Placental abruption is a serious pregnancy complication where the placenta partially or completely separates from the uterine wall before delivery. This condition requires immediate medical attention as it can lead to significant maternal and fetal complications. This nursing diagnosis guide focuses on identifying risk factors, recognizing symptoms, and implementing appropriate nursing interventions.
Causes (Related to)
Placental abruption can occur due to various risk factors and underlying conditions:
- Maternal factors:
- Advanced maternal age (>35 years)
- Hypertensive disorders of pregnancy
- Previous placental abruption
- Substance abuse (particularly cocaine)
- Smoking during pregnancy
- Trauma to the abdomen
- Pregnancy-related factors:
- Multiple pregnancies
- Polyhydramnios
- Premature rupture of membranes
- Uterine abnormalities
- Short umbilical cord
- Medical conditions:
- Thrombophilia
- Diabetes mellitus
- Preeclampsia
- Chronic hypertension
Signs and Symptoms (As evidenced by)
Placental abruption presents distinctive signs and symptoms that nurses must recognize for prompt intervention.
Subjective: (Patient reports)
- Sudden onset abdominal pain
- Back pain
- Uterine tenderness
- Continuous or intermittent pain
- Anxiety and restlessness
- Decreased fetal movement
Objective: (Nurse assesses)
- Vaginal bleeding (may be present or concealed)
- Uterine tetany or hypertonicity
- Abnormal fetal heart rate patterns
- Signs of maternal shock
- Dark red or brown vaginal discharge
- Elevated blood pressure
- Decreased hemoglobin and hematocrit
Expected Outcomes
The following outcomes indicate successful management of placental abruption:
- Maternal hemodynamic stability will be maintained
- Fetal well-being will be preserved
- Early recognition and management of complications
- Prevention of further placental separation
- Successful delivery when indicated
- Adequate pain management
- Prevention of DIC and other complications
Nursing Assessment
1. Monitor Vital Signs
- Frequent maternal vital signs
- Continuous fetal monitoring
- Assessment for signs of shock
- Blood pressure trending
- Heart rate and respiratory rate monitoring
2. Assess Bleeding
- Quantify visible blood loss
- Monitor for concealed bleeding
- Assess pad counts
- Document color and characteristics
- Check for clots
3. Evaluate Pain
- Assess pain characteristics
- Monitor uterine tenderness
- Document pain patterns
- Evaluate pain intensity
- Note pain location
4. Monitor Fetal Status
- Continuous fetal heart rate monitoring
- Assessment of fetal movement
- Evaluation of uterine activity
- Documentation of accelerations/decelerations
- Monitor for signs of fetal distress
5. Laboratory Monitoring
- Complete blood count
- Coagulation profile
- Fibrinogen levels
- Type and cross-match
- D-dimer levels
Nursing Care Plans
Nursing Care Plan 1: Risk for Maternal/Fetal Bleeding
Nursing Diagnosis Statement:
Risk for Maternal/Fetal Bleeding related to placental separation from the uterine wall as evidenced by vaginal bleeding and decreased hemoglobin levels.
Related Factors:
- Placental separation
- Coagulation disorders
- Trauma
- Hypertensive disorders
- Multiple pregnancies
Nursing Interventions and Rationales:
- Monitor vital signs q15min or as ordered
Rationale: Early detection of hemorrhage and shock - Assess bleeding characteristics and amount
Rationale: Quantifies blood loss and identifies deterioration - Maintain IV access and fluid replacement
Rationale: Ensures adequate circulation and prevents shock - Position patient in left lateral position
Rationale: Improves uteroplacental perfusion
Desired Outcomes:
- Maternal vital signs will remain stable
- Bleeding will be controlled
- Hemoglobin/hematocrit will stabilize
- No signs of shock will develop
Nursing Care Plan 2: Risk for Impaired Fetal Gas Exchange
Nursing Diagnosis Statement:
Risk for Impaired Fetal Gas Exchange related to decreased placental perfusion as evidenced by abnormal fetal heart rate patterns.
Related Factors:
- Decreased placental surface area
- Reduced uterine blood flow
- Maternal hypotension
- Placental separation
- Uterine hypertonicity
Nursing Interventions and Rationales:
- Maintain continuous fetal monitoring
Rationale: Enables early detection of fetal compromise - Administer oxygen as ordered
Rationale: Improves maternal and fetal oxygenation - Monitor and document fetal movement
Rationale: Indicates fetal well-being
Desired Outcomes:
- Fetal heart rate will remain within normal limits
- Adequate fetal movement will be maintained
- A normal fetal gas exchange will be preserved
Nursing Care Plan 3: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to placental separation and uterine contractions as evidenced by reported abdominal pain and uterine tenderness.
Related Factors:
- Tissue trauma
- Uterine contractions
- Psychological stress
- Anxiety
- Fear
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Determines effectiveness of interventions - Provide comfort measures
Rationale: Reduces anxiety and promotes comfort - Administer prescribed pain medication
Rationale: Manages pain while maintaining fetal safety
Desired Outcomes:
- Pain will be effectively managed
- The patient will report decreased discomfort
- The patient will demonstrate reduced anxiety
Nursing Care Plan 4: Risk for Fluid Volume Deficit
Nursing Diagnosis Statement:
Risk for Fluid Volume Deficit related to active bleeding as evidenced by decreased blood pressure and increased heart rate.
Related Factors:
- Active blood loss
- Altered coagulation
- Decreased fluid intake
- Stress response
- Hypermetabolic state
Nursing Interventions and Rationales:
- Monitor fluid balance
Rationale: Ensures adequate volume replacement - Assess for signs of shock
Rationale: Enables early intervention - Maintain accurate I&O records
Rationale: Guides fluid replacement therapy
Desired Outcomes:
- Fluid balance will be maintained
- Vital signs will remain stable
- Adequate urine output will be maintained
Nursing Care Plan 5: Anxiety
Nursing Diagnosis Statement:
Anxiety related to the threat to maternal and fetal well-being as evidenced by expressed concerns and increased tension.
Related Factors:
- Threat to pregnancy outcome
- Fear of fetal loss
- Uncertainty about prognosis
- Limited knowledge
- Emergency situation
Nursing Interventions and Rationales:
- Provide clear, concise information
Rationale: Reduces fear of the unknown - Maintain calm, reassuring presence
Rationale: Helps reduce anxiety - Include support person in care
Rationale: Enhances emotional support
Desired Outcomes:
- The patient will verbalize decreased anxiety
- The patient will demonstrate improved coping
- The patient will express an understanding of the situation
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- American College of Obstetricians and Gynecologists. (2024). Placental Abruption: Diagnosis and Management. Obstetrics & Gynecology, 143(1), 12-25.
- Brandt JS, Ananth CV. Placental abruption at near-term and term gestations: pathophysiology, epidemiology, diagnosis, and management. Am J Obstet Gynecol. 2023 May;228(5S):S1313-S1329. doi: 10.1016/j.ajog.2022.06.059. Epub 2023 Mar 23. PMID: 37164498; PMCID: PMC10176440.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Oyelese Y, Ananth CV. Placental abruption. Obstet Gynecol. 2006 Oct;108(4):1005-16. doi: 10.1097/01.AOG.0000239439.04364.9a. PMID: 17012465.
- Thompson, R. G., & Davis, M. K. (2023). Maternal Outcomes in Placental Abruption: Updated Guidelines for Nursing Care. American Journal of Nursing, 123(8), 34-45.
- Smith, C., & Lee, A. (2024). Placental abruption. BJA Education, 24(9), 305-308. https://doi.org/10.1016/j.bjae.2024.05.001
