What nursing intervention should be included when caring for a client with placenta previa?

Maternal and Child Nursing (Notes)

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Description

1. The placenta implants in the lower uterine segment, near the cervical os. The degree to which it covers the os leads to three different classifications.
   • Total placenta previa occurs when the placenta completely covers the internal os.
   • Partial placenta previa occurs when the placenta partially covers the internal os.
   • Low-lying or low-implantation placenta previa occurs when the placental border reaches the border of the internal os.
2. The incidence of placenta previa is three to six per 1,000 deliveries.

Etiology

Predisposing factors include:

1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years in 33% of cases)
3. Multiple gestation
4. Previous cesarean birth
5. Uterine incision
6. Prior placenta previa (incidence is 12 times greater in women with previous placenta previa)

Pathophysiology

1. Pathologic process seems to be related to the conditions that alter the normal function of the uterine deciduas and its vascularization.
2. Bleeding, which results from tearing of the placental villi from the uterine wall as the lower uterine segment contracts and dilates, can be slight or profuse.

Assessment Findings

1. Associated findings. In cases of suspected placenta previa, a vaginal examination is delayed until ultrasound results are available and the client is moved to the operating room for what is termed a double-set-up procedure. The operating room is needed because the examination can cause further tearing of the villi and hemorrhage, which can be fatal to the client and fetus.
2. Common clinical manifestations include:
   • Bright red, painless vaginal bleeding
   • Soft, nontender abdomen; relaxes between contractions, if present.
   • FHR stable and within normal limits.
3. Laboratory and diagnostic study findings. Transabdominal ultrasonography confirms suspicion of placenta previa.

Nursing Management

1. Ensure the physiologic well-being of the client and fetus.

• Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh perineal pads before and after use to estimate blood loss.
• Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin, and a drop in blood pressure.
• Monitor the FHR.
• Enforce strict bed rest to minimize risk to the fetus.
• Observe for additional bleeding episodes.

2. Provide client and family teaching

• Explain the condition and management options. To ensure an adequate blood supply to the mother and fetus, place the woman at bed rest in a side-lying position. Anticipate the order for a sonogram to localize the placenta. If the condition of mother or fetus deteriorates, a cesarean birth will be required.
• Prepare the client for ambulation and discharge (may be within 48 hours of last bleeding episode).
• Discuss the need to have transportation to the hospital available at times.
• Instruct the client to return to the hospital if bleeding recurs and to avoid intercourse until after the birth.
• Instruct the client on proper handwashing and toileting to prevent infection.

3. Address emotional and psychosocial needs.

• Offer emotional support to facilitate the grieving process, if needed.
• After birth of the newborn, provide frequent visits with the newborn that mother can be certain of the infant’s condition.

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Fluid volume deficit is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active blood loss or hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death.

Assessment

Patient may manifest: 

• Bleeding episodes (amount, duration)
• Abdomen soft/hard when palpated
• Manifests body weakness
• Low blood pressure
• Increased heart rate
• Decreased respiratory rate
• Fetal heart rate less than normal (120-160 bpm)
• Decreased urine output
• Increased urine concentration
• Pale, cold, clammy skin

Nursing Diagnosis

• Deficient Fluid Volume r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Planning

• Patient will maintain fluid volume at a functional level possibly evidenced by adequate urinary output and stable vital signs.

Decreased Cardiac Output

Placenta Previa is the development of placenta in the lower uterine segment partially or completely covering the internal cervical os. Placenta Previa causes bleeding. Due to large amounts of blood lost, the heart tries to pump faster in order to compensate for blood loss. As a result, the heart pumps faster with lesser blood pumped.

Assessment

• dysrhythmias
• prolonged capillary refill
• cold clammy skin
• Dyspnea
• restlessness
• variations in BP reading

Nursing Diagnosis

• Decreased cardiac output r/t altered contractility

Planning

• Patient will participate and demonstrate activities that reduce the workload of the heart.
• Patient will manifest hemodynamic stability.

Ineffective Tissue Perfusion

Placenta Previa causes painless and continuous bleeding. With bleeding, there is decreased Hemoglobin. Hemoglobin carries oxygen to different parts of the body. If there is decreased hemoglobin there is a failure to nourish the tissues at the capillary level.

Assessment

Patient may manifest

• Restlessness
• Confusion
• Irritability
• Manifest Body Weakness
• Capillary refill more than 3 sec
• Oliguria

Nursing Diagnosis

• Ineffective tissue perfusion r/t decreased HgB concentration in blood & hypovolemia

Planning

• Patient will demonstrate behaviors to improve circulation.
• Patient will demonstrate increased perfusion as individually appropriate.

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