Abruptio placentae is the premature separation of the placenta from the uterus.

Patients with abrubtio placenta also called placental abruption, typically present with bleeding, uterine contractions, and fetal distress. A significant cause of third-trimester bleeding associated with fetal and maternal morbidity and mortality, placental abruption must be considered whenever bleeding is encountered in the second half of pregnancy. Signs and Symptoms: • • • • • Abdominal pain Back pain Frequent uterine contractions Uterine contractions with no relaxation in between Vaginal bleeding

CASE STUDY
A 26-year old woman, gravida 3 para 0 therapeutic abortion 2, presented to the emergency room at 19 menstrual weeks with a history of several hours of sharp left lower quadrant and left pelvic pain. The patient had smoked 0,5 g of freebase cocaine immediately before the onset of symptoms. She had no vaginal bleeding but did have a tender uterus on examination. Sonography confirmed a gestational age of 19 weeks and revealed a large retroplacental hematoma with heterogenous placental echogenicity, suggesting intraplacental hemorrhage. The fetus was alive at the time of the examination, but on repeat examination the next day the hematoma appeared larger (involving more than 50% of the surface area of the placenta), and the fetus was dead. Prostaglandin E2 infusion was followed by vaginal delivery of the fetus. The placenta was manually removed, and a large abruption was identified. Maternal urine toxicology screen was positive only for cocaine and cocaine metabolites.

DRUG ANALYSIS
Drug Generic Name: Oxytocin Classifications: Hormones and synthetic substitute; oxytocic Dosage: Antepartum: Adult: IV start at 1 mU/min. May increase by 1 mU/min q15 min (max:20mU/min.) Postpartum: Adult: IV infuse a total of 10 U at a rate of 20-40 mU/min after delivery Action : Synthetic water soluble polypeptide consisting of 8 amino acids identical pharmacologically to the oxytocic principle of post. Pituitary. Uses: To initiate or improve uterine contraction at term only in carefully selected patients and all cervix is dilate and presentation of fetus has occurred; used to stimulate let-down reflex in nursing mother and to relieve pain from breast engorgement. Uses include management of inevitable, incomplete, or missed abortion; stimulation of uterine contractions during third stage of labor; stimulation to overcome uterine inertia; control of postpartum hemorrhage and promotion of postpartum uterine involution. Adverse Effects: fetal trauma from too rapid propulsion through pelvis, fetal death, anaphylactic reactions, postpartum hemorrhage, precordail pain, edema, cyanosis or redness of skin Nursing Implications: Start flow charts to record maternal BP and other v/s, I/O ration, weight, strength, duration and frequency of contractions, as well as fetal heart tone and rate, before instituting treatment. Monitor FHrate and maternal BP and pulse at least q 15 mins during infuson period; Monitor I&O during labor. If patient is receiving drug by prolonged IV infusion, waych out for water intoxication. Report changed in orientation Check fundus frequently during first few postpartum hours and several times thereafter.

NURSING CARE PLAN

Assessment S- “Masakit po yung tagiliran ko. Bigla po siya sumakit nung nanigarilyo ako.” O- She had a vaginal bleeding. When palpating, uterus is tender. • estimated blood loss • FHR pattern • BP compared to baseline • Pulse • Severe abdominal pain and rigidity • Pallor • Changes in LOC

Diagnosis Ineffective Tissue Perfusion related to Excessive blood loss secondary to premature placental separation Rationale: 0ne of the symptoms of premature separation of the placenta is uterine bleeding with a small amount to moderate amount of dark-red vaginal bleeding in 80% to 85% of cases. Bleeding may result in maternal hypovolemia (shock, oliguria, anuria) and coaglulopathy.

Planning Goal: Client will maintain adequate tissue perfusion by (date/time). Outcome: 1. Client will maintain BP and pulse (specify: BP >100/60 and pulse between 60-90 beats per minute), warm skin and dry. 2. Urine output not less than 30cc/hour. 3. Client will remain alert and oriented, FHR pattern remains reassuring.

Intervention • Assess patient’s condition especially the SaO2, BP, PR and RR. • Monitor for restlessness, anxiety, air hunger and changes in LOC. • Monitor accurately input and output. Evaluate also blood loss by weighing pads. • Continuously monitor FHR pattern compare to baseline data from prenatal record. Inform other health care team for any signs of non reassuring changes. • Assess for uterine irritability, abdominal pain, rigidity and increase abdominal girth • Assess client’s skin color, temperature, moisture, turgor and

Rationale • Assessment provides baseline information about client’s present condition. • S/Sx of the said condition provides information of developing indications of inadequate cerebral tissue perfusion. • Monitoring provides data about renal perfusion and function and the extent of blood loss. • The fetus may initially respond reassuring to decrease placental perfusion by raising the FHR above the normal baseline. Non reassuring FHR is an indication for delivery. • Assessment gives information about the severity of placental abruption. Bleeding may be occult causing abdominal rigidity and pain. • Assessment provides information about peripheral

Evaluation Patient’s blood pressure was maintained(100/ 60) Patient’s pulse was at least 60 beats per minute.

• Decrease urine output

capillary refill. • Initiate IV access with gauge 18 catheter and provide fluids, blood products, or blood as ordered. • Monitor laboratory results (Hgb, Hct, Clotting studies). • Observe client for signs of spontaneous bleeding. • Keep client and significant others informed of the condition and plan of care. • Notify caregivers and prepare for immediate delivery and neonatal resuscitation for maternal and fetal.

tissue perfusion. Hypovolemia results in shunting of blood away from peripheral circulation to the brain and vital organs. • Intervention provides venous access to replace fluids. • Laboratory studies provide information on extent of blood loss and signs of impeding DIC. • This provides information about the depletion of clotting factors and development of DIC. • Information of the condition of the client will promote understanding and cooperation. • Continued blood loss or development of DIC may lead to maternal or fetal injury or death.

Assessment S- “Masakit po yung tagiliran ko. Bigla po siya sumakit nung nanigarilyo ako.” O- She had a vaginal bleeding. When palpating, uterus is tender. • estimated blood loss • FHR pattern • BP compared to baseline • Pulse • Severe abdominal pain and rigidity

Diagnosis Altered comfort: acute pain related to increase pressure in the abdomen and bleeding between the uterine wall due to massive accumulation of blood clots behind the placenta secondary to premature separation of the placenta

Planning Short Term: After 45-60 minutes of administering anticoagulant agents and monitoring vital signs, the patient will be able to report improvements such as the decrease of pain in the abdomen due to the reduction of blood clots formed behind the placenta. Long Term: After 4-6hrs of monitoring patient’s vital signs, assessing pain scale, and providing comfort and safety

Intervention Educate patient to have a bed rest. Allow patient to be in the left side-lying position or any position that is comfortable for her. Administer tocolytic medications as ordered. Administer anticoagulant agents as ordered. Measure abdominal girth.

Rationale May relieve pain.

Evaluation After 1 hour of administering coagulant agents and monitoring vital signs, the patient has able to report improvements such as the decrease of pain in the abdomen due to the reduction of blood clots formed behind the placenta. After 4-6hrs of monitoring patient’s vital signs, assessing pain scale, and providing comfort and safety measures together with the

Tocolytic agents reduce uterine contractility/activity. To decrease/reduce blood clots. Increase in size that is more than normal may indicate that there is an abnormal accumulation inside the abdomen Vital signs usually is altered acute pain To help determine possibility of underlying condition requiring treatment. May alleviate pain To provide nonpharmocologic

Monitor patient’s vital signs. Assess for referred pain, as appropriate. Encourage verbalizations of feelings about the pain. Provide/perform comfort

• Pallor • Changes in LOC • Decrease urine output

measures together with the administration of tocolytic drugs (as ordered by the doctor), the patient’s improvements such as the reduction of pain will be maintained.

measures when necessary (back rub, change of position). Provide quiet environment and calm activities. Monitor fetal heart tone, beat, movements. If vague and absent, prepare for surgery/delivery. Prepare blood products, IV fluids for fluid replacement from bleeding and blood clotting.

treatment.

Vagueness/absence of fetal heart tone, beat, and fetal movements may indicate fetal hypoxia/death To replace the blood being formed to aclot and prevent replaced fluid loss that would lead to tissue injury due to dehydration. To help in the circulation, and avoid compressing the vena cava to continuously assess FHR The delivery method of choice is CS To help the SOs understand the critical condition of the mother and have reassurances of the mother’s current condition To help the SOs and mother to prepare physically and

administration of tocolytic drugs (as ordered by the doctor), the patient’s improvements such as the reduction of pain maintained.

Position mother in left lateral position

Begin electronic fetal monitoring Have equipment for emergency cesarean delivery readily available Prepare the patient and family members for the possibility of an emergency CS delivery, the delivery of a premature neonate and the changes to expect in the postpartum period offer emotional support and an honest assessment of the situation

emotionally to the situation tactfully discuss the possibility of neonatal death -tell the mother that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disordersassure her that frequent monitoring and prompt management greatly reduce the risk of death. Allowing them to understand clearly the situation Helps the SOs and mother cope with the situation properly To monitor extent and condition of the bleeding for prompt intervention (if the level of the fundus increases, suspect abruptio placentae) to determine the amount of blood loss

encourage the patient and her family to verbalize their feelings Help them to develop effective coping strategies, referring them for counseling if necessary Assess the patient’s extent of bleeding and monitor fundal height q 30 mins. Draw line at the level of the fundus and check it every 30 mins Count the number of pads that the patient uses, weighing them as necessary Monitor maternal blood pressure, pulse rate, respirations, central venous pressure, intake and

output and amount of vaginal bleeding q 10 – 15 mins

To determine any changes that can alter the mother’s condition, and for prompt intervention

Assessment S- “Masakit po yung tagiliran ko. Bigla po siya sumakit nung nanigarilyo ako.” O- She had a vaginal bleeding. When palpating, uterus is tender. • estimated blood loss • FHR pattern

Diagnosis Risk for fetal injury r/t impaired maternal – fetal nutrition and oxygen transfer to the fetus secondary to premature placental separation.

Planning Short Term: Within 20-40 minutes of administering IV fluids and oxygen supplement to the mother, the fetus will be able to receive adequate amount of oxygen and nutrients for life support. Long Term:

Intervention Educate mother to have a complete bed rest. Assess and monitor continuously the vital signs of the mother and the fetus.

Rationale Bed rest helps prevent further complications and helps limit oxygen consumption. Alterations of the vital signs of the mother and fetus from the normal values may indicate that there is something wrong in the body of the mother. To assess respiratory insufficiency.

Evaluate pulse oximetry of the mother to determine oxygen saturation in her body. Provide/administer supplemental oxygen saturation at lowest concentration or as indicated by

Evaluation Within 20-40 minutes of administering IV fluids and oxygen supplement to the mother, the fetus has able to receive adequate amount of oxygen and nutrients for life support. Within 1-4hrs of

• BP compared to baseline • Pulse • Severe abdominal pain and rigidity • Pallor • Changes in LOC • Decrease urine output

Within 1-4hrs of letting the mother have complete bed rest, providing safety measures and promoting a clean and quiet environment, the fetus will be able to receive continuous amount of oxygen necessary for the transportation of nutrients.

the laboratory results. Administer IV fluids, as indicated.

Provide safety measures (e.g. raise side rails and keeping off things that are sharp and edgy), and promoting a clean and quiet environment. Position mother in left lateral position Begin electronic fetal monitoring Have equipment for emergency cesarean delivery readily available Prepare the patient and family members for the possibility of an emergency CS delivery, the delivery of a premature neonate and the changes to expect in the postpartum period offer emotional support and an honest assessment of the situation tactfully discuss the possibility of neonatal death

This provides adequate supply of oxygen to the blood of the mother while circulating, thus nutrients and oxygen will be transported to the fetus. For nutritional support to the mother and fetus and for fluid replacement, if vaginal bleeding occurs. To protect client from injuries and to provide the patient comfort

letting the mother have complete bed rest, providing safety measures and promoting a clean and quiet environment, the fetus has able to receive continuous amount of oxygen necessary for the transportation of nutrients.

To help in the circulation, and avoid compressing the vena cava to continuously assess FHR The delivery method of choice is CS To help the SOs understand the critical condition of the mother and have reassurances of the mother’s current condition

encourage the patient and her family to verbalize their feelings Help them to develop effective coping strategies, referring them for counseling if necessary

To help the SOs and mother to prepare physically and emotionally to the situation Tell the mother that the neonate’s survival depends primarily on gestational age, the amount of blood lost, and associated hypertensive disordersassure her that frequent monitoring and prompt management greatly reduce the risk of death. Allowing them to understand clearly the situation Helps the SOs and mother cope with the situation properly

PATHOPHYSIOLOG Y
Predisposing factors: Age Sex Family History

ABRUPTIO PLACENTA
Unknown etiology Placental production of endothelin

Precipitating factors: Preeclampsia in previous pregnancy Multigravidity Diet (high in cholesterol, saturated fat and sodium intake)

Decrease perfusion in placenta Bleeding in decidua basalis Hematoma formation

Further separation of the placenta from the uterine wall

ABRUPTIO PLACENTA

Partial separation

Total separation

Marginal vaginal bleeding

Central concealed bleeding

Massive vaginal bleeding or concealed hemorrhage

If treated: Nursing Management: • Monitored for symptoms of shock. unborn baby will be watched for signs of distress, which includes an abnormal heart rate • Avoid drinking, smoking, or using recreational drugs during pregnancy. Get early and regular prenatal care. • Recognizing and managing conditions in the mother such as diabetes and high blood pressure also decrease the risk of placental abruption.

If not treated: POOR Maternal and Fetal Death

GOOD