PLACENTA PREVIAPLACENTA PREVIA

• I. Introduction:I. Introduction:• The upper part of the uterus is the most The upper part of the uterus is the most

favorable area for placental implantation favorable area for placental implantation because it is rich in blood and, therefore, because it is rich in blood and, therefore, nutrients and oxygen. The lower uterine nutrients and oxygen. The lower uterine segment is not and, therefore, it is possible that segment is not and, therefore, it is possible that if the baby implants too low (low-lying if the baby implants too low (low-lying placenta), risks of intrauterine growth placenta), risks of intrauterine growth restriction and preterm labor are much higher. restriction and preterm labor are much higher.

• During the last trimester, and especially in the During the last trimester, and especially in the last month, the lower uterine segment thins last month, the lower uterine segment thins appreciably and pulls up a bit, which is what appreciably and pulls up a bit, which is what causes cervical effacement (thinning) and early causes cervical effacement (thinning) and early dilatation. If the placenta is impinging on the dilatation. If the placenta is impinging on the lower segment and is not up in the fundus lower segment and is not up in the fundus where it is supposed to be, then part of the where it is supposed to be, then part of the placenta may dislodge and hemorrhage may placenta may dislodge and hemorrhage may occur. This condition is called PLACENTA occur. This condition is called PLACENTA PREVIA. PREVIA.

• PLACENTA PREVIA is an abnormal low PLACENTA PREVIA is an abnormal low implantation of the placenta in proximity implantation of the placenta in proximity

• to the internal cervical os. Placenta previa is a to the internal cervical os. Placenta previa is a condition in which the placenta attaches condition in which the placenta attaches

• to the uterine wall in the lower portion of the to the uterine wall in the lower portion of the uterus and covers all or part of the cervix. uterus and covers all or part of the cervix.

• Classification of Placenta Previa Classification of Placenta Previa • 1. Total Previa- the placenta completely covers 1. Total Previa- the placenta completely covers

the internal cervical os. the internal cervical os. • 2. Partial Previa- the placenta covers a part of 2. Partial Previa- the placenta covers a part of

the internal cervical os. the internal cervical os. • 3. Marginal Previa- the edge of the placenta lies 3. Marginal Previa- the edge of the placenta lies

at the margin of the internal at the margin of the internal • cervical os and may be exposed during dilatation. cervical os and may be exposed during dilatation. • 4. Low-lying placenta- the placenta is implanted 4. Low-lying placenta- the placenta is implanted

in the lower uterine segment but in the lower uterine segment but • does not reach to the internal os of the cervixdoes not reach to the internal os of the cervix

• II. Goals and Objectives: II. Goals and Objectives: • GOAL:GOAL:• We, the student nurses of Liceo de We, the student nurses of Liceo de

Cagayan University, aim to develop Cagayan University, aim to develop essential as well as skillful maternal essential as well as skillful maternal nursing care which is based on the nursing care which is based on the better and effective approach---- that will better and effective approach---- that will serve as a catalyst to promote health, serve as a catalyst to promote health, reduce illness and/or completely reduce illness and/or completely eliminate such diseases. We are also up eliminate such diseases. We are also up to in knowing the nature of the disease to in knowing the nature of the disease and on how to manage it in such a way and on how to manage it in such a way that it would be therapeutic to both that it would be therapeutic to both mother and child mother and child

• Objectives: Objectives: • By the end of this whole rotation, we, the student nurses of By the end of this whole rotation, we, the student nurses of

Liceo de CagayanlUniversity, willLiceo de CagayanlUniversity, will• be able to: be able to: • 1. Enhance our ability to manage the said disease in 1. Enhance our ability to manage the said disease in

regards to regards to • their cultural beliefs and lifestyle. their cultural beliefs and lifestyle. • 2. Develop an independent and collaborative work together 2. Develop an independent and collaborative work together • with the medical health team members.with the medical health team members.• 3. Prioritize things which are essential in assessing and 3. Prioritize things which are essential in assessing and

developing proper interventions in treating or alleviating developing proper interventions in treating or alleviating the illness. the illness.

• 4. Improve the use of the nursing process that would 4. Improve the use of the nursing process that would include assessment, diagnosis, planning, implementation include assessment, diagnosis, planning, implementation and evaluation into a more useful and more effective in and evaluation into a more useful and more effective in doing the patient’s care. doing the patient’s care.

• 5. Apply the core and fundamental systematic approach of 5. Apply the core and fundamental systematic approach of the the

• nursing profession in promoting health unto the clientsnursing profession in promoting health unto the clients

• III. Patient’s Profile:III. Patient’s Profile:• Name:Name: De Dios, Stella Mae Rosillo De Dios, Stella Mae Rosillo Age:Age: 22 22

y.oy.o• Religion:Religion: Roman Catholic Roman Catholic Civil Civil

Status:Status: Single Single• Nationality:Nationality: Filipino Filipino

Informant:Informant: Evelyn De Dios Evelyn De Dios •

Information related to HealthInformation related to Health• Date of Admission:Date of Admission: July 4, 2010 July 4, 2010 Time: Time: 6.25 am6.25 am• Attending Physician:Attending Physician: Dr. Tusalem Dr. Tusalem• Gravida:Gravida: 1 1• Parity:Parity: 0 0• Abortion:Abortion: 0 0• Live Birth:Live Birth: 0 0• LMP:LMP: December 29, 2009 December 29, 2009• AOG:AOG: 26 weeks 26 weeks• EDC:EDC: September 22, 2010 September 22, 2010• Weight: Weight: • Height:Height:• Temperature:Temperature: 36.7 36.7• Pulse:Pulse: 82 bpm 82 bpm• Respiration:Respiration: 21 cpm 21 cpm• Blood Pressure:Blood Pressure: 150/ 90 mmHg 150/ 90 mmHg

• IV Assesment:IV Assesment:• NURSING SYSTEM REVIEW CHARTNURSING SYSTEM REVIEW CHART• Name: Name: • Date: Date: July 5, 2010July 5, 2010• Vital Signs:Vital Signs:• Pulse: Pulse: 82 bpm82 bpm BP: BP: 120/09 mm Hg120/09 mm Hg Temp: Temp: 36.7 0 C36.7 0 C Height: Height: 5’2”5’2” Weight: Weight: 105 lbs105 lbs• EENT EENT • [] impaired vision [] blind[] impaired vision [] blind• [] pain reddened [] drainage[] pain reddened [] drainage • [] gums[] gums [] hard of hearing [] deaf[] hard of hearing [] deaf• [] burning[] burning [] edema[] edema [] lesion teeth[] lesion teeth• [] asses eyes, ears, nose[] asses eyes, ears, nose• [] throat for abnormality [X] no problem[] throat for abnormality [X] no problem

RESPIRATIONRESPIRATION • Frequent urinationFrequent urination• And vaginal spottingAnd vaginal spotting• [] asymmetric[] asymmetric [] tachypnea[] tachypnea [] barrel chest[] barrel chest • [] apnea [] apnea [] rales[] rales [] cough[] cough • [] bradypnea[] bradypnea [] shallow[] shallow [] rhonchi[] rhonchi • [] sputum[] sputum [] diminished[] diminished [] dyspnea [] dyspnea • [] orthopnea[] orthopnea [] labored[] labored [] wheezing[] wheezing• [] pain[] pain [] eyanotic[] eyanotic• [] assess resp rate, rhythm, depth, pattern[] assess resp rate, rhythm, depth, pattern• [] breath sounds, comfort [X]no problem [] breath sounds, comfort [X]no problem • GASTRO INTESTINAL TRACTGASTRO INTESTINAL TRACT• [] obese[] obese [] distention [] distention [] mass[] mass • [] dysphagia [] dysphagia [] rigidly[] rigidly [] pain[] pain • [] asses abdomen, bowel habits, swallowing[] asses abdomen, bowel habits, swallowing • [] bowel sounds, comfort [X]no problem[] bowel sounds, comfort [X]no problem• GENITO-URINARY and GYNEGENITO-URINARY and GYNE• [] pain [] pain [] urine color [] vaginal bleeding[] urine color [] vaginal bleeding• [] hematuria[] hematuria [X] discharge[X] discharge [] nocturia[] nocturia• [] assess urine freq., control, color, odor, comfort[] assess urine freq., control, color, odor, comfort• Back painBack pain• [] grip, gait, coordination, speech, []no problem[] grip, gait, coordination, speech, []no problem• NEURONEURO• [] paralysis[] paralysis [] stuporous[] stuporous [] unsteady[] unsteady [] seizure[] seizure• [] lethargic[] lethargic [] comatose[] comatose [] vertigo[] vertigo [] tremors[] tremors• [] confused[] confused [] vision[] vision [] grip[] grip• [] assess motor function, sensation, LOC, strength[] assess motor function, sensation, LOC, strength• [] grip, gait, coordination, speech, [X]no problem[] grip, gait, coordination, speech, [X]no problem• 22• MUSCULOSKELETAL and SKINMUSCULOSKELETAL and SKIN• [] appliance[] appliance [] stiffness[] stiffness [] itching[] itching [] petechiae[] petechiae• [] hot[] hot [] drainage[] drainage [] prosthesis[] prosthesis [] swelling[] swelling• [] lesion[] lesion [] poor turgor[] poor turgor [] cool[] cool [] deformity[] deformity• [] atrophy[] atrophy [] pain[] pain [] ecchymosis[] ecchymosis [] diaphoretic[] diaphoretic• [] assess mobility, motion, gait, alignment, joint function[] assess mobility, motion, gait, alignment, joint function• [] skin color, texture, turgor, integrity [X] no problem[] skin color, texture, turgor, integrity [X] no problem

Back pain

Frequent urinationAnd vaginal spotting

• V. DESCRIPTION OF DISEASE:V. DESCRIPTION OF DISEASE:• Placenta previa is an Placenta previa is an obstetricobstetric complication in complication in

which the which the placentaplacenta is attached to the uterine wall is attached to the uterine wall close to or covering the close to or covering the cervixcervix.[1] It can sometimes .[1] It can sometimes occur in the later part of the first trimester, but occur in the later part of the first trimester, but usually during the second or third. It is a leading usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal cause of antepartum haemorrhage (vaginal bleeding). It affects approximately 0.5% of all bleeding). It affects approximately 0.5% of all labours.labours.

• Predisposing Factors:Predisposing Factors:• Multiparity (80% of affected clients are Multiparity (80% of affected clients are

multiparous)multiparous)• Advanced maternal age (older than 35 years old in Advanced maternal age (older than 35 years old in

33% of cases33% of cases• Multiple gestationMultiple gestation• Previous Cesarean birthPrevious Cesarean birth• Uterine IncisionsUterine Incisions• Prior placenta previa ( incidence is 12 times Prior placenta previa ( incidence is 12 times

greater in women with previous placenta previa)greater in women with previous placenta previa)

• Complications for the baby include:Complications for the baby include:• Problems for the baby, secondary to acute Problems for the baby, secondary to acute

blood lossblood loss• Intrauterine growth retardation due to poor Intrauterine growth retardation due to poor

placental perfusionplacental perfusion• Increased incidence of congenital anomaliesIncreased incidence of congenital anomalies• Clinical Manifestations:Clinical Manifestations:• Painless vaginal bleeding > occurs after 20 Painless vaginal bleeding > occurs after 20

weeks of gestation, bright red in color weeks of gestation, bright red in color associated with the stretching and thinning of associated with the stretching and thinning of the lower uterine segment that occurs in the lower uterine segment that occurs in third trimester.third trimester.

• Adequately contract and stop blood flow from Adequately contract and stop blood flow from open vessels.open vessels.

• Stop blood flow from open vesselsStop blood flow from open vessels• Decreasing urinary outputDecreasing urinary output

• Normal Placenta During Normal Placenta During ChildbirthChildbirth

• Process of placental growth and uterine wall changes Process of placental growth and uterine wall changes during pregnancyduring pregnancy

• The placenta grows with the placental site during pregnancy.The placenta grows with the placental site during pregnancy.• During pregnancy and early labor the area of the placental During pregnancy and early labor the area of the placental

site probably changes little, even during uterine contractions.site probably changes little, even during uterine contractions.• The semirigid, noncontractile placenta cannot alter its surface The semirigid, noncontractile placenta cannot alter its surface

area.area.• Anatomy of the uterine/placental compartment at the Anatomy of the uterine/placental compartment at the

time of birthtime of birth• The cotyledons of the maternal surface of the placenta extend The cotyledons of the maternal surface of the placenta extend

into the decidua basalis, which forms a natural cleavage plane into the decidua basalis, which forms a natural cleavage plane between the placenta and the uterine wall.between the placenta and the uterine wall.

• There are interlacing uterine muscle bundles, consisting of There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches of the uterine arteries tiny myofibrils, around the branches of the uterine arteries that run through the wall of the uterus to the placental area.that run through the wall of the uterus to the placental area.

• The placental site is usually located on either the anterior or The placental site is usually located on either the anterior or the posterior uterine wall.the posterior uterine wall.

• The amniotic membranes are adhered to the inner wall of the The amniotic membranes are adhered to the inner wall of the uterus except where the placenta is locateduterus except where the placenta is located

• VI. PathophysiologyVI. Pathophysiology• No specific cause of placenta previa has yet been found but it No specific cause of placenta previa has yet been found but it

is hypothesized to be related to abnormal vascularisation of is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection.previous trauma, surgery, or infection.

• In the last trimester of pregnancy the isthmus of the uterus In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, it may shear off and placenta does overlie the lower segment, it may shear off and a small section may bleed.a small section may bleed.

• Women with placenta previa often present with painless, Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed. Leopold’s finds the uterus non-tender and relaxed. Leopold’s Maneuvers may find the fetus in an oblique or breech Maneuvers may find the fetus in an oblique or breech position or lying transverse as a result of the abnormal position or lying transverse as a result of the abnormal position of the placenta. Previa can be confirmed with an position of the placenta. Previa can be confirmed with an ultrasound.[3] In parts of the world where ultrasound is ultrasound.[3] In parts of the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with unavailable, it is not uncommon to confirm the diagnosis with an examination in the surgical theatre.an examination in the surgical theatre.

• The proper timing of an examination in The proper timing of an examination in theatre is important. If the woman is not theatre is important. If the woman is not bleeding severely she can be managed non-bleeding severely she can be managed non-operatively until the 36th week. By this time operatively until the 36th week. By this time the baby’s chance of survival is as good as the baby’s chance of survival is as good as at full term.at full term.

• VII. Diagnostic Evaluation:VII. Diagnostic Evaluation:• Placenta previa is diagnosed using Placenta previa is diagnosed using

transabdominal ultrasound.transabdominal ultrasound.-    transabdominal scans with fewer -    transabdominal scans with fewer false positive resultsfalse positive results

• Transvaginal ultrasoundTransvaginal ultrasound• If a woman is bleeding she is usually If a woman is bleeding she is usually

placed in the labor and birth unit or placed in the labor and birth unit or for cesarean birth because profound for cesarean birth because profound hemorrhage can occur during the hemorrhage can occur during the examination. This type of vaginal examination. This type of vaginal examination knows as the double- examination knows as the double- setup proceduresetup procedure

• Ultrasonographic scanUltrasonographic scan• If ultrasonographic scanning reveals a If ultrasonographic scanning reveals a

normally implanted placenta, an examination normally implanted placenta, an examination may be performed to rule out local causes of may be performed to rule out local causes of bleeding and a coagulation profile is bleeding and a coagulation profile is obtained to rule out other causes of bleeding obtained to rule out other causes of bleeding management of placenta previa depends of management of placenta previa depends of the gestational age and condition of the fetus the gestational age and condition of the fetus and the amount and cesarean birth.and the amount and cesarean birth.

• Complete blood count (CBC)Complete blood count (CBC)• To monitor mother’s blood volumeTo monitor mother’s blood volume• Fetoscope Fetoscope • To monitor fetal heart rate and conditionsTo monitor fetal heart rate and conditions

• VIII. Medical Management:VIII. Medical Management:• Maternal stabilization and fetal Maternal stabilization and fetal

monitoringmonitoring• Control of blood loss, blood replacementControl of blood loss, blood replacement• Delivery of viable neonateDelivery of viable neonate• With fetus of less than 36 weeks With fetus of less than 36 weeks

gestation, careful observation to gestation, careful observation to determine safety of continuing determine safety of continuing pregnancy or need for preterm deliverypregnancy or need for preterm delivery

• Hospitalization with complete bed rest Hospitalization with complete bed rest until 36 weeks gestation with complete until 36 weeks gestation with complete placenta previaplacenta previa

• Possible vaginal delivery with minimal Possible vaginal delivery with minimal bleeding or rapidly progressing laborbleeding or rapidly progressing labor

• IX. Nursing Interventions:IX. Nursing Interventions:• If continuation of the pregnancy is deemed safe for If continuation of the pregnancy is deemed safe for

patient and fetus administer magnesium sulfate as patient and fetus administer magnesium sulfate as ordered for premature laborordered for premature labor

• Obtain blood samples for complete blood count and Obtain blood samples for complete blood count and blood type and cross matchingblood type and cross matching

• Institute complete bed restInstitute complete bed rest• If the patient and placenta previa is experiencing If the patient and placenta previa is experiencing

active bleeding, continuously monitor her blood active bleeding, continuously monitor her blood pressure, pulse rate, respiration, central venous pressure, pulse rate, respiration, central venous pressure, intake and output, and amount of vaginal pressure, intake and output, and amount of vaginal bleeding as well as the fetal heart rate and bleeding as well as the fetal heart rate and rhythmAssist with application of intermittent or rhythmAssist with application of intermittent or continuous electronic fetal monitoring as indicated by continuous electronic fetal monitoring as indicated by maternal and fetal status.maternal and fetal status.

• Have oxygen readily available for use should fetal Have oxygen readily available for use should fetal distress occur, as indicated by bradycardia, distress occur, as indicated by bradycardia, tachycardia, late or available decelerations, tachycardia, late or available decelerations, pathologic sinusoidal pattern, unstable baseline, or pathologic sinusoidal pattern, unstable baseline, or loss of variability.loss of variability.

• If the patient is Rh-negative and not sensitized, If the patient is Rh-negative and not sensitized, administer Rh (D) immune globulin (RhoGAM) after administer Rh (D) immune globulin (RhoGAM) after every bleeding episode.every bleeding episode.

• Administer prescribed IV fluids and blood products.Administer prescribed IV fluids and blood products.• Provide information about labor progress and the Provide information about labor progress and the

condition of the fetus.condition of the fetus.• Prepare the patient and her family for a possible Prepare the patient and her family for a possible

caesarian delivery and the birth of a preterm neonate, caesarian delivery and the birth of a preterm neonate, and provide thorough instructions for postpartum care.and provide thorough instructions for postpartum care.

• If the fetus less than 36 weeks gestation expect to If the fetus less than 36 weeks gestation expect to administer an initial dose of betamethasone: explain that administer an initial dose of betamethasone: explain that additional doses may be given again in 24 hours and additional doses may be given again in 24 hours and possibly for the next 2 weeks to help mature the possibly for the next 2 weeks to help mature the neonates lungs.neonates lungs.

• Explain that the fetus survival depends on gestational Explain that the fetus survival depends on gestational age and amount of maternal blood loss. Request age and amount of maternal blood loss. Request consultation with a neontologist or pediatrician to consultation with a neontologist or pediatrician to discuss a treatment plan with the patient and her family.discuss a treatment plan with the patient and her family.

• Assure the patient that frequent monitoring and prompt Assure the patient that frequent monitoring and prompt management greatly reduce the risk of neonatal death.management greatly reduce the risk of neonatal death.

• Encourage the patient and her family to verbalize their Encourage the patient and her family to verbalize their feelings helps them to develop effective coping strategies, feelings helps them to develop effective coping strategies, and refer them for counseling, if necessary.and refer them for counseling, if necessary.

• Anticipate the need for a referral for home care if the patient Anticipate the need for a referral for home care if the patient bleeding ceases and she’s to return home in bed rest.bleeding ceases and she’s to return home in bed rest.

• During the postpartum period, monitor the patient for signs During the postpartum period, monitor the patient for signs of early and late postpartum hemorrhage and shock.of early and late postpartum hemorrhage and shock.

• Monitor VS for elevated temperature, pulse, and blood Monitor VS for elevated temperature, pulse, and blood pressure, monitor laboratory results for elevated WBC count, pressure, monitor laboratory results for elevated WBC count, differential shift; check for urine tenderness and malodorous differential shift; check for urine tenderness and malodorous vaginal discharge to detect early signs of infection resulting vaginal discharge to detect early signs of infection resulting from exposure of placental tissue.from exposure of placental tissue.

• Provide or teach perineal hygiene to decrease the risk of Provide or teach perineal hygiene to decrease the risk of ascending infection.ascending infection.

• Observe for abnormal fetal heart rate patterns such as loss Observe for abnormal fetal heart rate patterns such as loss of variability, decelerations tachycardia to identify fetal of variability, decelerations tachycardia to identify fetal distress.distress.

• Position the patient in side lying position and wedge for Position the patient in side lying position and wedge for support to maximize placental perfusion.support to maximize placental perfusion.

• Assess fetal movement to evaluate for possible fetal hypoxia.Assess fetal movement to evaluate for possible fetal hypoxia.• Teach woman to monitor fetal movement to evaluate well Teach woman to monitor fetal movement to evaluate well

beingbeing• Administer oxygen as ordered to increase oxygenation to Administer oxygen as ordered to increase oxygenation to

mother and fetus.mother and fetus.

• X. Discharge Plan:X. Discharge Plan:• Medication Medication • Betamethasone (Celestone) is a corticosteroid Betamethasone (Celestone) is a corticosteroid

that acts as an anti-inflammatory and that acts as an anti-inflammatory and immunosuppressive agent.immunosuppressive agent.

• Assess for contraindications of Betamethasone Assess for contraindications of Betamethasone administration. Obtain reports of urine and administration. Obtain reports of urine and cervical cultures and fibronectin.cervical cultures and fibronectin.

• ExerciseExercise• Needs to adequate her time with her child to be Needs to adequate her time with her child to be

certain he or she is all right, and nurse can certain he or she is all right, and nurse can states hearing fetal heart beat helps to reassure states hearing fetal heart beat helps to reassure her about baby’s health.her about baby’s health.

• Attach contraction and fetal heart rate Attach contraction and fetal heart rate monitoring for continuous evaluation of monitoring for continuous evaluation of contractions of fetal response.contractions of fetal response.

• TreatmentTreatment• Used of drugsUsed of drugs• CatheterizationCatheterization

• Health TeachingHealth Teaching• Maintain a bed restMaintain a bed rest• Maintain a 8 glasses of waterMaintain a 8 glasses of water• Ongoing AssessmentOngoing Assessment• Assess client’s home surrounding to determine whether Assess client’s home surrounding to determine whether

they are appropriate for bed rest and continuing they are appropriate for bed rest and continuing monitoring at home. Administer oral dose and home monitoring at home. Administer oral dose and home monitoring requires professional supervision.monitoring requires professional supervision.

• DietDiet• She might to begin to neglect her diet or her She might to begin to neglect her diet or her

supplementary vitamins because “It doesn’t matter supplementary vitamins because “It doesn’t matter anymore”.anymore”.

• SpiritualSpiritual• Assess anxiety level of client over preterm labor possible Assess anxiety level of client over preterm labor possible

feelings.feelings.• Determine whether client wants a support person to be Determine whether client wants a support person to be

wit her, to the presence of a support person can offer wit her, to the presence of a support person can offer additional comfort to a client.additional comfort to a client.

• Possible Nursing Diagnosis for Placenta Possible Nursing Diagnosis for Placenta Previa:Previa:

• Risk for Impaired Fetal Gas Exchange r/t Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental ImplantationDisruption of Placental Implantation

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

• Active Blood Loss r/t Low Placental ImplantationActive Blood Loss r/t Low Placental Implantation• Fear r/t Threat to Maternal and Fetal Survival Fear r/t Threat to Maternal and Fetal Survival

Secondary to Excessive Blood LossSecondary to Excessive Blood Loss• Activity Intolerance r/t Enforced Bed Rest During Activity Intolerance r/t Enforced Bed Rest During

Pregnancy Secondary to Potential for HemorrhagePregnancy Secondary to Potential for Hemorrhage• Altered Diversional Activity r/t Inability to Engage Altered Diversional Activity r/t Inability to Engage

in Usual Activities Secondary to Enforced Bed in Usual Activities Secondary to Enforced Bed Rest and Inactivity During PregnancyRest and Inactivity During Pregnancy

• XI. Referral and Follow – up:XI. Referral and Follow – up:• Patient is reffered to Dr. Tusalem, andPatient is reffered to Dr. Tusalem, and• CONTACT A CAREGIVER IF: CONTACT A CAREGIVER IF: • • • You have abdominal cramps, pressure, or You have abdominal cramps, pressure, or

tightening. tightening. • • • Your heart is beating faster then what is Your heart is beating faster then what is

normal for you. normal for you. • • • You have a fever (high body temperature). You have a fever (high body temperature). • • • You have any questions or concerns about your You have any questions or concerns about your

pregnancy, condition, or care. pregnancy, condition, or care. • SEEK CARE IMMEDIATELY IF: SEEK CARE IMMEDIATELY IF: • • • You have any bleeding from your vaginaYou have any bleeding from your vagina

• XIV. References:XIV. References:• We able to come up with this study with We able to come up with this study with

the help primarily of our awesome God the help primarily of our awesome God next would be the cooperation and next would be the cooperation and accommodation of our patient: these are accommodation of our patient: these are our sources:our sources:

• Maternal & Child Nursing , Adele PilliteriMaternal & Child Nursing , Adele Pilliteri• http://wikipedia.orghttp://wikipedia.org• Pregnancy carePregnancy care• http://nursingcrib.com/author/lhynnelli/http://nursingcrib.com/author/lhynnelli/

•THANK YOU! GOOD NIGHT!THANK YOU! GOOD NIGHT!•MIDNIGHT SNACK NATO MIDNIGHT SNACK NATO DHA!! DHA!! GROUP GROUP

77