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Robin Petersen, MSN, RN

Valley Medical Center

Slides authored by Kathy O’Connell, MN, RN

Perinatal Clinical Nurse Specialist

University of Washington Medical Center

� Describe nursing care for patients

experiencing retained placenta, uterine

inversion, and umbilical cord prolapse

� Describe the pathophysiology and nursing

care for selected bleeding complications,

including: abruptio placenta, placenta

previa, vasa previa, and ruptured uterus.

� Responsible for ~30% of maternal deaths

� Antenatal etiology

� Placental abruption

� Placenta previa

� Placenta accreta

� Physiology of pregnancy

� Increased blood volume

� Decreased blood pressure

� Decreased peripheral vascular resistance

� Increased cardiac output

� Pregnant woman can lose approximately 35% of

their blood volume before vital signs affected

� Definition: separation of placenta from the

site of implantation prior to delivery

� Partial vs. Complete

� Apparent vs. Concealed

� Incidence� 1980’s = 1:150-225

� 1992-1994 = 12% of 40,000 deliveries (Parkland

Hospital study)

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� Initiated by hemorrhage into decidua basalis

� Splitting of decidua with adherent piece left

on the myometrium

� Decidual hematoma

� Incidence

increases with age

�Higher in women

of greater parity

�More common in

African American

or Latinas

�Hypertension

�Preterm PROM

�Maternal trauma

�Cigarette smoking

�Cocaine abuse

�Multiple pregnancy

�Assisted

reproductive

therapy (ART)

�Stabbing pain

�Uterine tenderness

or back pain

�Dark red bleeding

�Uterine rigidity

�Continuous

contractions

� Increased fundal

size

�Fetal distress

�Shock

�Bedrest

�Vital signs

�NST

�Ultrasound

�Assess bleeding

�Labs

�Prep for c-section

�Delivery and

management of

blood loss

�Fear and grief

counseling

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� Definition: Placenta located over or very

near the internal cervical os

� Total: internal os completely covered

� Partial: internal os partially covered

� Marginal: edge of placenta is at the margin of the

internal os

� Low-lying: placenta is implanted in the lower

uterine segment

� Estimated 1% of pregnancies

� Contradictory statistics

� Recent study shows more frequent following

c-section

� Zygote implants very low in uterine cavity

� Symptoms present in 2nd or 3rd trimester

� Multiparity

� Advancing maternal age

� Previous induced or spontaneous abortion

� Smoking

� May be associated with placenta accreta or

increta

� Painless uterine bleeding

� Soft, non-tender uterus

� Malpresentation

� Bedrest

� Monitor vital signs

� Assess bleeding

� No vaginal exams

� Prepare for c-section

� Grief and fear counseling

� If home on bedrest, patient teaching includes

no vaginal penetration

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� Associated with velamentous insertion

� Umbilical cord implanted into membranes, rather

than into the placenta

� Fetal vessels in the membranes cross the

internal os and occupy a position ahead of

the presenting part.

� No Wharton’s jelly surrounding the umbilical vein

and arteries

� Can occasionally be felt on vaginal exam

� ROM in these patients can cause rupture of

fetal vessels

� Succenturiate-lobed placenta

� Bilobed placenta

� Placenta previa

� In vitrofertilization

� Multiple gestation

� Fetal anomaly

� Painless vaginal bleeding

� Sudden appearance of bright red blood at

spontaneous or artificial rupture of membranes

AND

� Abnormal or indeterminate fetal heart rate

tracing

� Prep for immediate c-section

� Neonatology and NICU team present at

delivery

� Anticipate and prepare transfusion of infant

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� Remember:

� At term, blood flows through uterus at

600mL/min.

� Placental separation normally occurs within 10

minutes of delivery

� If no placental separation within 30 minutes,

manual removal may be indicated

� If that doesn’t work…. suspect an abnormal placental

adherence

� Accreta

� Placenta attached directory to myometrium

(78%)

� Increta

� Placenta invates the myometrium (17%)

� Percreta

� Placenta penetrates the myometrium

� Notify blood bank for type and crossmatch

� Weigh pads for quantitative measurements of

blood loss

� Increase IV fluids

� Administer oxygen, monitor VS, lab work

� Maintain empty bladder, monitor intake and

output

� Attend mother

� Maintain empty bladder, insert indwelling

catheter

� Monitor I&O

� Attend mother while provider attempts

manual removal

� If manual removal unsuccessful, prepare

patient for surgery

� The greater the degree of the accreta, the

greater the risk for hysterectomy

� Turning inside out of uterus

� Current incidence: 1 in 2000

� Classification

� Puerpural: associated with abortion, miscarriage,

or labor

� Nonpuerpural: non-pregnant uterus

� Acute: immediately or within 24 hours of delivery

� Subacute: diagnosis over 24 hours but less than 4

weeks after delivery

� Chronic: present for 4 or more weeks

� First

� Corpus or wall extends to the cervix, not beyond

the cervical ring

� Second

� Protrusion or corpus or wall through cervical ring

but not to perineum

� Third

� Inverted fundus extends to perineum

� Fourth

� Vagina inverted along with uterus

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� Placenta accreta

� Short cord

� Congenital weakness or anomaly of uterine

wall or cervix

� Tumors

� Manual removal of placenta

� Increased intra-abdominal pressure

� Mismanagement of 3rd stage of labor

� PREVENTION

� Guard the uterus when performing fundal

massage

� Measure blood loss accurately

� Continuous monitor of VS

� Provide aggressive fluid replacement

� Watch for hemorrhage, hypovolema, shock

� Administer analgesics or tocolytics as needed

� Place indwelling catheter

� Provide pain relief

� Blood replacement as indicated

� Notify anesthesia

� Following manual replacement, fundal

massage performed very carefully

� Continue IV fluids and oxytocin

� Surgical replacement if manual replacement

fails

� Antibiotic prophylaxis

� Most people grossly underestimate blood loss

� Use formal methods to assess blood loss

� Weigh blood soaked material on gram scale

� Subtract known dry weight of materials

� 1 gram = 1 mL blood

� Simulation training for delivery complications

� Displacement of umbilical cord to a position

at, or below, the fetal presenting part

� Classification

� Occult: hidden or not visible at any time during

labor or not ROM

� Complete: cord seen or palpated ahead of

presenting part

� Incidence

� 1:160 to 1:174 deliveries

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� Polyhydramnios

� Multiple gestation

� Ruptured membranes

� Transverse or breech presentation

� Low lying placenta

� Fetal presenting part not engaged

� Premature delivery

� Small fetus

� Visualize cord outside vulva

� Feeling cord during vaginal exam

� Ultrasound

� Bradycardia on EFM

� Non-reassuring fetal status following AROM

� Call for emergency assistance and notify

provider

� Administer oxygen

� Increase IV fluids

� Stop any labor induction or augmentation

agents

� Patient in Trendelenberg or knee-chest

� Perform continuous vaginal exam

� Avoid trauma to cord

� Prepare for emergent c-section

� Keep mother and family informed throughout

emergency

� Be prepared for neonatal resuscitation

�Simpson, K. and Creehan, P. (2014).

Perinatal Nursing. 4th ed. Lippincott:

Philadelphia, PA.

�American Academy of Pediatrics and

American College of Obstetricians and

Gynecologists. (2012). Guidelines for

perinatal care. 7th ed.