Placental Abruption Nursing Care Plans Diagnosis and Interventions
Placental Abruption NCLEX Review and Nursing Care Plans
The placenta is a highly vascular organ that develops within the walls of the uterus during pregnancy and fetal development.
This structure is primarily responsible for the supply of oxygen and nutrients to the fetus.
Given the importance of its role for fetal development, any deviations to the placenta’s integrity will cause undue harm for both the mother and the unborn child.
One obstetric example of such complications is Abruptio placentae (placental abruption). It is a medical condition characterized by the displacement, either partially or fully, of the placenta against the inner uterine wall.
Abruptio placentae is uncommon; however, it posts such great risks to the mother and fetus.
It occurs unexpectedly, oftentimes needing immediate medical intervention for it endangers the mother and her unborn child.
Signs and Symptoms of Placental Abruption
Abruptio placentae usually occurs at the third trimester or a few weeks before giving birth. The classic triad of the clinical manifestation of Abruptio placentae are:
- Vaginal bleeding – varies in amount and is present in 80% of patients diagnosed of placental abruptions; the remaining 20% are those with concealed hemorrhages
- Abdominal/uterine tenderness or rigidity and back pain – occurs suddenly; sometimes severe
- Abnormal uterine contractions – completes the triad of Abruptio placentae; usually continuous in nature, one contraction coming after another
It is important to note that the absence of vaginal bleeding does not rule out the diagnosis of Abruptio Placentae.
Causes and Risk Factors Placental Abruption
The etiology of Abruptio Placentae is unknown.
Possible causes include trauma or injury to the abdomen due to an accident.
It can also result from oligohydramnios, which is the rapid low levels of amniotic fluid.
The risk factors that increase the likelihood of Abruptio Placentae include:
- History of abruptio placentae that is not cause by traumatic abdominal injury
- Chronic hypertension
- Hypertension-related problems during preeclampsia, eclampsia, HELLP syndrome (which stands for Hemolysis, Elevated liver enzymes and Low Platelet levels)
- Abdominal trauma – usually due to fall
- Drug abuse during pregnancy – specifically cocaine
- Early rupture of membranes
- Chorioamnionitis – intrauterine infection during pregnancy
- Age – mothers aged 40 and above
Complications of Placental Abruption
Abruptio placentae impose a variety of complications that are life-threatening for both the mother and her unborn child.
Maternal complications may lead to:
- Hypovolemic shock
- Blood clotting problems that may lead to DIC (Disseminated Intravascular Coagulation)
- Multi-organ failure as result of insufficient blood supply in the circulation.
- Hysterectomy, or the surgical resection of the uterus. This is done to prevent more blood loss brought upon by Abruptio Placentae.
Fetal complications may lead to:
- Stunted and insufficient growth of the fetus
- Hypoxia due to rupture of primary source of oxygen
- Still birth
Diagnosis of Placental Abruption
- Complete Blood Count or CBC – to determine hemodynamic status but not necessarily predicts acute blood loss
- Fibrinogen studies – to check for fibrinogen levels; fibrinogen levels of 200mg/dl or below is highly suggestive of severe abruption and would necessitate transfusion of fresh frozen plasma or cryoprecipitate
- Prothrombin time (PT) activated partial thromboplastin time (APTT) – to check for coagulation status that is needed prior corrective surgery
- Blood Urea nitrogen (BUN)/ creatinine –to monitor renal function
- Blood and Rh types – to prepare the patient for the possibility of blood transfusions due to bleeding.
- Kleihauer-Betke test – to determine the volume of fetal blood transfused into the maternal circulation. This will also determine the appropriate dosage of Rh (D) immune globulin for significant fetal-maternal hemorrhage.
- Ultrasound – to eliminate differential diagnoses of third trimester bleeding besides Abruptio Placentae.
- Non-stress test / external fetal monitoring – to assess general fetal condition. Late decelerations and fetal bradycardia are indicative of fetal distress. Furthermore, increased uterine resting tone, along with frequent contractions, may progress to hyperstimulation of the uterus.
- Biophysical profile – to evaluate patients with chronic abruptions, who are managed conservatively. BPP scores of 6 and below (from a maximum score of 10) is an early sign of fetal distress and compromise.
Treatment for Placental Abruption
The management of Abruptio placentae includes careful planning, initial control of symptoms, the manner of fetal delivery, dietary and lifestyle modification, and the use of tocolytics.
- Hospitalization. Due to the nature of the condition, consideration of inpatient admission to a hospital with ICU and neonatal ICU is warranted before fetal delivery. Monitoring for fetal heart tones and contractions, stabilizing hemodynamic status through fluid resuscitation or blood transfusions, correction of coagulopathy, administration of Rh immune globulin (if patient is Rh negative) and initiation of corticosteroid for fetal lung maturity (for less than 37 weeks gestation) are implemented as initial treatment measures.
- Manner of Fetal Delivery. Choosing between vaginal delivery or through Caesarian section is based on the stability of the mother’s health. Caesarian section is the standard approach to stabilize the maternal and fetal health. Also, during C-section can the surgeon properly address and control the bleeding brought about by the condition. Placing the patient on “Nothing By Mouth” (NBM or NPO) is necessary to prepare the patient for emergent delivery. A modified bedrest regimen is prescribed to limit maternal and fetal distress.
- Medications. The following medications can be considered in a patient with Abruptio placentae:
- Tocolytics or anti-contraction drugs – used for premature labor suppression. Tocolysis is controversial and is only considered for patients hemodynamically stable and have no evidence of fetal threat.
- Calcium channel blockers – utilizing this prohibits the influx of calcium to the uterine walls, thus decreasing contractions
- Magnesium sulfate – drug of choice for managing Abruptio placentae. Also acts as neuroprotection for maternal seizures
- Corticosteroids – used to aide in lung maturity for preterm fetus with abruptions
Placental Abruption Nursing Diagnosis
Nursing Care Plan for Placental Abruption 1
Nursing Diagnosis: Altered Uteroplacental Tissue Perfusion related to maternal bleeding secondary to abruptio placentae, as evidenced by vaginal bleeding, abnormal uterine contractions, abdominal and uterine tenderness and pain, and changes in fetal heart rate
Desired Outcome: Patient has stable vital signs and the baby has a stable fetal heat rate.
|Placental Abruption Nursing Interventions||Rationales|
|Admit the patient and perform close monitoring for both the mother and the baby.||Decrease in fetal activity may mean fetal compromise or distress, which requires immediate medical attention and monitoring through hospitalization.|
|Provide the necessary treatments for maternal hemodynamic stabilization such as intravenous fluid resuscitation or blood transfusion.||Monitoring for fetal heart tones and contractions, stabilizing hemodynamic status through fluid resuscitation or blood transfusions, correction of coagulopathy, and administration of Rh immune globulin (if patient is Rh negative).|
|Administer corticosteroid as prescribed.||Administer corticosteroid for fetal lung maturity (for less than 37 weeks gestation) as an initial treatment measure.|
|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.|
|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 abruptio placentae.|
|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 Placental Abruption 2
Nursing Diagnosis: Deficient Fluid Volume related to active blood loss secondary to abruptio placentae, 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.
|Placental Abruption 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.||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.|
|Speak to the patient and family about the need for hospitalization for severe abruptio placentae or serious hemorrhage.||To closely monitor the symptoms of abruptio placentae and deficient fluid volume in the appropriate setting.|
|Prepare the patient for C-section and surgical intervention related to maternal bleeding. Place the patient on a nothing by mouth (NBM or NPO) status.||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. Placing the patient on “Nothing By Mouth” (NBM or NPO) is necessary to prepare the patient for emergent delivery. A modified bedrest regimen is prescribed to limit maternal and fetal distress.|
|Prepare for blood transfusion as required.||To increase blood volume.|
|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 an extremely low salt intake may increase dehydration, while high salt intake may cause edema formation.|
Nursing Care Plan for Placental Abruption 3
Nursing Diagnosis: Risk for Shock related to uterine malformations, multiple pregnancies, hypertension, history of cesarean delivery, renal or vascular disorders, abdominal trauma, previous third trimester bleeding, huge placenta, and a short umbilical cord secondary to placental abruption.
As a risk nursing diagnosis, the Risk for Shock is utterly irrelevant to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead.
- The patient will be hemodynamically stable.
- The patient will be able to regain vital signs at an average level.
- The patient will be able to verbally express his or her knowledge of the disease process, risk factors, and care plan.
- The patient will have normal central venous pressure.
- The patient will have warm and dry skin.
- The patient’s fetal heart rate will be within the usual range.
- The patient will produce an acceptable urine volume with normal specific gravity.
- The patient will exhibit his or her usual level of mentation.
|Placental Abruption Nursing Interventions||Rationale|
|Examine the patient for a history or the presence of disorders that could lead to hypovolemic shock.||Hypovolemic shock is an emergency health condition in which the heart cannot pump enough blood to the body due to substantial blood or other fluid loss. Many organs may stop working as a result of this type of trauma. Thus, the disorder can potentially decrease the body’s circulating blood volume and ability to sustain tissue perfusion and function.|
|Observe the patient thoroughly for persistent or substantial fluid or blood loss.||When a person loses too much blood, the body experiences shock. As a result, the heart cannot deliver enough blood to the organs, potentially resulting in organ damage. It is likely a consequence of severe cuts, traumatic injuries, excessive bleeding, endometriosis, or placental abruption. Since this is an emergency, the amount of fluid or blood loss must be monitored to identify the level of shock.|
|Examine the patient’s vital signs and tissue and organ perfusion. Keep track of any clinical signs as well.||The goal of this intervention is to identify alterations related to shock states. Tachycardia, lowered systolic blood pressure, constricted pulse pressure (or immeasurable diastolic pressure), decreased or absence of urine output, diminished mental status (or loss of consciousness), and cold and pale skin are all symptoms of shock. The level of hemorrhage is indeed life-threatening. Thus, to avoid serious consequences, healthcare providers must be aware of these signs.|
|Examine the patient’s laboratory data.||Laboratory tests are frequently performed as part of a routine examination to determine anomalies in a patient’s health. Laboratory data also help medical providers in the diagnosis of other medical issues, the planning or evaluation of treatments, and the monitoring of diseases. This intervention aims to understand the probable origins of shock and the extent of organ involvement.|
|Assist the patient in the prompt treatment of underlying problems. Also, aid the patient with his medical and surgical treatments.||This intervention aims to improve systemic circulation as well as tissue and organ perfusion.|
|Administer oxygen through the proper method, if necessary.||Gradually increasing the amount of oxygen administered improves systemic or tissue oxygenation.|
|Administer blood or blood products as prescribed by the physician.||Hypovolemic shock is a potentially fatal condition. Blood keeps the body temperature stable and transports oxygen and nutrients to all cells. If the blood volume becomes too low, the organs will be unable to function. Consequently, this therapeutic intervention aims to restore or maintain circulating volume and electrolyte balance quickly.|
|Using an external monitor, assess the patient’s uterine contractions and fetal heart rate.||This method determines whether labor is present and the state of the fetus; the external system prevents cervical damage.|
|Refrain the patient from drinking any liquids.||This approach anticipates the necessity for emergency surgery.|
|Assess the patient’s intake and production of urine.||Urine output is an essential clinical indicator for determining renal function and blood volume status, particularly in critically ill multiple trauma patients or those suffering from shock.|
|Weigh the patient’s perineal pads to determine maternal blood loss.||This method tries to provide verifiable evidence of the amount of bleeding.|
|Instruct the patient to maintain a positive outlook on the fetal outcome.||This intervention aims to promote mother-child attachment.|
|Provide support and encouragement to the patient and her life partner.||This method aids the patient in problem-solving, hampered by low self-esteem.|
Nursing Care Plan for Placental Abruption 4
Nursing Diagnosis: Acute Pain related to the rapid separation of the placenta from the uterine wall, as well as the pain associated with labor contractions during the initial separation secondary to placental abruption as evidenced by a sharp, prickling sensation in the uterine fundus, along with uterine tenderness.
- The patient will report pain alleviation or control.
- The patient will adhere to the pharmaceutical regimen advised.
- The patient will discuss non-pharmacological means of relief.
- The patient will show the application of relaxation strategies and diversional activities.
|Placental Abruption Nursing Interventions||Rationale|
|As needed, evaluate the patient’s pain. Ask the patient to rate her pain on a scale of 1 to 10 and describe the discomfort she is enduring.||The pain scale is used by doctors better to comprehend specific characteristics of a person’s discomfort. Pain duration, severity, and type of pain are some of these characteristics. Pain scales can also assist clinicians in making an accurate diagnosis, developing a treatment strategy, and determining the effectiveness of treatment. This intervention also aids in determining whether an underlying illness or organ failure requires treatment.|
|Take note of the patient’s locus of control.||People who have an external locus of control may take little or no accountability for pain control.|
|Take note and analyze any differences from past reports of pain.||Further assessment criteria, including location and quality, are critical in determining pain management therapies. Since patients may experience discomfort in regions other than the affected area, a piece of verbal information is essential. This intervention also seeks to prevent the underlying illness from worsening or complications from developing.|
|Recognize the patient’s description of pain and express approval of the patient’s pain reaction.||Obtaining a pain-related history utilizing the “OPQRST” mnemonic (Onset, Provocation, or Palliative cause, Quality, Region or related manifestations, Severity, and Time features) provides all relevant information. This strategy is helpful for the patient in describing her pain accurately.|
|Observe the patient’s skin color, temperature, and vital signs thoroughly.||Chronic pain is frequently associated with nerve injury. The organs, muscles, and skin are all supplied by the same nerves. If these nerves are injured, they may no longer adequately “supply” the skin. Acute pain can cause the skin’s color or texture to change. Furthermore, pain can have a variety of effects on vital signs. A natural response to pain, for example, is a rise in pulse rate, respiratory rate, and blood pressure. Abnormal vital signs can indicate that the pain is severe and causing harm to one’s health.|
|Take note of any pain reported by the patient and provide intervention as quickly as possible.||Pain causes patients and their loved ones stress and suffering. Pain can also raise heart rate and blood pressure, which can impair healing. Thus, immediate pain management reduces the patient’s discomfort.|
|Provide comfort measures, a quiet setting, and activities that are relaxing.||Reducing unwanted noise can enhance the patient’s perspective of the healing environment. A quiet environment also provides patients satisfaction and recovery. This method also promotes non-pharmacological pain management.|
|As needed, administer analgesics.||Analgesics are a type of medication used to alleviate pain. They function by either stopping pain signals from reaching the brain or interfering with the brain’s processing of those signals.|
|Encourage the patient to have enough rest.||Chronic pain makes it difficult to achieve restful sleep, and a lack of sleep can cause patients to wake up in pain. Sleep deprivation can lower one’s pain threshold and tolerance and aggravate discomfort. Sleeping allows the body to mend and rebuild itself. That is why it is necessary to help the patient achieve adequate rest and sleep.|
|If the pain does not subside, refer the patient to a specialist.||Pain management experts are clinicians who specialize in the diagnosis and treatment of individuals who are in pain. A pain management professional creates a treatment regimen to relieve, decrease, or manage pain and assist patients in returning to daily activities without surgery or a significant reliance on medication.|
Nursing Care Plan for Placental Abruption 5
Risk For Injury (Fetal and Maternal)
Nursing Diagnosis: Risk for Injury (Fetal and Maternal) related to tissue hypoxia, physical stress, and aberrant placental development secondary to placental abruption.
- The fetus will have normal FHR and beat-to-beat variability, with no alarming periodic alterations in reaction to placental abruption.
- The fetus will be successfully delivered with no congenital issues or severe ailments.
- The patient will verbally communicate his or her comprehension of individual risks and the justifications for various interventions.
- The patient will follow instructions to protect himself and the fetus from harm.
- The patient will avoid avoidable harm or consequences.
|Placental Abruption Nursing Interventions||Rationales|
|Manually and electrically monitor the baseline fetal heart rate (FHR).||Placental abruption may affect FHR since it may cause the baby to become hypoxic and develop acidosis. Therefore, it is necessary to note that fetal heart rate ranges typically between 120–160 bpm with average fluctuation, increasing in response to maternal exercise, fetal motion, and uterine contractions. Intermittent auscultation, a fetoscope or Doppler transducer, or continuous electronic fetal monitoring can all be used to determine the FHR. During the latent phase, FHR may be assessed every hour for low-risk clients, every 30 minutes for high-risk clients, and at any time during the bursting of the membranes, before and after ambulation, before and after anesthesia administration, after physical examination, if contractions are irregular, or if there are signs of placental abruption.|
|Examine the variability of FHR patterns and periodic variations in response to placental abruption.||The baseline rate, baseline variability, episodic alterations, and periodic changes of the FHR must be assessed. Periodic alterations in the FHR caused by placental abruption, such as accelerations and decelerations, are just temporary. Thus, when the FHR fluctuates by more than 25 beats over the baseline, it indicates cord rupture or maternal hypotension. Absent variability is associated with changes from baseline of fewer than six beats per minute for ten minutes and is often caused by placental abruption.|
|If necessary, assist the patient with ultrasonography.||Ultrasound is the primary (and often only) imaging modality to assess placental abruption. If placental abruption is present, ultrasonographic investigations can help promptly diagnose it as the cause of the bleeding. An ultrasonographic image of a placental abruption shows a retroplacental clot.|
|Examine the mother’s prenatal records for a history of previous pregnancies. Prenatal records, as a clinical tool, provide prompts and care instructions for a wide variety of physical and psychosocial health factors during pregnancy. Thus, it can also play an essential role in recognizing any complications with pregnancy, including placental abruption.|
|Instruct the patient to notify the doctor right away if she experiences vaginal bleeding during her pregnancy.||Vaginal bleeding is the most common symptom of placental abruption. The mother may also experience pain, contractions, discomfort, soreness, and abrupt, continuous stomach or back pain. Hence, if bleeding develops, tell the patient to see a doctor as soon as possible to avoid further severe complications.|
|Regularly check the patient’s temperature.||Recent data reveals that rising temperatures are linked to placental abruption, a contributing factor to stillbirth. Therefore, make sure the patient has an average body temperature.|
|Regularly check the patient’s blood pressure.||High blood pressure during pregnancy can impair placental growth, limiting the baby’s nutrition and oxygen supply. This condition can result in premature birth, a low birth weight, placental abruption, and other health issues for the baby.|
|Admit the patient to an intensive care unit (ICU) if her current state requires it.||It may be necessary to transfer a patient to the intensive care unit (ICU) before or after delivery if the patient is hemodynamically unstable, if shock develops and if central monitoring is required.|
|Advise the patient to notify the health care team immediately if the placental abruption symptoms change or become more frequent.||This intervention seeks to detect any difficulties with pregnancy as soon as possible. Early intervention will help to avoid more severe consequences.|
|Advise the patient not to disregard any irregularities she may have experienced during her pregnancy. Vaginal bleeding, pelvic pain, or stomach cramps are all possibilities.||Ignoring even minor signs that appear unimportant may endanger the baby and the mother. That is why it is critical to disclose any irregularities, no matter how little, to prevent the risk of fetal and maternal injury.|
More Nursing Diagnosis for for Placental Abruption
- Fear related to threat of fetal death
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
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