CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

MODULE 04 – THIRD TRIMESTER CONDITIONS [PLACENTA PREVIA, ABRUPTIO

NCM 0109
PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES]
● The placenta might not be able to supply
OUTLINE adequate nutrients and oxygenation to the
I Third Trimester Conditions fetus
A Placenta Previa
B Premature Separation of the Placenta (Abruptio
Placenta) FOUR DEGREES OF PLACENTA PREVIA
C Premature Rupture of Membranes
GRADE I. LOW-LYING PLACENTA (LOW IMPLANTATION)

● Implantation in lower rather

INTRODUCTION than upper portion of uterus
(normally, placenta implants in
PRETEST (True or False)
the upper portion of the uterus)
● Certain parts is present in the
1. The four classification of placenta previa include: lower portion
High-lying placenta, marginal implantation, partial ● >3 cm
placenta previa, and total placenta previa.
GRADE II. MARGINAL IMPLANTATION
2. After the diagnosis of placenta previa, an internal
examination should be done to detect the degree
● Placenta edge or lower border of
of cervical dilatation. the uterus approaches that of
the cervical os
3. In abruptio placenta, the placenta appears to have ● Near the edge of the cervix
been implanted correctly. Suddenly, it begins to ● Within 3 cm
separate and results in bleeding.

GRADE III. PARTIAL PLACENTA PREVIA

4. A red-colored Nitrazine paper suggests premature
rupture of membranes.
● Implantation occludes a portion
5. A woman is encouraged to do tub bathing, of the cervical os
● Partly over the cervix
douching, and coitus if with premature rupture of ● A part of placenta obstructs the
membranes. cervix but does not completely
obstruct
MODULE PROPER

PLACENTA PREVIA GRADE IV. TOTAL/COMPLETE PLACENTA PREVIA

● Implantation that totally
● LOW IMPLANTATION OF THE PLACENTA obstructs the cervical os (there
○ Most common cause of painless vaginal will be an evident bleeding
bleeding in the third trimester of pregnancy especially when there is a
○ May be caused by uterine abnormalities contraction)
○ Forces the placenta to spread to find an ● The amount of bleeding may not
adequate exchange surface necessarily reflect the real
○ Normal Implantation amount of blood loss (there
● Occurs on the upper uterine fundus, rich in may be a concealed bleeding =
blood supply look for other signs and
● FERTILIZATION, IMPLANTATION, AND ATTACHMENT symptoms)
○ Fertilization and fetal implantation take place ● CS delivery is done
● Occurs in 5/1000 pregnancies
● EFFECTS TO PREGNANCY I. ASSESSMENT
○ ↑ congenital anomalies
RISK FACTORS

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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES

● Increased parity bleeding of damaged blood vessels and villi

○ Caused by trauma (tissue (exposes uterine sinuses)
scarring/endometrial and myometrial ○ Creates an emergency situation as the open
damage) and sloughing off from previous vessels of the uterine deciduas (maternal
pregnancy blood) place the mother at risk for hemorrhage
● Leads the zygote to look for an area that will ○ Painless as there is no pressure on the adjacent
make it grow well tissues
● Advanced maternal age
○ Linked to changes of the reproductive system CHARACTERISTICS
and aging of uterine vasculature ● Bright red since it is fresh
● Pregnancy history blood and there is close
○ Past cesarean births COLOR proximity of uterine
○ Previous miscarriage endometrium on the lower
○ Previous induced abortion portion, cervix to vagina
○ Past uterine curettage (suction curettage) for ● Abrupt/sudden; does not
spontaneous abortion begin until the lower uterine
● Can lead to the development of adhesions segment starts to
that could limit the space where the differentiate its shape from
placenta can implant ONSET
the upper uterine segment
● Multiple gestation (two separate eggs fertilized by ● It may slow after the initial
two separate sperm) hemorrhage but linger as
○ Due to increase in the placental mass continuous spotting
● Male fetus Not associated with increased
○ Indicated in literatures but reason is unclear ASSOCIATED activity or participation in
● Asian/African women FACTORS
sports
● Cigarette smoking/cocaine use d/t
vasoconstriction ● Decreased fetal oxygen and nutrient supply
○ Narrowing of blood vessels make it difficult for ○ The abnormal implantation (loose)
the placenta to implant normally compromises fetal supply
● Preterm labor d/t placental loosening
SIGNS AND SYMPTOMS
ADDITIONAL ASSESSMENT
● S/Sx do not normally occur unless the uterine
MATERNAL
segment will start to differentiate in shape from the FETAL COMPLICATIONS
COMPLICATIONS
upper uterine segment, as well as (+) uterine
contractions and (+) cervical dilatation ● Severe bleeding ● Premature birth
during pregnancy, ● LBW
REMEMBER: PREVIA labor, and delivery ● Respiratory issue due to
● Painless bright red bleeding ● Blood loss underdeveloped lungs
● Relaxed soft and nontender uterus ● Early delivery (<40 ● Congenital anomalies
● Episodes of mild–profuse bleeding (cervical weeks) ● IUGR
effacement tears vessels in placenta) ● Placenta accreta ● (+) Bleeding causes
● Visible bleeding (nasa baba ‘yung placenta then spectrum fetal hypoxia = fetal
malapit sa cervix and vagina) ● Placental abruption development is affected
● Intercourse post-bleeding (malapit lang ‘yung
placenta sa cervix so it is easily damaged) II. DIAGNOSIS
● Abnormal fetal position (hindi pwede cephalic kasi
nakaharang ‘yung placenta) ● Early detection of placenta previa is made possible
by routine sonography in the first and second
● Painless vaginal bleeding (week 30) trimesters of pregnancy
○ Caused by inability of the placenta to stretch ○ VAGINAL ULTRASOUND
to accommodate the changing shape of the ● Shows the position of the fetus, placenta,
cervix (dilatation d/t contractions) → small and cervix
portion of the placenta loosens leading to

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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES

III. THERAPEUTIC MANAGEMENT ○ Accurately determines placenta’s location

(how much placenta covers the
A. BASELINE DATA AND HEALTH HISTORY cervix/classification)
● Helps HCP assess whether vaginal
● Duration of Pregnancy: determine AOG and
birth—the safest option for the infant—is
possibility of preterm labor
feasible
○ Be prepared to give lung surfactant to those
with younger AOG NSD ● Previa is under 30%
● Bleeding: time began, accompanying pain, color
● Previa is over 30% and the fetus
(red blood = fresh or continuing), prior episodes of
is mature
bleeding during pregnancy, and management
● Transverse uterine incision may
○ Weigh linens and pads and estimate blood loss
still be possible, although the
through cups and tablespoons CS
uterine cut must be made high,
● Estimates the present rate of blood loss
possibly vertically above the low
● Weigh the perineal pads before and after
implantation site of the
use then calculate the difference
placenta
○ Ask what she has done to stop the bleeding; if
she used a tampon to note for possibility of
● (-) PELVIC OR RECTAL EXAMINATION
hidden bleeding and risk for infection
○ Do not attempt if there is (+) painless bleeding
○ Inspect the perineum for bleeding
late in pregnancy
● Gynecologic History: ask for prior cervical surgery
○ Any agitation of the cervix when there is a
or premature cervical dilatation
placenta previa might lead to tearing of the
● Vital Signs:
placenta causing further bleeding
○ Continuously assess blood pressure (every 5–15
○ Massive hemorrhage is fatal to both the mother
minutes)
and baby
● Determines possibility of hypovolemic
○ Can cause additional placental separation and
shock and if the patient is losing too much
tearing of the placenta
blood
○ DO NOT perform internal examination and
○ Monitor urine output frequently, as often as
oxytocin administration to stimulate labor
every hour, as an indicator her blood volume is
unless UTZ is done (shows that fetus needs to
remaining adequate to perfuse her kidneys
be expelled)
● Laboratory Values: Hg, Hct, prothrombin and partial
thromboplastin time, fibrinogen, platelet count,
If only a minimum previa is detected, the HCP may
blood type and cross-matching, and antibody
attempt a careful speculum examination of the
screening
vagina and cervix to establish degree of fetal
○ Detects possible clotting disorder and prepares
engagement and to rule out another cause for
for blood transfusion
bleeding (e.g., ruptured varices and cervical trauma).

B. IMMEDIATE CARE MEASURES CONDITIONS FOR PERFORMING VAGINAL EXAM

● POSITIONING
✅ Should be done in a double set-up room (OR or in
a fully-equipped birthing room)
○ Place the woman immediately on bed rest in a
○ Hemorrhage may occur with manipulation,
side-lying position to increase blood flow to
thereby requiring immediate CS birth to
the uterus and improve uteroplacental
remove the child and bleeding placenta to
insufficiency
contract the uterus
● TEST STRIP PROCEDURES
○ Perform alkali denaturation test (Apt) or
✅ Oxygen equipment (10L/min via non-rebreather
mask) should be made available
Kleihauer-Betke test to check whether the
○ Replaces oxygen lost from bleeding
blood is of fetal or maternal origin
○ Prevents fetal distress
● SONOGRAM
○ WOF fetal distress, brady/tachycardia, and
○ Anticipate the order for
late decelerations
transvaginal/abdominal sonogram

● EXTERNAL MONITORING EQUIPMENT

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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES
○ Attach to check for fetal well-being and
presence of late decelerations (likely d/t
placental abnormalities)
○ To record fetal heart sounds and uterine
contractions (an internal monitor for either fetal
or uterine assessment is contraindicated)
● INTRAVENOUS FLUID THERAPY
○ Use a large-gauge catheter for rapid
replacements of fluids or to prepare for blood
transfusions
C. CONTINUING CARE MEASURES
● Point at which a diagnosis of placenta previa is
made and the AOG dictates final management
● DECISIONS ABOUT PREGNANCY AND DELIVERY
○ Birth Decision
● >37 weeks AOG at the time of initial
bleeding
● (+) amniocentesis analysis [favorable
lecithin:sphingomyelin ratio]
● Delivery must take place in a controlled
setting in case more than the usual blood
loss occurs
○ Continuation of Pregnancy
● Initial bleed occurs <34 weeks AOG and
subsides
● Fetus not yet mature
● Continue pregnancy until bleeding occurs
again, labor begins, the fetus shows
symptoms of distress, or the fetus is 36–37
weeks
C.1. (+) LABOR, CONTINUOUS BLEEDING, FETAL
DISTRESS, AND PLACENTA PREVIA TOTALIS
● Hospital bed rest for 24–48 hours
● Immediate birth regardless of AOG usually via
cesarean section
C.2. BLEEDING HAS STOPPED, FHT AND MATERNAL VS
OF GOOD QUALITY, <36 WEEKS AOG, AND GRADE
I–III/PARTIAL PLACENTA PREVIA
● Expectant monitoring is done as management
○ Monitor vital signs
○ Provide IV fluids
○ If delivery can be delayed, check if NSD is
possible
● If the bleeding stops, she can be sent home with a
referral for bed rest and home care
○ Prolonged walking and sitting is prohibited
○ Some patients have personal doppler
C.3. ADDITIONAL MANAGEMENT
● Careful assessment of fetal heart sounds
● Laboratory tests (Hg and Hct) are conducted
frequently
● BETAMETHASONE (Pregnancy Category C)
○ Steroid that hastens fetal lung maturity as it
accelerates the production of lung surfactant
even if the baby is born prematurely
○ May be prescribed if the fetus is >34 weeks AOG
ACTION
● Anti-inflammatory; immunosuppressive
● Prevents respiratory distress syndrome
● Given 12–24 hours before birth
DOSAGE AND TIMING
● 12–12.5 mg IM
● Repeat after 24 hours and 1–2 weeks
POSSIBLE ADVERSE EFFECTS FOR THE MOTHER
Burning, itching, irritation at injection site, swelling
tachycardia, headache, dizziness, weight gain, Na
and fluid retention, high risk for infection (long term
use)
NURSING INTERVENTIONS
● Explain purpose of the drug
● Assist with measures to halt preterm labor if
indicated
● Continue to monitor maternal VS and FHR
● (+) Tocolytic Agents
○ WOF cardiac decompensation d/t
drug-to-drug interactions and as steroids
may change the structure of the heart
○ Observe for ↑PR, ↓BP, and (+) edema
● Assess for S/Sx of possible infection with
long-term use
● (-) COITUS
○ Coitus may result to another cause of bleeding
● ADEQUATE REST AND CALL HCP AT ANY SIGN OF
VAGINAL BLEEDING
IV. NURSING MANAGEMENT
POSSIBLE NURSING DIAGNOSIS
● Fear r/t outcome of pregnancy after episode of
placenta previa bleeding
● Deficient fluid volume r/t hypovolemia secondary
to blood loss
● Impaired gas exchange (fetus) r/t decreased
blood volume and maternal hypotension
● Anxiety r/t concern for own personal status and the
baby’s safety
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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES
NURSING INTERVENTIONS
● Provision of emotional support to the client
● Allow the client to voice out her concerns and
provide her with a correct understanding of her
current condition
● POSTPARTUM PERIOD
○ Be sure a woman has adequate time with her
child
● They may be worried that because of the
problem with placental implantation, there
might be something wrong with the baby
○ Check if the mother feels comfortable taking
care of the child before leaving the facility
● WOF POSTPARTUM HEMORRHAGE
○ Placental site is in the lower uterine segment,
which does not contract as efficiently and
adequately as the upper uterine segment
● WOF ENDOMETRITIS
○ Placental site close to cervix (can cause
infection or inflammation in that area)
● PLACENTA LARGER
○ As the uterine blood supply is less in the lower
segment, the placenta tends to grow larger
than it would normally, leaving a larger
denuded surface area when it is removed
PREMATURE SEPARATION OF THE PLACENTA
(Abruptio Placenta)
● Unlike placenta previa, in premature separation of
the placenta, the placenta appears to have been
implanted correctly
● PREMATURE SEPARATION that results in bleeding
○ The separation occurs before the fetus is born
and late in pregnancy; even as late as during
the 1st or 2nd stage of labor until it reaches the
full cervix dilation and effacement and the fetal
delivery
○ When the vascular structures supporting the
placenta get severed, placental abruption
occurs due to the sudden stretching of the
uterus
○ NORMAL: Placenta separates on the 3rd stage
of labor, which is about 10–20 minutes after
fetal delivery
● Occurs in 10% of pregnancies
● Most frequent cause of perinatal death
○ Associated with compromised uteroplacental
perfusion, hindering the fetus from receiving
adequate nutrients
● Because premature separation of the placenta
may occur during an otherwise normal labor, it is
important to always be alert to both the amount
and kind of pain and vaginal bleeding a birthing
parent is having in labor
○ BLEEDING IN ABRUPTIO PLACENTA
● May be visible or concealed
○ Placenta will cover blood (placenta will
lose its function of delivering nutrients
and oxygen to the fetus)
● Mother can experience shock because of
internal bleeding
● WHY IS THIS A PROBLEM?
○ The placenta helps maintain pregnancy, deliver
oxygen and nutrients, and remove waste
○ Once this is compromised, the fetus becomes
in danger as well
DEGREES OF SEPARATION
ASYMPTOMATIC
No symptoms of separation were apparent from
0 maternal or fetal signs; diagnosis made after
birth/retrospectively (may madi-discover na
blood clot sa maternal side ng placenta)
MINIMAL SEPARATION
Minimal separation, but not enough to cause
1 vaginal bleeding and changes in the maternal
vital signs; no fetal distress or hemorrhagic shock
occurs; 40% incidence, can safely deliver the fetus
MODERATE SEPARATION
There is (+) evidence of fetal distress; the uterus is
tense and painful on palpation with tetanic
2 contractions; 45% incidence; increased PR of
mother; normal BP; possible moderate amount of
bleeding
EXTREME SEPARATION
Board-like uterus; without immediate
3 interventions = maternal hypovolemic shock,
painful uterine contractions, and fetal death will
result; 15% incidence
Unless the separation is minimal (grades 0 and 1),
pregnancy must be terminated or immediate
delivery is needed because the fetus is in distress as
it cannot obtain adequate oxygen and nutrients
I. ASSESSMENT
PREDISPOSING FACTORS
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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES
● UNKNOWN
OBSTETRIC HISTORY
●
○ Multigravida status (high parity, possibly d/t
overstretching of the uterus)
GYNECOLOGIC HISTORY
●
○ Advanced maternal age
○ Rapid decrease in uterine volume (sudden
release of AF and sudden decrease of pressure
inside the uterine cavity will suck the
attachment of the placenta to the uterine wall;
PROM)
○ Rapid uterine decompression (hydramnios;
multiple gestation)
● Suddenly changes the structural function of
the uterus
○ Previous history of abruptio placenta
○ Increased alpha-fetoprotein in 2nd trimester
● PHYSICAL FACTORS
○ Short umbilical cord (when baby moves, it pulls
the placenta)
○ Chronic hypertensive disease
○ Pregnancy-induced hypertension (narrowing of
the blood vessels and decreased blood supply
to the placenta)
○ Direct trauma (automobile accident or intimate
partner violence)
○ Vasoconstriction from cocaine or cigarette use
○ Thrombophilic conditions (e.g., disseminated
intravascular coagulation)
○ Chorioamnionitis (infection of the fetal
membranes and amniotic fluid)
○ Male sex
○ Amniocentesis (port-wine color)
○ Abdominal trauma; automobile
accident/physical abuse
● SOCIAL FACTORS
○ Low socio-economic status
SIGNS AND SYMPTOMS
If your health care provider suspects placental
abruption, they will do a physical exam to check for
uterine tenderness or rigidity. To help identify
possible sources of vaginal bleeding, your provider
will likely recommend blood and urine tests and
ultrasound.
REMEMBER: DETACHED
● Dark red bleeding (naging concealed siya
somewhat and the blood has been there for a
while)
● Extended fundal height d/t blood accumulation
● Tender uterus
● Abdominal pain
● Concealed bleeding (bleeding from inside =
shock)
● Hard abdomen (rigid)
● Experiencing DIC = d/t release of thromboplastin =
clots = fibrinolysis to dissolve clots = depletion of
clotting factors = hindi na-a-address ‘yung
bleeding sa uterus d/t AP
● Distressed baby: placenta delivers o2 and nutrients
GENERAL S/SX
● Sharp, stabbing pain high in the uterine fundus
○ The placenta is attached to the upper uterine
fundus
○ Pain is felt upon separation
○ If labor begins with the initial separation, each
contraction will be accompanied by pain over
and above the pain of the contraction
● Dark red and heavy bleeding
○ Dark red: unlike placenta previa, the location
involved is in the upper uterine fundus.
Therefore, the blood would not be fresh.
○ Not all cases of abruption placenta will lead to
massive bleeding, others will be a concealed
bleeding
● The amount of vaginal bleeding varies, but
it does not determine the severity of the
placental separation as it is possible for the
blood to remain inside the uterus
FIVE CLASSIC S/SX
● Vaginal bleeding
○ Depends on placental separation first and does
not reflect true amount of blood loss
○ External bleeding: placenta separates first at
the edges/margins (duncan; marginal
AP/marginal sinus rupture); blood escapes
freely and into the cervix, leading to vaginal
bleeding
○ Internal bleeding: placenta separates first at
the center (schultz; central AP); blood pools
under the placenta as the edges did not
separate yet
● Abdominal and lower back aching/dull pain
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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES
● Tenderness on uterine
palpation (localized to site
of abruption)
○ Due to accumulation of
blood
○ Uteroplacental apoplexy
or Couvelaire uterus:
board-like, hard uterus;
extravasation/infiltration
of blood into the uterine
musculature especially with internal bleeding
○ Requires hysterectomy
● Uterine irritability with frequent low-intensity
contractions
● High uterine resting tone
● Signs of hypovolemic shock, fetal death
○ Tachycardia, hypotension, tachypnea, weak
diminished/thready peripheral pulses
S/SX INDICATING CONCEALED HEMORRHAGE
● Increase in fundic height and abdominal girth
○ Inconclusive sign
○ Associated with accumulation of blood
● Hard, board-like abdomen
● Persistent abdominal pain
● Systemic signs of early hemorrhage/impending
hypovolemic shock caused by blood loss
○ Beginning Shock: hypovolemic shock
● Lightheadedness and syncope (fainting)
because of bleeding internally = ↓ blood
volume; ↓ oxygen saturation
○ Severe Shock
● Rapid respirations: the body would
compensate to increase the oxygen by
increasing respiration because of rapid loss
of blood, and there is decreased RBCs and
hemoglobin, lowering the oxygen and blood
volume in the body (also note for cool and
moist skin and pallor/cyanosis)
● Falling BP: due to falling blood volume
(directly proportional)
● Rapid and thready pulse: tachycardia
(both the mother and fetus) as the heart
compensates by increasing its cardiac
contraction to increase the falling blood
volume and BP
○ Also note for ↓ Hg and Hct levels d/t bleeding
and urine output, restlessness, agitation,
difficulty concentrating
● Persistent late deceleration in FHR r/t
uteroplacental insufficiency even despite changing
the maternal position and administration of oxygen
● Vaginal bleeding can be slight or absent as
bleeding is internal or concealed
● Signs of shock whether blood is evident or not
○ The mother might be bleeding internally and
hindi lang nakakalabas sa vagina
● Tense and rigid uterus might also be a sign of
internal bleeding
● Disseminated intravascular coagulation
○ Contributes to severe bleeding (d/t lack of
fibrinogen and platelets)
○ Placental detachment causes damage, which
then results in the escape of thromboplastin
into the maternal circulation
○ Because of this, DIC occurs, consequently
affecting circulation to major organs
II. DIAGNOSIS
● ULTRASOUND: shows location of bleeding and helps
assess the fetus
III. THERAPEUTIC MANAGEMENT
● Because abruptio placenta threatens both
maternal and fetal well-being, it is deemed as an
emergency situation
MANAGEMENT ACCORDING TO DEGREE OF
SEPARATION
CLASS 0: ASYMPTOMATIC
Continuous maternal and fetal monitoring
●
● Mother will receive intravenous (IV) fluids and
supplemental oxygen
CLASS 1: MINIMAL SEPARATION
● Admitted for continuous maternal and fetal
monitoring
● Mother will receive intravenous (IV) fluids and
supplemental oxygen
● Blood work for type and crossmatch
CLASS 2: MODERATE SEPARATION
● Unless contraindicated (eg. fetus is preterm), the
baby will be delivered vaginally
○ If the AOG is less than 34 weeks, the mother will
be closely monitored until she reaches 34
weeks.
● In case of fetal distress, CS delivery is required
● During delivery, fluids and circulatory volume will be
monitored and managed
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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES

● Monitored for postpartum hemorrhage and ● TOCOLYTIC AGENTS: decreases uterine

alterations in the clotting profile
CLASS 3: EXTREME SEPARATION
● Unless contraindicated (eg. fetus is preterm), the
baby will be delivered vaginally
○ If the AOG is less than 34 weeks, the mother will
be closely monitored until she reaches 34
weeks.
● In case of fetal distress, CS delivery is required
● During delivery, fluids and circulatory volume will be
monitored and managed
● Monitored for postpartum hemorrhage and
alterations in the clotting profile
● Blood transfusion is required if vaginal bleeding is
severe
NURSING MANAGEMENT
A. BLEEDING
activity/contractions
○ Administered based on the physician’s orders
● POSITIONING
○ Lateral position with head flat on bed to
increase cardiac return and restrict maternal
movement
● Prevents pressure on vena cava = no
interference with fetal circulation
● Provide simple explanation, reassurance, emotional
support to reduce anxiety (increases oxygen
demand)
C. MONITORING
● FHR and maternal VS every 5–15 minutes
● Note for prolonged fetal bradycardia, recurrent, late
decelerations, and decreased short-term variability
(all signs of possible fetal harm)
● Careful observation of infection in the postpartum
period

● ASSESS BLEEDING: time, accompanying pain, D. ADDITIONAL MANAGEMENT

amount, and kind
● LABORATORY ASSESSMENT
○ Hg, typing and crossmatching (to prepare for
blood transfusion), clotting ability and
fibrinogen levels (to detect DIC)
○ Quick assessment of blood clotting ability
● NR: aspirate 5 mL of maternal blood; place
in a clean and dry test tube untouched →
after 5 min = clot should form
○ If there is no formation of clot, it may be
concluded that there is interference with
blood coagulation
● INTRAVENOUS THERAPY
○ Fluid replacement
● Uncontrolled bleeding places the patient at
higher risk of shock due to blood loss
○ Use a large-gauge needle for rapid blood
transfusion
● IV administration of fibrinogen or
cryoprecipitate prior and during CS if with
DIC to prevent massive bleeding
○ NSS (0.9% sodium chloride) or LRS to maintain
adequate UO
B. PROMOTING TISSUE OXYGENATION
● (-) ABDOMINAL/VAGINAL/PELVIC EXAMINATION
○ May affect already-vulnerable condition of the
area (may result in severe placental
separation)
○ Causes increase in BP
● BIRTH METHOD
○ NSD is preferred since CS results in greater
blood loss and higher risk of hemorrhage
● To terminate the pregnancy especially if
the fetus is no longer receiving oxygen and
nutrients
● WOF FOR EXTENSIVE HEMORRHAGE
○ Leads to shock → circulatory collapse → renal
failure → maternal death
DIFFERENTIAL DIAGNOSIS
Placenta Previa vs Abruptio Placenta
● Bleeding that occurs during the second half of
pregnancy can be due to placenta previa or
placental abruption
● Proper diagnosis of the underlying reproductive
disorder is crucial in creating effective
patient-centered care

● OXYGEN INHALATION PLACENTA PREVIA ABRUPTIO PLACENTA

○ Administered through a mask ONSET
○ Prevents fetal distress and maternal Quiet and sneaky Sudden and stormy
complications such as hypoxia and shock
BLEEDING
● MONITOR FHT

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 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES

External External or concealed ○ Lungs: loss of amniotic fluid inside can cause
the underdevelopment of fetal lungs
COLOR OF BLOOD
(oligohydramnios) causing pulmonary
Bright red Dark venous hypoplasia (incomplete development of lungs
ANEMIA AND SHOCK d/t oligohydramnios) → breathing difficulties
Greater than apparent during delivery → respiratory distress syndrome
To blood loss
blood loss ● BOW helps in developing the lungs by
PREECLAMPSIA stimulating breath-like movements
○ Potter-like syndrome: distorted facial features
Absent May be present
● Non-fluid-filled environment → distorted
PAIN facial features + pulmonary hypoplasia
Only labor; unrelated to (because of the pressure between the fetus
Severe and steady
placenta previa and the uterine wall; abnormally small
UTERINE TENDERNESS lungs) → potter-like syndrome (widely
Absent Present separated eyes, broad nose, low set ears,
UTERINE TONE receding chin)
○ Fetal presentation: malpresentation before
Soft and relaxed Firm and stony hard
engagement occurs
UTERINE CONTOUR
Enlarged and changes in I. ASSESSMENT
Normal
shape
FETAL HEART TONE RISK FACTORS

Present Present or absent

● UNKNOWN
ENGAGEMENT ● OBSTETRIC HISTORY
Absent ○ Multiple pregnancy (sudden release of
(as the presenting part maternal pressure)
May be present
is the placenta, not the GYNECOLOGIC HISTORY
●
fetus)
○ Previous history of PROM
PRESENTATION
○ Hydramnios
May be abnormal No relationship ○ PP/AP
○ Incompetent cervix
PREMATURE RUPTURE OF MEMBRANE ○ Bleeding during pregnancy
● PHYSICAL FACTORS
● Breaking open of membranes (amniotic sac), ○ Chorioamnionitis (infection of the fetal
resulting in a loss of amniotic fluid before 37 weeks membrane and amniotic fluid)/endometritis
of pregnancy (infection of the endometrium)
● The cause of preterm rupture is unknown, but it is ○ Tobacco use (due to vasoconstriction)
associated with infection of the membranes ○ Low BMI
(chorioamnionitis) and physiologic weakening ○ UTI (infections)
● Occurs in 5–10% of pregnancies ○ Maternal genital tract anomalies
● SERVING AS A CUSHION AND PROTECTION from ○ Trauma
pressure changes and infection is one of the ○ Amniocentesis (punctures the B.O.W.)
primary functions of an intact bag of water ● SOCIAL FACTORS
● WHAT HAPPENS WHEN THE B.O.W. IS ○ Low socio-economic status
COMPROMISED?
○ Infection: ruptures early in pregnancy → no seal
SIGNS AND SYMPTOMS
to the fetus (there is no protective barrier) →
uterine and fetal infection ● Sudden gush of clear fluid from the vagina with
○ Cord: the loss of amniotic fluid will increase continued minimal leakage
pressure, prolapse (protrudes through the
vaginal canal), and compression on the cord
MATERNAL COMPLICATIONS
● Negatively affects fetal circulation → no
fetal nutrient supply

NCM 0109|9
 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES
● Rupture of membranes (causing release of
prostaglandins → stimulating uterine contractions)
○ Leads to preterm labor, ending the pregnancy
regardless of AOG
● Abruptio placenta (AP)
● Retained placenta
● Hemorrhage
● Maternal sepsis
● Maternal death (related to sepsis)
II. DIAGNOSIS
AMNIOTIC FLUID VS URINE
An exam may be done with a tool (speculum) to look
inside the vagina. The healthcare provider will look for
fluid leaking from the cervix. However, this is
discouraged since the risk of infection is significantly
higher when the membranes have ruptured. Since it is
difficult to differentiate amniotic fluid from urine, the
fluid will also be tested. Testing may include:
● POOLING OF FLUID AT VAGINA
○ Sterile vaginal speculum examination
● Color of AF (clear)
○ Different from urine by appearance
● NITRAZINE PAPER TEST OR pH BALANCE TESTING
○ The pH balance of amniotic fluid is different
from vaginal fluid and urine
○ The healthcare provider will place the fluid on a
test strip to check the balance
● BLUE: alkalinic; amniotic fluid; PROM
● YELLOW: acidic; urine
● FERNING
○ Done by assessing the sample under a
microscope
○ When amniotic fluid is dry, it has a fern-like
pattern due to the presence of high amounts of
estrogen
○ (-) ferning = urine
● ULTRASOUND
○ This is done to check the amount of amniotic
fluid around your baby (amniotic fluid index)
○ Sonogram is sort of used as a precautionary
measure or for “fetal surveillance” with patients
with PROM
● ALPHA FETOPROTEIN
○ Testing for the presence of alpha fetoprotein, a
substance produced in the fetal liver, may also
be conducted to ascertain whether it is
amniotic fluid or urine
○ Increased level of AFP in the vagina = AF/PROM
ADDITIONAL ASSESSMENTS
● Cultures for Neisseria gonorrhoeae, streptococcus
B and Chlamydia are usually taken
○ Vaginal infections are associated with PROM
○ Since the mother and fetus are at risk of
infection, this is done to prevent another
infection from occurring
● Blood is drawn for WBC and C-reactive protein
○ ↑ WBC and c-reactive protein →
infection/inflammation → PROM → ↑ risk for
infection → possible sepsis and death
● ↑ WBC = infection
● ↑ C-reactive protein = inflammation
III. NURSING MANAGEMENT
POSSIBLE NURSING DIAGNOSIS
● Risk for infection r/t preterm rupture of membranes
without accompanying labor
● Risk for impaired gas exchange (fetus) r/t
compression of the umbilical cord secondary to
prolapse of cord
● Ineffective coping r/t unknown outcome of the
pregnancy
THERAPEUTIC MANAGEMENT
FIBRIN-BASED COMMERCIAL SEALANTS
●
○ Following endoscopic intrauterine procedures,
membranes can be resealed
○ This process allows the amnion to heal and
continue the pregnancy to term
○ Disadvantage: future possibility for premature
rupture of the membranes
However, in current practice, the mother is
●
encouraged to undergo bedrest (home/hospital)
for continuous monitoring of signs of labor, fetal
activity, and symptoms of infections
NURSING INTERVENTIONS
● Avoid doing routine vaginal examination until the
woman is in active labor
○ Reduces the time between rupture of
membranes and onset of labor (latency)
○ Increases the risk of infection due to
introduction of microorganisms
● POSITIONING
○ Left side-lying: prevents supine hypotensive
syndrome and uteroplacental insufficiency
○ Trendelenburg: done when there is umbilical
cord prolapse
● MONITORING
NCM 0109|10
 MODULE 04 — PLACENTA PREVIA, ABRUPTIO PLACENTA, AND PREMATURE RUPTURE OF MEMBRANES

○ Check for fever, uterine tenderness, and

ANSWER KEY
odorous vaginal discharge PRE-TEST:
● If the woman is taking at-home care, she is 1. FALSE
to take her temperature 2x and report 2. FALSE
temperatures that exceed 100.4 ˚F or 38˚C 3. TRUE
4. FALSE
○ Also assess the WBC count daily;
5. FALSE
>18,000–20,000/mm3 signifies infection
(normal is 5,000-10,000 mm3)
○ Fetal monitoring should also be conducted as Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Paras
PROM may indicate fetal distress BSN 2025
● EDUCATION
REFERENCES
○ Inform the client to not take tub baths, douche, Asynchronous Lecture: Module 04
and engage in coitus to prevent infections Module: NCM 0109 Third Trimester Conditions
● EMOTIONAL SUPPORT Book: Maternal and Child Health Nursing
○ You can assure a woman that there is no such Presentation Deck:
A. Question Bank 1
thing as a dry labor because amniotic fluid is B. Question Bank 2
always being formed by the fetus voiding and C. Question Bank 3
through production of fluid by the amnion layer
of the fetal membranes
● AMNIOINFUSION
○ NO DRY LABOR
○ Amniotic fluid during pregnancy is crucial in
cushioning the fetus as they thrive inside the
womb of their mothers

PHARMACEUTICAL INTERVENTIONS

● CORTICOSTEROIDS
○ Betamethasone is administered via
intramuscular route (12 mg OD for 2 days; 6 mg
q12° for 4 doses as maintenance) to prevent
respiratory distress syndrome, intraventricular
hemorrhage (accelerates maturation of blood
vessels in the brain), and necrotizing
enterocolitis
● BROAD SPECTRUM ANTIBIOTICS
○ IV administration of penicillin or ampicillin as
prophylaxis against Streptococcus B to
decrease the risk for infection in newborns and
maternal sepsis
○ This also allows the corticosteroid to take effect
since it can delay the onset of labor
● OXYTOCIN
○ This is administered intravenously at the time of
rupture to stimulate labor, especially when the
fetal age of gestation is >34 weeks OR if the
fetus is in danger/distress
● Fetus is estimated to be mature enough to
survive in an extrauterine environment
○ This is to prevent the fetus from acquiring the
possible infections that may come with PROM
● Fetus is born before infection can occur

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