placenta previa

Placenta Previa - Newborn Care • Promote neonatal physiologic adaptation • Immediate laboratory assessment and monitoring once the baby is born o Hemoglobin, cell volume, and erythrocyte count checked • Anticipate potential need for O2, blood administration and admission to a special care nursery; need to be prepared for the baby.

Abruptio Placentae • Premature separation of a normally implanted placenta from the uterine wall • Cause largely unknown • Medical emergency

Risk Factors • Maternal HTN • Blunt external abdominal trauma • Cocaine use, cigarette use • History of abrutipo placentae • Premature rupture of membranes • Multi-fetal pregnancy

Assessment Objective • Firm and bordlike abdomen • Tenderness • Hypertonic contractions • Fetal distress • S/S of hypovolemic shock

Assessment and Monitoring • Electronic monitoring of uterine contractions and resting • Tone between contractions o Provides information about the labor pattern and effectiveness of oxytocin induction

Assessment and Mont. Cont. • Hourly abdominal girth measurements • Monitor for DIC o Coagulation tests o Levels of fibrin-degradation products

Nursing assessment cont. • Bleeding usually begins as scant and becomes more profuse • Anticipate an unengaged fetal presentation part • Transverse lie of the baby is common. • Watch fetal status

Assessment of fetal status • FHR - continuous external fetal monitoring so fetal HR constantly electronic monitor tracing • Anticipate need for blood transfusion; mom is potentially going to lose a lot of blood • Assess maternal VS every 15 minutes if no hemorrhage. Every 5 minutes with active hemorrhage • External tocodynometer

Clinical Therapy • Immediate priorities are maintaining the maternal cardiovascular status and developing a birth plan • Cesarean birth is often the safest option.

Clinical therapy cont. • Induction of labor may be indicated. o Decrease the risk of DIC • Type and crossmatch for blood transfusions (at least 3 units available) • Evaluate clotting mechanism • Administer IV fluids

Assessment Subjective • Report intense localized tenderness or diffuse tenderness • Report dark red vaginal bleeding

Confirmation • Labs: Hgb & Hct, coagulation factors, clotting defects checked, Klelhauer-Betke test (to detect fetal erythrocyte in maternal blood)

Disseminated Intravascular Coagulation (DIC) • Over-activation of the normal clotting process • Leads to excessive clotting initially, but then decrease in platelet function and depletion of plasma clotting factors

DIC: o Tissue factor enters blood circulation - coagulation and fibrinolytic systems become imbalanced - clots formed and fibrin deposited into microcirculation (can cause infarction) - cell or tissue damage - further coagulation occurs as well as fibrinolytic system activated - fibrin split products formed - decrease in platelet function and inhibits coagulation depletion of plasma clotting factors

Abruptio Placentae - Moderate to Severe Separation • Cesarean birth follows treatment of hyperfibrinogenemia • Vaginal birth impossible with a Couvalaire uterus o Lack of proper uterine contractions in labor o Hysterectomy often needed

Fluid Volume Status • Hypovolemia associated with severe abrutipo placentae is LIFETHREATENING • Requires administration of whole blood • If fetus is alive but experiencing stress: do an ASAP emergency C-section

Confirmation • Labs: o Thrombocytopenia o Fibrinogen o Platelet count o Fibrin degradation product counts o Fibrin split products

Health Promotion: Nursing • Assist in procedures to help reverse causative factors - DIC is cured once the underlying condition causing it is resolved • Fluid resuscitation • Give blood products • Make sure BP support meds ordered • Provide emotional support because it's scary!

Diagnostics • Ultrasound • Biophysical profile

Implications • Maternal: risk of hemorrhage, shock, DIC • Fetal: neonatal outcomes depending on degree of abruption, fetal death depending on degree of placental separation, fetal compilations including preterm labor, amenia and hypoxia

Risk Factors • Preeclampsia • Abruptio placentae • Fetal demise • Amniotic fluid embolism • Maternal liver disease • Abortion without complete expulsion of products of conception; septic abortion

Is a Complication of ... • Severe preeclampsia • Eclampsia • HELLP Syndrome

Fluid vol. status cont. • If fetus is stillborn: vaginal birth is preferred if bleeding has stabilized unless maternal shock from hemorrhage • Administer IV fluids • Hourly central venous (CVP) pressure monitoring

Laboratory testing • Includes Hgb Hct and coagulation status o Hematocrit maintained at 30 percent through administration of packed red blood cells or whole blood

Placenta Previa - Nursing Care • During Active Bleeding: o Want to make sure you're assessing and managing directed towards the S/S for physical support • Address emotional aspects simultaneously

Nursing care cont. • Explain assessments and TX. measures. • Provide time for questions • Advocate for the family • Stay with the family • Use therapeutic touch to help reassure

Placenta Previa: Risk Factors • Women of Asian descent • History of Prior C-section • Previous induced abortion • Previous abortion • High gravity • High parity • Advanced maternal age • Cigarette smoking • Male fetus

Placenta Previa - Fetal Prognosis • Depends on the extent of placenta previa • Profuse bleeding yields fetal compromise and hypoxia • Fetal heart rate monitoring is imperative upon maternal admission, particularly if vaginal birth is anticipated, as the presenting fetal part may obstruct the placental or umbilical cord blood flow- need to watch baby carefully

Placenta Previa - Indications for Cesarean Birth • Non-reassuring fetal status • Diagnosis of complete or partial previa; then birth must take place.

Placenta Previa - Nursing Assessment • ***Maternal assessment for painless, bright red, vaginal bleeding • Most accurate diagnostic sign of placenta previa • If this sign develops during the last 3 months of pregnancy, placenta previa should always be considered until ruled out by ultrasound examination.

Third Trimester of bleeding overview of nursing care: • Frequent monitoring of vital signs • Assess for signs of shock • Estimate blood loss • Monitor fetal status and HR • Electronically monitor contractions

Third Trimester of bleeding overview of nursing care cont: • Administer blood as needed. • Monitor urine output • Facilitate and monitor diagnostic tests and results. • Support and educate the woman and her family.

Placenta Previa • Placental implantation in the lower uterine segment • As lower uterine segment contracts and dilates, placental villi are torn from uterine wall. • Uterine sinuses exposed at placental site. • Amount of bleeding may range from scant to perfuse

Types of previa • Complete or Total: when the placenta completely covers the opening from the womb to the cervix • Incomplete or Partial: when the placenta partially covers the cervical opening • Marginal or Low-lying: when the placenta is located adjacent to, but not covering, the cervical opening