Placenta Previa

Placenta Previa Nursing Diagnosis Interventions and Care Plans

Placenta Previa NCLEX Review Care Plans

Nursing Study Guide on Placenta Previa

The placenta is the structure that develops inside the uterus and envelops the unborn fetus. This supplements the fetus of the needed nutrients and oxygen. Also, it serves as a medium for the elimination of by-products and wastes from the fetus.

In most pregnancies, the placenta attaches at the top or side of the placenta.

However, in placenta previa, the placenta attaches into the bottom part and near the cervix, which is the outlet of the uterus.

The condition may be partial or complete obstruction of the cervix, hence the name of its two types, complete placenta previa and partial placenta previa.

Tearing of this membrane during pregnancy and delivery predisposes the patient to severe bleeding, which is life-threatening to both the mother and fetus.

A combination of preventive measures, corrective surgery and pharmacological management are utilized to manage placenta previa.

Signs and Symptoms of Placenta Previa

Placenta previa occurs usually at the second or third trimester of pregnancy.

It presents as a sudden, painless, bright red vaginal bleeding which may or may not have associated uterine contractions.

It often stops spontaneously then recurs during active labor.

Majority of patients diagnosed with placenta previa resolves naturally as the fetus grows and the distance between the cervix and placenta increases.

However, there are some instances wherein this is not the case, thus making it riskier for the mother and her unborn child.

The risk compounds even further if the placenta lies nearer to the cervical opening.

Upon physical examination, a mother with placenta previa may have:

  1. Profuse bleeding
  2. Hypotension
  3. Tachycardia
  4. soft and nontender uterus
  5. usually with normal fetal heart tones

Causes and Risk factors of Placenta Previa

The exact cause of the condition is unknown.

Susceptibility in developing placenta previa generally may either be by internal factors (race and ethnicity), external (e.g. smoking), latent and/or causative risks (gynecologic history).

Nevertheless, there are risk factors associated to its development and they are:

  1. Previous pregnancies
  2. Scars in the uterus from previous surgeries (e.g. Cesarian sections, dilatation and currage, etc.)
  3. maternal history of a previous placenta previa
  4. more than one fetus in the womb
  5. women aged 35 or older
  6. Non-white ethnicity
  7. Smoking and drug-abuse history (e.g. cocaine)

Complications of Placenta Previa

 Maternal complications associated with placenta previa are:

  1. Hemorrhage. Once the placenta tears apart, severe vaginal bleeding may occur during labor, during delivery and/or the first few hours after delivery. 
  2. Preterm birth. If the placental membranes rupture before the fetus is in full term, it will require an emergency C-section to prevent further complications.
  3. Increase risk of post-partum associated endometritis

Neonatal/fetal complications associated with placenta previa are:

  1. Congenital malformations – brought about by unplanned birth
  2. Fetal uterine growth retardation – due to premature fetal delivery
  3. Fetal anemia – Neonates born will often develop anemia due to prematurity
  4. Abnormal fetal presentation
  5. Low birth weight
  6. Neonatal respiratory distress syndrome
  7. Increased risk for infant neurodevelopmental delay and sudden infant death syndrome (SIDS)

Diagnosis of Placenta Previa

Imaging – diagnosing placenta previa is usually done through ultrasonography, oftentimes during a routine prenatal check-up or after an episode of vaginal bleeding.

It may involve using ultrasound abdominally and transvaginally to visualize properly the placental structures.

Instruments or fingers during a routine vaginal examination should be avoided to prevent unnecessary rupture of membranes and bleeding.

Differential diagnosis – Other differential diagnosis before diagnosing placenta previa that should be noted are:

  1. Vasa previa – another condition in which fetal blood vessels places near or across the opening of the uterus
  2. cervical or vaginal laceration
  3. vaginal sidewall laceration
  4. miscarriage
  5. infection (vaginitis, cervicitis, etc.)
  6. vaginal bleeding
  7. actual delivery
  8. premature rupture of membranes

Treatment for Placenta Previa

Symptomatic control.

There is no medical or surgical treatment to cure this condition. However, anticipating for massive bleeding is necessary to limit further complications of placenta previa. The management would depend on various factors:

  1. amount of bleeding
  2. when the bleeding stopped
  3. length and duration left of the pregnancy
  4. maternal and fetal health
  5. placement of the placenta and the fetus

Management depending on the amount of bleeding.

For patients wherein placenta previa did not resolve, the main goal of treatment is to help the patient get close as possible to her expected due date.

If this is not possible to achieve, caesarean section (C-section) will be the primary choice to safely deliver the baby and prevent maternal and fetal complications.

  1. For little to no bleeding – It is recommended to avoid strenuous activities that may trigger bleeding.
  2. For heavy bleeding – Treatment would entail immediate medical management and blood transfusions to manage effectively. Caesarian sections would be the preferred choice for delivering the baby to avoid complications. If planned delivery will be earlier than 37 weeks age of gestation, corticosteroids is prescribed to help the fetus’ lungs to develop.
  3. For uncontrolled bleeding – Immediate C-section will be performed, regardless if the fetus   is premature or in full term. Corrective surgery to control the bleeding will also be done and may involve some surgical techniques such as:
  4. Oversewing the placental implantation site
  5. bilateral uterine artery ligation – made to control bleeding and limit blood supply to affected area
  6. internal iliac artery ligation– implemented as additional control measures for restricting blood supply to affected site
  7. Packing with gauze or tamponade with the Bakri balloon catheter – will acts as pressure dressing over the bleeding site
  8. B-lynch stitch
  9. Caesarian Hysterectomy

Tocolytics

Medical management includes the use of tocolytics to prolong duration of pregnancy. The following tocolytic medications can be used:

  1. Magnesium sulfate – seizure prophylaxis for preeclampsia
  2. Corticosteroids – given to aide with the development of the fetal lungs
  3. Adrenergic agonists– administered to act on the beta2-receptors in the uterus thus promoting relaxation of uterine contractions
  4. Uterotonics. These medications will be given with caution for bleeding control and resolve uterine atony.

Nursing Care Plans for Placenta Previa

Nursing Care Plan 1

Nursing Diagnosis: Altered Uteroplacental Tissue Perfusion related to maternal bleeding secondary to placenta previa, as evidenced by intrauterine fetal growth retardation viewed in the scans and changes in fetal heart rate

 Desired Outcome: Patient has stable fetal heat rate when subjected to contraction stress test.

InterventionsRationales
Teach the patient and her partner or next of kin on how to perform home assessment which includes noting daily fetal movements and identifying signs of fetal distress and how to get help immediately.Decrease in fetal activity may mean fetal compromise or distress, which requires immediate medical attention.  
Encourage the pregnant patient to follow a healthy lifestyle, such as smoking cessation and avoidance of illegal drug use, proper hydration, enough sleep, and appropriate diet.Fetal movement and activity can be affected by cigarette smoking, drug abuse, dehydration, sleep deprivation, and poor dietary choices.
Educate the patient on the signs of abruptio placenta and instruct to get help immediately if any of these occur.To give the patient enough information on the warning signs of abruptio placentae, which include uterine tenderness, vaginal bleeding, decreased fetal activity, and abdominal pain.  
Monitor fetal growth by measuring the fundus and check fetal heart rate at each clinic visit.To determine if the baby is experiencing intrauterine growth retardation related to placenta previa.  
If the baby needs to be delivered prematurely, give IM corticosteroids as prescribed, not more than 7 days prior to expected date of delivery.To enhance the production of surfactants which are necessary to speed up the pulmonary maturity of the fetus and avoid respiratory distress syndrome.

Nursing Care Plan 2

Nursing Diagnosis: Deficient Fluid Volume related to active blood loss secondary to placenta previa, as evidenced by an average blood pressure level of 85/50, body weakness, decreased urinary output, decreased fetal heart rate, and pale, clammy skin

Desired Outcome: The patient will re-establish a functional body fluid volume and a balanced input and output status.

InterventionRationale
Assess vital signs, conduct physical examination, and commence daily weight monitoring.Edema, headaches, low blood pressure, and pain are associated with the mother’s blood loss. Fluid retention may be evident if the mother has a weight gain of more than 1.5kg/month during the 2nd trimester, or more than 0.5 kg/week during the 3rd trimester.
Start input and output monitoring. Perform urine dipstick analysis using a midstream urine (MSU).To monitor circulatory blood volume. To ensure that the mother has adequate oral hydration or if there is a need to commence IV hydration therapy. To check for the presence of protein in the urine.
Provide a schedule for prenatal visit of a pregnant woman with placenta previa Consider hospitalization for severe placenta previa or serious hemorrhage.To closely monitor the symptoms of placenta previa and deficient fluid volume in the appropriate setting.
Prepare the patient for C-section and surgical intervention related to maternal bleeding.For heavy bleeding, immediate C-section will be performed, regardless if the fetus   is premature or in full term. Corrective surgery to control the bleeding will also be done and may involve some surgical techniques as appropriate.
  Refer the patient to a dietitian for proper monitoring and advice of salt, caloric and protein intake.  Consuming salt between 2 to 4 g per day is ideal as very low salt intake may increase dehydration, while high salt intake may cause edema formation.

Nursing Care Plan 3

Nursing Diagnosis: Decreased cardiac output related to altered cardiac contractility secondary to placenta previa, as evidenced by cardiac dysrhythmias, cold and clammy skin, shortness of breath, variations in blood pressure readings, and restlessness

Desired Outcome: The patient will have an improved cardiac output through well-controlled blood pressure levels throughout the remainder of her pregnancy.

InterventionRationale
Assess vital signs, conduct physical examination, and commence daily weight monitoring. Monitor the patient for any changes in heart rate and signs of dysrhythmia.Fluid retention may be evident if the mother has a weight gain of more than 1.5kg/month during the 2nd trimester, or more than 0.5 kg/week during the 3rd trimester.
Instruct the patient to have bedrest and avoid environmental stressors.To avoid further bleeding, maintain blood pressure levels, improve cardiac rate, and enhance utero-placental perfusion.
For high blood pressure levels, administer antihypertensives as prescribed.To lower blood pressure levels as needed.
Prepare to deliver the baby by Cesarean section.The baby may be delivered earlier than expected if the risks for the mother and the baby become higher.

Other Nursing Diagnoses:

  • Fear related to threat of fetal death
  • Impaired Fetal Gas Exchange
  • Risk for Deficient Diversional Activity

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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