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.
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:
- Profuse bleeding
- Hypotension
- Tachycardia
- soft and nontender uterus
- 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:
- Previous pregnancies
- Scars in the uterus from previous surgeries (e.g. Cesarian sections, dilatation and currage, etc.)
- maternal history of a previous placenta previa
- more than one fetus in the womb
- women aged 35 or older
- Non-white ethnicity
- Smoking and drug-abuse history
Complications of Placenta Previa
Maternal complications associated with placenta previa are:
- Hemorrhage. Once the placenta tears apart, severe vaginal bleeding may occur during labor, during delivery and/or the first few hours after delivery.
- 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.
- Increase risk of post-partum associated endometritis
Neonatal/fetal complications associated with placenta previa are:
- Congenital malformations – brought about by unplanned birth
- Fetal uterine growth retardation – due to premature fetal delivery
- Fetal anemia – Neonates born will often develop anemia due to prematurity
- Abnormal fetal presentation
- Low birth weight
- Neonatal respiratory distress syndrome
- 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:
- Vasa previa – another condition in which fetal blood vessels places near or across the opening of the uterus
- cervical or vaginal laceration
- vaginal sidewall laceration
- miscarriage
- infection (vaginitis, cervicitis, etc.)
- vaginal bleeding
- actual delivery
- 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:
- amount of bleeding
- when the bleeding stopped
- length and duration left of the pregnancy
- maternal and fetal health
- 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.
For little to no bleeding – It is recommended to avoid strenuous activities that may trigger bleeding.
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.
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:
- Oversewing the placental implantation site
- bilateral uterine artery ligation – made to control bleeding and limit blood supply to affected area
- internal iliac artery ligation– implemented as additional control measures for restricting blood supply to affected site
- Packing with gauze or tamponade with the Bakri balloon catheter – will acts as pressure dressing over the bleeding site
- B-lynch stitch
- Caesarian Hysterectomy
- Tocolytics. Medical management includes the use of tocolytics to prolong duration of pregnancy. The following tocolytic medications can be used:
- Magnesium sulfate – seizure prophylaxis for preeclampsia
- Corticosteroids – given to aide with the development of the fetal lungs
- Adrenergic agonists– administered to act on the beta2-receptors in the uterus thus promoting relaxation of uterine contractions
- Uterotonics. These medications will be given with caution for bleeding control and resolve uterine atony.
Nursing Diagnosis for Placenta Previa
Nursing Care Plan for Placenta Previa 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.
| Placenta Previa Nursing Interventions | Rationales |
| 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 for Placenta Previa 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.
| Placenta Previa Nursing Interventions | Rationale |
| 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 for Placenta Previa 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.
| Placenta Previa Nursing Interventions | Rationale |
| 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. |
Nursing Care Plan for Placenta Previa 4
Impaired Gas Exchange (Fetal)
Nursing Diagnosis: Impaired gas exchange (fetal) related to altered blood flow, altered oxygen-carrying capacity of blood from maternal anemia, and decreased surface area of gas exchange at site of placental attachment, possibly evidenced by changes in fetal heart rate/activity and release of meconium
Desired Outcome: The patient (fetus) will be able to maintain normal heart rate, with the absence of meconium staining and fetal distress.
| Placenta Previa Nursing Interventions | Rationale |
| Evaluate the patient’s vital signs such as the maternal heart rate, respirations, blood pressure, oxygen saturations and fetal heart tones every 15 minutes, unless indicated otherwise. | Vital signs monitoring ensures that baseline data of the patient are established in case deviations from the usual occurs as the condition improves or worsens, especially in light of impending maternal blood loss. |
| Ensure that the patient is maintained on bed rest or chair rest whenever possible. Give ample and frequent rest periods and uninterrupted sleep at night. | Adequate rest periods is mandatory and warranted for the patient with placenta previa in order to reduce fatigue and enhance strength. |
| Take note of the characteristics of patient bleeding, particularly the amount and type. | Recognizing the bleeding patterns of a patient with placenta previa will promote objective monitoring of bleeding episodes so that on-time interventions are applied as complications occur. |
| Always place the mother on her left side. | The left side-lying position will help in promoting placental perfusion and alleviate pressure on the internal organs of the mother. |
| Avoid vaginal examination of the mother with placenta previa. | Due to the nature of the condition, with the placenta completely or partially blocking the internal cervix, any manipulation introduced into the birth canal can compound and worsen the condition of the bleeding in placenta previa. |
| Observe the mother’s uterine contractions and the fetal heart rate through an external monitor. | This is done to ascertain if labor is imminent. It also ensures the checking of the fetal status externally without compromising the integrity of the cervical structures that is already compromised by the placenta previa. |
| Project a positive outlook to the mother and significant other about the condition of the fetus. | Projecting a positive outlook helps with the nurturing bond of the mother with the child, especially in times of stressful situations such as placenta previa. |
| Render oxygen supplementation as ordered and as needed. | Oxygen supplementation supports fetal oxygenation despite the lack of adequate maternal circulating blood. |
| Monitor for signs of cyanosis such as bluish discoloration of nail beds, oral mucosa, etc. | Central cyanosis characterized by the bluish discoloration of the tongue and oral mucosa signifies severe hypoxia and would necessitate immediate and prompt medical intervention. |
| Observe the clinical manifestations of hypercapnia. | Hypercapnia is defined as the abnormal build-up of carbon dioxide in the blood. Manifestations of hypercapnia are as follows: headaches, dizziness, lethargy, diminished ability to comply with commands, confusion, and even coma. |
| Place the patient in a semi-fowler’s position, preferably with the head of the bed elevated at 45 degrees when in the supine position. | An upright or semi-Fowler’s position allows for the proper expansion of the thorax and improvement of patient respirations. Since there is a lack of adequate circulating maternal blood toward the fetus, ensuring that correct maternal posture for breathing is maintained will promote better oxygenation to the fetus. |
| Integrate a schedule of nursing interventions for the patient with placenta previa. | Employing a schedule for nursing interventions ensures that adequate rest can be provided to the patient. Furthermore, it can decrease unnecessary patient fatigue, thus supplementing further the protective interventions for a mother already on bed rest due to placenta previa. |
| Help the patient in activities of daily living. | Activities promote the consumption of an already depleted oxygen supply. Because of these, careful planning and prompt assistance are necessary to avoid fatigue and patient hypoxia that may compound the status of the fetus. |
Nursing Care Plan for Placenta Previa 5
Nursing Diagnosis: Fear related to threat of death to self or fetus, possibly evidenced by verbalization of specific concerns, increased tension, sympathetic stimulation.
Desired Outcomes:
- The patient will be able to openly discuss and recognize healthy versus unhealthy fears regarding own status, fetal integrity, and future pregnancies.
- The patient will be able to report lessened fear or fearful behaviors.
| Placenta Previa Nursing Interventions | Rationale |
| Enlighten the patient and significant other of the current situation. | Explaining the current situation gives out essential information regarding the patient’s reaction to what is happening. In instances of incomplete or imminent abortion, be certain that the patient comprehends that the pregnancy is already lost and that the planned interventions are tailored to protect the mother from bleeding and infection per se. |
| Allow the patient and partner to elaborate on their perception and issues within appropriate times. | Some patients subdue their feelings about their miscarriage and are anxious and readily willing to forget these unsettling experiences. Short-term repression may be beneficial in helping the patient address their anger or grief with the loss of the pregnancy. However, the client is susceptible to bleeding due to the repression of the medication regimen done together with repressing the experience. |
| Practice active listening to the concerns of the patient. | Active listening by the healthcare provider encourages the patient to have a sense of control over the disheartening experience and provides an opening to developing solutions to their own issues. The grief and anxiety experienced by the patient and her partner may occur longer and deeper, due to questions about what might have happened. |
| Explain methods and what the manifestations may mean. | The right information can assuage fears and foster a sense of power over the unfortunate situation. Most patients adjust well after an abortion, particularly when given truthful and extensive knowledge about what to expect during and after the process. |
| Allow the patient to ask questions. Answer them as truthfully as possible. | Accurate information will help the patient to effectively cope as much as possible with the distressing situation. Written data allows the patient to review the taught information in which they may find hard to understand initially due to the level of anxiety. Honest answers promote better patient-nurse interaction, better comprehension, and the reduction of latent fear. |
| Include the patient in the formulation of plans and in active participation in care. | The anxious patient given the opportunity to participate in their care brings a sense of control that will likewise reduce fear. A patient who experienced placenta previa not only will have grief stages to face but also may have decreased self-image issues. |
| Involve the clergy or spiritual advisor if proper and requested by the patient. | The spiritual advisor may help patients who are undergoing fear and anxiety issues, (i.e., placenta previa) Spiritual support can help the patient cope with the loss and grief experienced. |
| Assess and recognize the patient’s religious or cultural beliefs and practices. | Some clients may request or refuse religious practices to be done to products of conception after an irrevocable abortion. They may want to see and hold the fetus, take memories (e.g., taking pictures) or allow other members of the family to stay with her for support. |
| Monitor the patient’s responses, both verbal and non-verbal. | Verbal and non-verbal responses can be a means for the nurse to gauge the level of fear that the patient may be having. These patients would need assistance in accepting the reality of loss. Furthermore, they will need counseling for future pregnancies due to innate fears stemming from previous experiences of placenta previa that progressed to inadvertent abortion. |
| Take note of the fetal heart sounds together with the patient and significant other. | Joining the couple in listening for the fetal heartbeat may help in alleviating fear by being actively aware of the fetus’ condition. A listening ear will also help the patient be comforted that someone is always ready to listen to her fears, both the pregnancy and herself. |
Nursing Care Plan for Placenta Previa 6
Nursing Diagnosis: Deficient Knowledge related to lack of exposure to proper and accurate information secondary to placenta previa as evidenced by knowledge-seeking behaviors and the lack of comprehension regarding the condition and its management.
Desired Outcome: The patient will be able to gain sufficient and accurate knowledge that is needed for addressing the healthcare goals of the patient.
| Placenta Previa Nursing Interventions | Rationale |
| Evaluate the patient’s willingness to learn or the desire to perform health-related interventions. | The patient with placenta previa would be in a higher level of distress, thus learning new information would be a struggle. The healthcare provider being able to recognize early on the educational needs of the patient will help in planning and establishing realistic health goals that the patient currently needs to address her issues. |
| Evaluate the patient’s motivation and willingness to learn. | Motivation and willingness to learn will vary from person to person. A patient who is currently experiencing placenta previa would be on higher level of emotional distress that may hinder learning. Recognizing and addressing first the patient’s emotional distress would assist in guiding the patient towards necessary information needed for her recovery. |
| Ascertain and prioritize the knowledge base of the patient when considering the health management plan. | Setting a priority list ensures that the problems needing the most attention are given focus first in order to address health issues effectively and efficiently. In the case of patients with placenta previa, addressing first the physiological needs (e.g., bleeding, pain episodes) is superior to other issues such as behavioral or psychological problems. |
| Take note and correct, without judgment, any misconceptions that the patient may have regarding placenta previa. | Placenta previa is a condition wherein the placenta is located over the internal cervix, may it be partial or impartial. With this in mind, educating the patient of the realities of the condition, special considerations in care, and the relevance of interventions will help the patient be directed to take better choices for their health. |
| Evaluate barriers to patient learning such as perceived lifestyle changes, cultural patterns, etc. | Each patient is unique, especially when addressing concerns regarding their health, due to the varied backgrounds, values, and perceptions they may have. With this in mind, each learning episode is different thus requiring the healthcare provider to approach issues tailor-fit to the needs of the patient. |
| Render physiological comfort first to the patient before addressing emotional needs. | According to the principles in Maslow’s hierarchy of needs, physiological needs should be addressed first before going to other health issues such as educational needs. Making sure that physical comfort is addressed first will help the patient concentrate on the information being taught by the healthcare provider. |
| Offer a conducive environment promoting respect, openness, collaboration, and trust. | Nurturing a professional relationship with mutual respect is particularly essential in educating the patient with varied values and beliefs. It also promotes a conducive environment for better learning and retention of taught information. |
| Include the patient in the formulation of specific teaching outcomes, such as recognizing, which is the most important to be learned, in accordance with the patient’s perception and lifestyle. | Patient involvement and participation is necessary so as to properly improve their compliance rate to the prescribed therapeutic regimen. It also reinforces teaching as a partnership with the patient towards their desired health goals. |
| Utilize the teach-back method in order to assess the patient’s comprehension of what was taught: The nurse teaches the information in a caring way, in ordinary language. Requests the patient to answer using her own words. Restate the data if unable to repeat accurately. Ask the patient again to teach back the data utilizing her own words in the vernacular. If the patient is still unable, consider other techniques. | This method known as the teach back technique includes a series of steps done repeatedly in order to assess the receiver’s knowledge of the topic discussed. Patients who find it difficult to proceed with this technique after multiple attempts are considered cognitively impaired. |
| Provide positive and constructive feedback to the patient receiving the teaching. | Maintaining a positive outlook by the patient will allow her to feel good of gained accomplishments, increase her confidence and retain self esteem that is needed in motivating her towards better health goals. |
More Placenta Previa Nursing Diagnosis
- 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. (2022). 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. (2020). 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
