Placenta Previa:Placental Abruption

1. PLACENTA PREVIA/
PLACENTAL ABRUPTION
Allison Krickl
Edgewood College School of Nursing

2. DEFINITIONS
! Placenta previa- an abnormal implantation of the placenta in the
lower segment of the uterus near or over the cervical os instead of
attaching to the fundus.
• Complete/total-the cervical os is completely covered by the placental
attachment.
• Incomplete/partial-the cervical os is only partially covered by the
placental attachment.
• Marginal/low-lying-the placenta is attached in the lower uterine
segment but does not reach the cervical os.
• (Sommer, et al., 2013).

4. INCIDENCE/ETIOLOGY
! Placenta previa affects approximately 1 in 200 term pregnancies.
! Risk factors include:
• History of previous placenta previa
• History of previous cesarean birth
• History of prior suction curettage
• Advanced maternal age
• Multifetal gestation, multiparity, or closely spaced pregnancies
• Smoking
• (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

5. CLINICAL MANIFESTATIONS
! Subjective Data
• Painless, bright red vaginal bleeding during the second or third
trimester.
! Objective Data
• Soft, relaxed, nontender uterus with normal tone.
• Fundal height greater than expected for gestational age.
• Breech, oblique, or transverse position of fetus.
• Reassuring FHR.
• Vital signs within normal limits.
• Decreasing urinary output may be a better indicator of blood loss.
• (Sommer, et al., 2013).

6. ! Hemorrhage
! Abnormal placental attachment
• Placenta accreta
• Placenta increta
• Placenta percreta
! Hysterectomy
! Surgery-related trauma
! (Lowdermilk, et al., 2012)
MATERNAL/FETAL OUTCOMES
! Preterm birth
! Stillbirth
! Malpresentation
! Fetal anemia
! Intrauterine growth restriction (IUGR)
! Increased incidence of fetal anomalies

7. ABNORMAL PLACENTAL
ATTACHMENT

8. DIAGNOSIS
! Diagnostic Procedures
• Transabdominal or transvaginal ultrasound for placement of the
placenta.
• Fetal monitoring for fetal well-being assessment.
• (Sommer, et al., 2013).

9. MANAGEMENT
! Expectant management (observation and bed rest)
• Laboratory tests
• Assess for bleeding, leakage, or contractions
• Pelvic rest
• Administer IV fluids, blood products, and medications as prescribed
• Home care
! Active Management (immediate cesarean birth)
• Assess maternal and fetal status while preparing woman for surgery
• Emotional support
(Lowdermilk, et al., 2012)

10. DEFINITIONS
! Placental abruption-the premature separation of the placenta from
the uterus.
• Grade 1: Mild separation (10%-20%)
• Grade 2: Moderate separation (20%-50%)
• Grade 3: Severe separation (>50%)

• (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

12. INCIDENCE/ETIOLOGY
! 1 in 75 to 1 in 226 pregnancies are complicated by placental abruption.
! 1/3 of all antepartum bleeding is caused by placental abruption.
! Risk Factors
• Maternal hypertension (chronic or gestational)
• Cocaine use
• Blunt external abdominal trauma (motor-vehicle crash, maternal battering)
• Cigarette smoking
• History of abruption in a previous pregnancy
• Preterm rupture of membranes
• Multifetal pregnancy
• (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

13. CLINICAL MANIFESTATIONS
! Subjective Data
• Sudden onset of intense localized uterine pain with dark red vaginal
bleeding.
! Objective Data
• Area of uterine tenderness may be localized or diffuse over uterus
and board-like
• Contractions with hypertonicity
• Fetal distress
• Signs of hypovolemic shock
• (Sommer, et al., 2013).

14. ! Hemorrhage
! Hypovolemic shock
! Hypofibrinogenemia
! Thrombocytopenia
! Renal failure
! Pituitary necrosis
! Rh Sensitized
! (Lowdermilk, et al., 2012)
MATERNAL/FETAL OUTCOMES
! Perinatal morality rate of 20-30%
! If >50% abruption, fetal death is likely
to occur.
! Intrauterine growth restriction (IUGR).
! Preterm birth
! Risk for neurologic defects, cerebral
palsy, and death from SIDS are increased.

15. DIAGNOSIS
! Diagnostic Procedures
• Ultrasound for fetal well-being and placental assessment
• Biophysical profile to ascertain fetal well-being
• (Sommer, et al., 2013).

16. MANAGEMENT
! Expectant Management
• Woman is monitored closely.
• Assess FHR pattern
• Administer IV fluids, blood products, and medications as prescribed.
! Active Management (Immediate birth)
• Large-bore IV line
• Maternal vital signs are assessed frequently
• Laboratory studies
• Continuous EFM
• Catheter
• (Lowdermilk, et al., 2012) & (Sommer, et al., 2013).

17. ! Placenta previa
• Edward Rigsby
• Braxton Hicks
• Lawson Tait
• Charles Macafee
• (Chamberlain, 2006)
BACKGROUND

18. REVIEW OF TOPIC
! Management of a patient with placenta previa includes elective
cesarean delivery.
! Collaborative care planning
! Current treatment of obstetric hemorrhage
! (Bergakker, 2010), (Kim & Cha, 2011), (Rouse & Bardelman, 2009)

19. EXPERT INTERVIEW
! Dee Dee Krickl, RN-BSN: OB-OR Coordinator at Meriter
• Sees 6 placenta previa or placenta abruption cases a month on
average in the OB-OR
• All are treated as high-bleed risk patients
• 20 years in practice-things have changed
• Treatment of hemorrhage
• Collaborative care planning

20. EXPERT INTERVIEW
! Vasa-previa case
• Went in for a scheduled
cesarean section at 9:45 AM
• Arrived at the ICU at 7:45 PM
! What nurses need to know about
placenta previa/placental abruption
• It is important to be proactive
and 1 step ahead.
• Always anticipate problems
and plan for them for the best
patient outcome.

21. ! A nurse is providing care for a client who is diagnosed with a
marginal placental abruption. The nurse is aware that all of the
following findings are risk factors for developing the condition,
EXCEPT?
! A. Maternal hypertension
! B. Blunt abdominal trauma
! C. Cocaine use
! D. Maternal age
! E. Cigarette smoking
! (Sommer, et al., 2013).

22. ! A nurse is providing care for a client who is at 32 weeks of
gestation and who has a placenta previa. The nurse notes that the
client is actively bleeding. Which of the following types of
medications should the nurse anticipate the provider will prescribe?
! A. Betamethasone (Celestone)
! B. Indomethacin (Indocin)
! C. Nifedipine (Adalat)
! D. Methylergonovine (Methergine)
! (Sommer, et al., 2013).

23. ! A client is admitted to the labor suite complaining of painless
vaginal bleeding. The nurse assists with the examination of the client
knowing that a routine labor procedure contraindicated with this
client’s situation is:
! A. Leopold maneuvers
! B. External electronic fetal heart rate monitoring
! C. A manual pelvic examination
! D. Hemoglobin and hematocrit evaluation
! (Silvestri, 2006).

24. ! A nurse is assigned to assist in caring for a client with abruptio
placentae who is experiencing vaginal bleeding. The nurse collects
data from the client knowing that abruptio placentae is accompanied
by which additional finding?
! A. Abdomen soft on palpation
! B. No complaints of abdominal pain
! C. Lack of uterine irritability or tetanic contractions
! D. Uterine tenderness on palpation
! (Silvestri, 2006).

25. ! A nurse is collecting data on a client diagnosed with placenta
previa. Select all findings that the nurse would expect to note.
! A. Bright red vaginal bleeding
! B. Uterine rigidity
! C. Soft, relaxed nontender uterus
! D. Uterine tenderness
! E. Severe abdominal pain
! F. Fundal height may be greater than expected for gestational age
! (Silvestri, 2006).

26. REFERENCES
! Bergakker, S. A. (2010). Case report: Management of elective cesarean
delivery in the presence of placenta previa and placenta accreta. AANA Journal,
78(5), 380-384.
! Chamberlain, G. (2006). British maternal mortality in the 19
th
and early 20
th

centuries. Journal of the Royal Society of Medicine, 99(11), 559-563.
! Kim, K. J., & Cha, S. J. (2011). Supracervical cerclage with intracavitary
balloon to control bleeding associated with placenta previa. Journal of Perinatal
Medicine, 39, 477-481.

27. REFERENCES
! Lowdermilk, D. L., Perry, S. E., Cashion, K., & Alden, K. R.
(2012). Maternity and women’s health care (10
th
ed.). St. Louis, MO:
Elsevier Mosby.
! Rouse, C. L., & Bardelman, K. (2009). Collaborative care planning.
AORN Journal, 89(6), 1115-1120.
! Silvestri, L. A. (2006). Comprehensive review for the NCLEX-PN
examination. (3
rd
ed.). St. Louis, MO: Saunders Elsevier.

28. REFERENCES
! Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill,
L. (2013). RN maternal newborn nursing (9.0 ed.). Assessment
Technologies Institute, LLC.
! Todd, N. (2013). Understanding placenta previa—the basics. Retrieved
from http://www.webmd.com/baby/understanding-placenta-previa-
basics