Care of Mother and Child At-Risk or with
Problems (Acute and Chronic)- Lecture
STUDENT ACTIVITY SHEET
LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT
CLIENT (GESTATIONAL CONDITIONS-PLACENTA PREVIA
AND ABRUPTIO PLACENTA)
LEARNING OUTCOMES:
At the end of the lesson, the student nurse can:
1. Define Placenta Previa and Abruptio Placenta in relation to
pregnancy, including pre-existing factors that contribute to its
development.
2. Integrate knowledge of Placenta Previa and Abruptio
Placenta in relation to pregnancy and nursing process to
achieve quality maternal and child health nursing care
LESSON PREVIEW/REVIEW (5 minutes)
MAIN LESSON (50 minutes)
Causes of Bleeding in the Third Trimester of Pregnancy
(Please refer to Chapter 21: Nursing Care of A Family Experiencing a Sudden Pregnancy Complication-Bleeding During
Pregnancy p. 537-541)
PLACENTA PREVIA
It is the low implantation of the placenta in the uterus;
as the cervix softens & begins to efface & dilate, placental It is the premature separation of the normally implanted
sinuses are opened causing progressive hemorrhages
Four Degrees of Placenta Previa
1. Low-lying Placenta- implantation in the lower
rather than in the upper portion of the uterus
2. Marginal Implantation- the placenta edge
approaches that of the cervical os.
3. Total Placenta Previa-implantation that totally
obstruct the cervical os
*The degree to which the placenta covers the internal
cervical os is generally estimated in percentages:
100%, 75%, 30%, and so forth.
This document and the information thereon is the property of PHINMA
Education (Department of Nursing)
BS NURSING / SECOND YEAR
Session # 10
Materials:
Book, pen, SAS and notebook
References:
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
th
Maternal and Child Health Nursing, 8 Edition.
USA: Lippincott Williams and Wilkins
Perry, Shannon, Hockenberry, Marilyn J.,
Lowdermilk Deitra Leonard and Wilson, David
th
(2015) Maternal and Child Nursing Care,6
Edition. USA: Elsevier
Hockenberry, Marilyn and Wilson, David (2013)
Wong’s Essential of Pediatric Nursing,9th
Edition. USA: Elsevier
PREMATURE SEPARATION OF THE PLACENTA
(ABRUPTIO PLACENTA)
th
placenta after the 20 week of pregnancy, typically with
severe hemorrhage
Types of Abruptio Placenta:
1. MARGINAL ABRUPTION- separates only at the
edges causing vaginal bleeding & a little pain
2. CENTRAL (CONCEALED) ABRUPTION- may not
result in bleeding but increasing uterine irritability
& tenderness
3. COMPLETE SEPARATION (100%)- complete
separation from the uterine wall resulting in
profuse bleeding
1 of 7
 PREMATURE SEPARATION OF THE PLACENTA:
DEGREES OF SPEARATION
GRADE CRITERIA
0 No symptoms of separation are apparent from
maternal or fetal signs; the diagnosis is made after
birth, when the placenta is examined and a
segment of the placenta shows a recent adherent
clot on the maternal surface.
1 Minimal separation, but enough to cause vaginal
bleeding and changes in the maternal vital signs;
no fetal distress or hemorrhagic shock occurs,
however.
2 Moderate separation; there is evidence of fetal
distress; the uterus is tense and painful on
palpation.
3 Extreme separation; without immediate
interventions, maternal hypovolemic shock and
fetal death will result.

Assessment Assessment
 Painless  Sharp, stabbing pain
 (+) bright red bleeding  rigid, board like abdomen
 (+/-) vaginal bleeding
 Abdominal circumference may increase as
bleeding increases; dark red bleeding
 Shock if bleeding is extensive
 DIC may occur as the fibrinogen is used up to stop
the bleeding
Etiology Etiology

 Increased parity  Multiparity,

 advanced maternal age  preeclampsia,
 past CS births  direct trauma,
 past D & C  advanced maternal age,
 multiple gestation  Drug use or smoking,
 male fetus (?)  uterine anomalies,
 short umbilical cord
Diagnosis Diagnosis

 Ultrasonography- 95% accurate, detects site of  Clinical diagnosis- symptomatic

implantation  Ultrasound- detects bleeding
 Clotting studies- reveal DIC: small fibrin clots in
the circulation
Hypofibrinogenemia: decrease normal fibrinogen
results in the absence of normal blood coagulation

Management Management

This document and the information thereon is the property of PHINMA 2 of 7

Education (Department of Nursing)
  Bed rest in a side-lying position  Bed rest, left side-lying position
 Assess VS, bleeding (1 cup = 240 ml, 1 Tbsp =  IVT (18-gauge needle for fluid replacement)
15 ml), pain, shock, contractions, FHR  O2 therapy
 Monitor hgb, hct, platelet, PT, PTT; do blood  Monitor: FHR, maternal VS q 5 to 15 mins,
typing & cross-matching fibrinogen levels, I & O, labor onset, pain, bleeding
 Never perform vaginal or pelvic exam  Psychological support
 Vaginal exams are done only in a double set-  Prepare for emergency CS or vaginal birth
up to allow emergency CS  Observe for postpartum complications
 Begin IVT & prepare for possible BT
 Double set-up: room is set up for vaginal delivery Complications
and emergency CS

Hemorrhagic shock
 If labor has begun, bleeding is continuous or fetus

DIC
is compromised, birth must be accomplished

Couvelaire uterus- the placenta does not contract
 If bleeding stops, FHT & maternal VS are of good
well postpartum
quality hospital observation for 48h, sent on bed
 CVA
rest at home
 Hypofibrinogenemia
 If labor has begun, bleeding is continuous or fetus
is compromised, birth must be accomplished  Renal failure
 If bleeding stops, FHT & maternal VS are of good  Infection
quality hospital observation for 48h, sent on bed  Prematurity
rest at home COUVELAIRE uterus (UTEROPLACENTAL
APOPLEXY)

 if the placenta separates first at the center, blood

pools under the placenta & is hidden from view;

 blood then may infiltrate uterine muscles forming a

hard, board like uterus with no apparent bleeding

CHECK FOR UNDERSTANDING (30 minutes)

You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Multiple Choice

This document and the information thereon is the property of PHINMA 3 of 7

Education (Department of Nursing)
1. Loisa who is 22 weeks pregnant, has a routine ultrasound performed. The ultrasound shows that the placenta
is located at the edge of the cervical opening. As the nurse you know that which statement is FALSE about this
finding:
A. This is known as marginal placenta previa.
B. The placenta may move upward as the pregnancy progresses and needs to be re-evaluated with another ultrasound at
about 32 weeks gestation.
C. The patient will need to have a c-section and cannot deliver vaginally.
D. The woman should report any bleeding immediately to the doctor.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2. Krizzia who is 34 weeks pregnant is diagnosed with total placenta previa. Krizzia’s blood type is A positive.
What nursing interventions below will you include in the patient’s care? Select all that apply:
A. Routine vaginal examinations
B. Monitoring vital signs
C. Administer RhoGAM per MD order
D. Assess internal fetal monitoring
E. Placing patient on side-lying position
F. Monitoring pad count
G. Monitoring CBC and clotting levels
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Claudia A 28-year-old female, who is 33 weeks pregnant with her second child, has uncontrolled hypertension.
What risk factor below found in her health history places her at risk for abruptio placentae?
A. childhood polio
B. preeclampsia
C. c-section
D. her age
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Nana Deka a 36-year-old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and symptoms can
present with abruptio placentae? SELECT ALL THAT APPLY:
A. Decrease in fundal height
B. Hard abdomen
C. Fetal distress
D. Abnormal fetal position
E. Tender uterus
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

5. The following are patients who are at risk for developing placenta previa: SELECT ALL THAT APPLY
A. A 37-year-old woman who is pregnant with her 7th child.
B. A 28-year-old pregnant female with chronic hypertension.
C. A 25-year-old female who is 36 weeks pregnant that has experienced trauma to abdomen.
D. A 20-year-old pregnant female who is a cocaine user.
ANSWER: ________

This document and the information thereon is the property of PHINMA 4 of 7

Education (Department of Nursing)
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. You’re performing a head-to-toe assessment on a patient admitted with abruptio placentae. Which of the
following assessment findings would you immediately report to the physician?
A. Oozing around the IV site
B. Tender uterus
C. Hard abdomen
D. Vaginal bleeding
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. Which statement is TRUE regarding abruptio placenta?

A. This condition occurs due to an abnormal attachment of the placenta in the uterus near or over the cervical opening.
B. A marginal abruptio placenta occurs when the placenta is located near the edge of the cervical opening.
C. Women who have abruptio placenta complains of painless vaginal bleeding.
D. Fetal distress is not common in this condition as it is in placenta previa.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Select all the signs and symptoms associated with placenta previa:
A. Painless bright red bleeding
B. Concealed bleeding
C. Hard, tender uterus
D. Normal fetal heart rate
E. Abnormal fetal position
F. Rigid abdomen
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

9. Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when
the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are
released into mom’s circulation, leading to clot formation and then clotting factor depletion.
A. Placenta previa, fibrinogen
B. Placenta previa, platelets
C. Abruptio placenta, fibrinogen
D. Abruptio placentaA, thromboplastin
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10.Kristy a patient who is 25 weeks pregnant has partial placenta previa. As the nurse you’re educating the
patient about the condition and self-care. Which statement by Kristy that requires you to re-educate her?
A. “I will avoid sexual intercourse and douching throughout the rest of the pregnancy.”
B. “I may start to experience dark red bleeding with pain.”
C. “I will have another ultrasound at 32 weeks to re-assess the placenta’s location.”
D. “My uterus should be soft and non-tender.”

ANSWER: ________

This document and the information thereon is the property of PHINMA 5 of 7

Education (Department of Nursing)
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
2. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
3. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
4. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
5. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
6. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
7. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
8. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
9. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________
10. ANSWER: ________
RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PERIOD 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PERIOD 3
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

This document and the information thereon is the property of PHINMA 6 of 7

Education (Department of Nursing)
AL STRATEGY: CAT: Student Response Cards
1. You instructor will give you response card with answers on it and will disseminate.
2. Your instructor will ask a question to the class regarding information just covered in your lesson.
3. You and your classmates will hold up their card with the corresponding answer to the question of your instructor.

(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-
Premature Rupture of Membranes p.546 and Hypertensive Disorders in Pregnancy p.547)

This document and the information thereon is the property of PHINMA 7 of 7

Education (Department of Nursing)