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GENERAL OBJECTIVE:

This study aims to provide efficient nursing careto patients diagnosed with Placenta previathrough understanding the patients record,

disease process, treatment and management. It

also aims to develop essential as well as skillfulmaternal nursing care which is based on a betterand effective approach that will serve as a

catalyst to promote health and preventoccurrence of illness. This would also serve as abasis to determine the proper ways to manage

the situation in such a way that it would betherapeutic to both the mother and child

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SPECIFIC OBJECTIVES: To be able to familiarize ourselves with the causes

underlying the occurrence of the illness such as itscausative agents, predisposing and precipitating factorscontributory to the development of the illness.

To determine the signs and symptoms of the illness

To present the nursing history of the patient presentingthe development of the disease. To be familiarized with the systems involved in the

disease process and further understand its parts andfunction.

To trace the pathophysiology of the disease and determinethe factors that may have precipitated its development

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To identify and familiarize ourselves with themedications taken by the patient for the said kind ofailment, determine their action, indications,contraindications, side effects and adverse effects, andenumerate the necessary nursing considerations for eachdrug.

To distinguish any deviation or alterations from thenormal physical findings and physiology of the human

body through physical examination. To be able to suitably plan and prioritize independentnursing responsibilities or interventions based on thelevel of necessity and needs of the patient.

To apply different nursing interventions and make use ofthe process as a framework for the overall care of the

patient that would enable us to render appropriate andeffective interventions. To be able to identify and enumerate preventive measures

for the illness.

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PLACENTA PREVIA refers to anabnormal implantation.

Nidation of the zygote normally takes

place high on the anterior or posteriorwall of the uterus. Placenta previa is acondition of pregnancy in which theplacenta is implanted abnormally in the

uterus. It is the most common cause ofpainless bleeding in the third trimester ofpregnancy.

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Low- lying placenta

- implantation in thelower rather in the

upper portion of theuterus. The placentamay migrate upwardas the uterus

stretches and grows.

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Marginal Implantation

- the placental edgeapproaches the cervical

os that lies within 2 to 3cm of the internal os butdoes not cover it.

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Partial placentaprevia

- implantation that

occludes a portionof the cervical os.

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Total placentaprevia

- implantation

that totallyobstructs thecervical os.

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The incidence of placenta previa isapproximately 1 in 200 pregnancies.

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Previous cesarean birth Suction curettage for miscarriage or induced abortion Multiple gestation Closely spaced pregnancies

Advanced maternal age older than 30 years. African/ Asian ethnicity Male fetal sex Smoking

Cocaine use Multiparity Artificial Insemination

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Sudden, painless bleeding during the secondor third trimester of pregnancy is the primarysymptom. Bleeding may begin slight ormoderately and become severe and is brightred in color. Bleeding can occur as early as the20th week of pregnancy but is most commonduring the third trimester.

Cramping in some women. Signs of pretermlabor. One in 5 women with signs of placentaprevia also has uterine contractions.

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Bleeding from placenta previa may taper offand even stop for a while. However, it nearlyalways starts again days or weeks later.

Abnormal fetal position in the uterus. Some women with placenta previa do not have

any symptoms. In this case, placenta previamay only be diagnosed by an ultrasound donefor other reasons

Decreased urine output

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Prematurity

Prolapsed cord

Intrauterine growth retardation due to poor

placental perfusion

Transplacental hemorrhage

Hypovolemia/Hypoxia

Congenital anomalies Asphyxia

Fetal mortality

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Uterine atony. When implantation is low, theplacenta is usually thinner than normal anddevelops over a greater area. Consequently,the lower uterine segment is overstretchedduring pregnancy. The inability of thesemuscles to compress the blood vessels isconductive to uterine atony.

Lacerations. As the placenta develops, thetissues become more friable, and the cervix ismore likely to lacerate.

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Infection. Infection is dangerous becauseanemia usually reduces the patientsresistance. It is likely to occur since pieces ofplacental tissue can be retained and left lying

close to the external os. Hemorrhage. Excessive bleeding may result in

hypovolemic shock.

Increased risk for anemia secondary toincreased blood loss and infection secondaryto invasive procedures to resolve bleeding.

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The differential diagnosis for antepartum bleeding inthe third-trimester includes:

placenta previa placental abruption

vasa previa uterine rupture cervicitis, cervical polyp, cervical ectropion,

cervical cancer

preterm labor (bloody show) premature rupture of the membranes intercourse vulvovaginitis

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1) Transabdominal ultrasound Ultrasound allows visualization of the uterine

contents. High- frequency, inaudible sound wavesbare directed toward the uterus. The sound waves

reflected back are converted into a visual image.

Nursing Responsibilities: Explain the procedure to the mother.

Asked the mother to have a full bladder. Thisallows the other structures to be assessed inrelation to the bladder.

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This study allows better evaluation of pelvic anatomy and earlydiagnosis of pregnancy. It also circumvents the poor visualizationencountered with obese patients.

Purpose: to evaluate abnormal pregnancy

to diagnosed fetal abnormalities and placental location

to evaluate the uterine lining ( in cases of dysfunctional uterinebleeding)

Nursing Responsibilities :

Describe the Vaginal UTZ to the patient and explain the reason forthe test.

Assure the patient that the procedure is safe.

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- Its findings give valuable diagnostic information about the hematologic

and other body system, prognosis and result to treatment and recovery- The basic evaluation of the cellular components of the blood ( RBC,WBC, and Platelets)- Auto matured machines perform this test in < 1 minute in a small drop ofblood

Purpose: To determine the number of RBCs, WBCs, Platelets and the amount of

hemoglobin in the blood To identify persons who may have an infection To identify acute and chronic illness, bleeding tendencies, and white blood

cell disorders such as leukemia

Nursing responsibility: Explain the procedure and its purpose. Explain that slight discomfort may

be felt when skin is punctured Avoid stress if possible because altered physiologic status influences and

changes normal hemogram values

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Amniocentesis (also referred to as amnioticfluid testor AFT), is a medical procedure usedin prenatal diagnosis of chromosomal

abnormalities and fetal infections, in which asmall amount of amniotic fluid, which containsfetal tissues, is extracted from the amnion oramniotic sac surrounding a developing fetus,

and the fetal DNA is examined for geneticabnormalities

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ProcedureBefore the start of the procedure, a local

anesthetic can be given to the mother in order to

relieve the pain felt during the insertion of theneedle used to withdraw the fluid. After the local isin effect, a needle is usually inserted through themother's abdominal wall, then through the wall ofthe uterus, and finally into the amniotic sac. With

the aid of ultrasound-guidance, a physicianpunctures the sac in an area away from the fetusand extracts approximately 20 ml of amniotic fluid.After the amniotic fluid is extracted, the fetal cellsare separated from the sample.

Purpose in placenta previa:Prediction of lung maturity

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Nursing responsibilities:

Obtain patients consent Explain the procedure to the client

Position the patient assuming Fowlersposition to help bring down thepresenting part and reduced the chancethat the cord will prolapsed.

Monitor fetal heart rate every 15 minutes

during first stage of labor and notifyphysician if there is any change in rateand regularity.

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Kleihauer-Betke (KB) test is a blood test thatmeasures the amount of fetal hemoglobintransferred from a fetus to the mothers

bloodstream. It is usually done for the purpose

of determining the RhoGam dose. This test isused to predict certain types of pregnancycomplications particularly after a mother hassuffered a traumatic injury.

In placenta previa, KB test is done to detectweather the blood is fetal or maternal in origin.

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Purpose of Kleihauer Betke Test:

Complication related to pregnancy. This test is usedto predict certain types of pregnancy complications,particularly after a mother has suffered a traumaticinjury.

Measures fetal cells in maternal circulation. Staining

of postpartum maternal blood for identification ofpercentage of fetal cells present Used in assessing for Rh Sensitization ( Maternal

blood Rh negative, Large antepartum bleed) Determine possible fetal maternal hemorrhage in

the newborn, aid in diagnosis of certain types ofanemia in adults; assess the magnitude of fetalmaternal hemorrhage; calculate dosage of Rh immuneglobulin to be given.

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Before the Procedure Assess for latex allergy.

Assess for bleeding disorders. Note any medication or supplement taken by the patient that may cause

excessive bleeding.

During the procedure The nurse selects a vein that will be used in the test. In most cases, the

vein in the arm is usually selected. A tourniquet (large rubber strap) is secured above the selected vein. The skin over the vein is cleaned, and a needle will be inserted. Instruct the client to hold very still while the blood is collected. After blood is collected into one or more tubes, the tourniquet is removed. Expose blood smear to acid bath (this removes adult hemoglobin, which

is acid-sensitive) but not fetal hemoglobin. Stain smear (fetal cells appearpink; maternal cells look like ghosts).

Count lots of cells and report percentage of cells that are fetal(specifically: you count the number of fetal blood cells per 50 low powerfields. If you see 5 cells per 50 low power fields, thats equivalent to a 0.5mL fetomaternal hemorrhage).

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After the Procedure

A bandage, cotton ball or gauze is placed onthe area where the needle was inserted.

Apply pressure to the area. Strenuous exercises should be avoided after

the test is done.

Pain, redness, swelling or discharges from thepuncture site should be reported to thephysician immediately

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The fetus is visualization by inspection through afetoscope ( an extremely narrow, hollow tube insertedby amniocentesis technique), can be helpful to assessfetal well- being. If a photograph is taken through thefetoscope, it can document a problem or reassureparents that their infant is perfectly formed.

Purpose: Confirm the intactness of the spinal column. Obtain biopsy samples of fetal tissue and fetal blood

samples.

Nursing Responsibilities Explain the procedure to the mother. Prepare the mother and draped as for amniocentesis.

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NURSINGINTERVENTIONS

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When the patient is admitted to the laborroom, the nurse can obtain much of theinformation she needs about the bleeding while

she helps the patient get into bed. The nurseshould determine the amount of bleedingimmediately, remembering that what the patientmight report as hemorrhage may be mere

spotting to the nurse.

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The nurse can elicit a fairly accurate estimateof blood loss by asking the patient when thebleeding started, and whether they weresaturated or heavily soiled. She should also

ask whether the bleeding was dark or brightred, and whether the woman has passed anyclots of blood. Often the nurse and the patientcan communicate best by comparing this

bleeding with a normal menstrual flow.

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. The physician will also want to know whetherpain has accompanied the bleeding, whetherthe fetus has been active since the bleedinghas started, and patient has wearing a pad

when she is admitted, the nurse shouldestimate the amount of blood on the pad anddetermine how much bleeding has taken placesince admission.

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If the patient is bleeding actively when she isadmitted, her obstetrician should be notified atonce. While she is waiting at the obstetrician toarrive, the nurse should note ;

1) the rate and the quality of fetal heart soundsand

2) the mothers pulse rate and blood pressure.She should ask whether the patient has fallenor suffered any severe trauma to the abdomen.This information enables her to give the doctor

an immediate idea of the extent of bleeding.

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If the obstetrician plans to do an amniotomy,he usually wants the patient to assumeFowlers position to help bring down the

presenting part and to reduce the chance thatthe cord will prolapsed. Meanwhile the nurseshould monitor fetal heart rate at least every 15minutes during first stage of labor. The doctor

needs to be notified immediately if there is anychange in rate or regularity.

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With total placenta previa thebleeding starts earlier than withpartial or marginal placenta previa,

and caesarean section is usuallynecessary . when this happens, thewoman must be treated for shock,

and lost blood must be replaced.

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Treatment of placenta previa is designed to :

1. Assess, control and restore blood loss

Starting an I.V. line using a large bore catheter

Drawing blood for hemoglobin levels andhematocrit as well as type and crossmatching

Monitoring maternal blood pressure, pulse rate,and respirations

Assessing the amount of vaginal bleeding

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2. To deliver a viable infant Initiating external electronic fetal monitoring

Careful observation to allow the fetus more time tomature

As soon as the fetus is sufficiently mature, or in case ofintervening severe hemorrhage, immediate delivery bycesarean birth may be necessary

Vaginal delivery is considered only when the bleedingis minimal and the placenta previa is marginal, or whenthe labor is rapid.

Pediatric team should be on hand during such deliveryto immediately assess and treat neonatal shock, blood

loss and hypoxia.

3. To prevent coagulation disorders

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1. Cesarean Section

Cesarean birth is used most often as aprophylactic measure, to alleviate problems of

birth such as cephalopelvic disproportion,placenta previa, fetal distress or failure toprogress in labor

In Placenta Previa, Cesarean delivery is

usually indicated if the degree of previa is morethan 30% or if there is excessive bleeding. CSshould be performed immediately.

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Get good prenatal care during apregnancy. It will not prevent previa, butcan help identify complications early.

Don't smoke (or use cocaine) duringpregnancy. Smoking also causes a

secondary problem that can lead to poorgrowth of the fetus.