in diet.
Body
weight
assessed
regularly,
level of
albumin,
hemoglobin
and
heamatocrit
level
monitored.
The
practice of
sound sleep
was taught
to the
patient. As
well as
other health
advices
about rest
and sleep
given to
 patient.
Small and
frequent
meals
provided
patients.
02 Subjective Ineffectiv To Plan to Monitored After
Client e tissue maintain monitor Vital VitalSigns.nursing
report perfusion oxygen Signs interventi
Objective related to level. Plan to ons my
On decrease Encourage Encouraged patient
observation in Hb in quiet & restful quiet & saturation
blood as environment. restful level is
manifeste Plan to environmen maintaine
d by Encourage use t d.
dyspnea. of relaxation
techniques Encouraged
Plan to use of
Provide relaxation
supplemental techniques.
oxygen to the
client as Provided
prescribed by supplement
the physician. al oxygen
to the client
as
prescribed
by the
physician.
03 Subjective Deficient Plan to Vital Vital Signs After
Client fluid Signs Monitor Monitored nursing
report volume Plan to FHR interventi
Objective related to Monitor. Plan ons my
Blood to Initiate IV FHR patient
loss as fluids as Monitored fluid
manifeste ordered by volume is
d by vital physician. Initiate IV maintaine
sign Plan to Place fluids as d.
changes. the patient in ordered by
left lateral physician.
position. Place the
patient in
left lateral
position.
04 Subjective Disturbed Client will 1. To review 1. Changes Client
Client report- sleep report changes in in normal reports
 Difficulty pattern improvem normal sleep sleep increased
in falling related to ent in requirement requirement sense of
asleep puerperal sleep/rest. associated with s associated well-being
sepsis as delivery. with and
 Interrupte manifeste delivery feeling
d sleep d by 2. To determine assessed. rested.
during interrupte current sleep
mid- d sleep, pattern.
difficulty 2. Current
night.
in falling 3. To suggest sleep pattern
 Not comfortable assessed and
asleep,
feeling position with found to be
not
well feeling pillow between irregular and
rested well legs for support intermittent
during rested under mattress. of 5 hours
daytime. during only
4.To evaluate 3. Client
daytime.
the level of suggested
Objective fatigue. side-lying
On Encourage position
observation- client to rest 1- with pillow
 Fatigue 2 hours during between
daytime and legs for
and
obtain 8 hours support
lethargy. of sleep per under
 Difficulty night. mattress.
in
focusing. 5. To provide
information 4. Level of
 Dark
about normalcy fatigue
circles of moderate assessed.
visible fatigue. Client was
under Reassess encouraged
eyes. commitments to rest 1-2
to job and hours during
family. daytime and
obtain 8
hours of
sleep
between 9
pm to 6 am
per night.

5. Client
was
provided
information
about
normalcy of
 moderate
fatigue.
Client’s
commitment
to job and
family and
found not
hard to be
fulfilled.
05 Subjective Deficient Client will 1. To establish 1. A trusting Client
Client knowledg demonstrat trusting relationship demonstra
reports- e e relationship with client te
 Inadequate regarding understand with client and was understan
understand puerepura ing of develop mutual established ding of
ing of l sepsis as coping and goals for by inter coping
manifeste express learning. personal and
disease
d by realistic relationship express
conditions. requests expectatio 2. To provide skills and realistic
 Lack of for ns. information certain goals expectatio
experience informatio about normal established ns about
or n, physiological for mutual puerepural
statements changes leaning. sepsis.
exposures
of associated with
concerns, 4th stage of 2. Detailed
Objective misconce labour. information
On ption. about
observation 3.To discuss normal
client- when to notify physiologica
 Requests physician. l changes
for associated
3. informat with third
informatio ion and trimester.
n skills
 Statements needed
of for 3. The client
understa was taught
concerns
nding when to
or and notify the
misconcep coping physician.
tions after
 Inappropri birth. 4.Client was
ate 4. To taught about
provide information
behaviors
health and skills
agitation, needed for
educatio
apathy. n about understandin
puerepur g and coping
al sepsis. after birth.

Provided
 health
education
about
puerepural
sepsis.

HEALTH EDUCATION

Medication: -

* Explained mother and family the importance of taking medicine in correct time and
dose.

* Explained not to neglect the course of treatment and instruet the importance of
completing treatment regimen.

* Instruct mother and family to maintain hygiene during medication and handle with
clean hands.

Nutrition

* Advice and educate the mother and family about importance of good nutritious diet
in haemorrhage condition.

* Explain foods rich in iron e.g. spinach, fenugreek, dates etc.

* Instruct to have milk and milk products and explain its importance in mother health
and lactation and encouraged to have soft diet like dahlia.

Rest and sleep: -

* Hard and strenuous activities should be avoided in the beginning after and
gradually it should be increased.

* Instruct to be in bed rest and in comfort position as she feel good.

Exercise: -

* Explained the importance of postnatal exercise to strengthen the weak abdominal

muscle like pelvie tilt exereise, tailor sit, sleeping position, brisk walk in the morning
and evening. etc.

* Day-to-day domestic and social activities can start gradually.

* Teach deep breathing exercise in relaxation and improving cireulation like palm
method, balloon method, candle method, ete.
Care of the vulva: -

* Clean the vulva after each and every urination and defecation. * Inspect the vulva
for any presence of infection or discharge.

* Use a sterile pad in vulva for control of bleeding. * Pad should be changed
frequently if more bleeding is there.

* Check the pad for foul smelling, excessive elots and pus particles.

Care of the breast: -

* Breast should be cleaned before and after the feeding.

* Inspect the breast and nipples for any presence of redness, edema and discharge.

* Check the breast and nipples for crack and engorgement.

* Palpate the both breast for presence of any mass and gland formation.

Follow up: -

* Teach mother and family to report immediately in:

For mother fever, excessive pain in abdomen, dyspnea, breast swelling or pain,
burning mieturation, depression, active vaginal bleeding, fever with chills.

For newborn> poor suckling of breast milk, hypothermia, hyperthermia, skin changes,
elimination problems etc.

Family planning: - Education is given regarding family planning.

* Aware mother and family regarding health services about family planning.

* Explain about the importance of breast feeding in spacing and baby's health and
advice to breastfeed baby till6 month only breastfeed.

Immunization: -

* Explain the mother regarding immunization schedule. Aware mother and family
member not to give milk after giving polio vaccine

CONCLUSION

My client Mrs. Sunita W/O Mr.Rakesh was admitted in Dr. B.R.A.M. Hospital,
Raipur having the case of 38 weeks pregnancy with puerperal sepsis on at 10:00 AM.
Now with the help of the treatment and care provided to her, she is able to cope up
with her condition. Her prognosis was good.
 BIBLIOGRAPHY
BOOK REFERENCES:-

1). John T. Queenan, John C. Hobbins, Catherine Y.200s. Protocols for high-risk pregnancies
Spong. 4th edition.

2) Dutta DC,Text book of Obstretics.2007, new central books agency: page 246-250

3) Daftery Shirish N.,Chakrevarty Sudip,assisted by Daftery.S.:2007.Manual of

Obstretics.2edition.page no 230- 235

4) Maternal & Child Nursing Seventh Edition Vol.1 page 413.

5) Maternity nursing, Lowdermilk Perry, seventh edition, chapter 23. page 751. 6) Maternal
Neonatal Nursing Lippincott manual of Nursing Practice.

NET REFERENCE:-