I.

Introduction:
The upper part of the uterus is the most favorable area for placental implantati
on because it is rich in blood and, therefore, nutrients and oxygen. The lower u
terine segment is not and, therefore, it is possible that if the baby implants t
oo low (low-lying placenta), risks of intrauterine growth restriction and preter
m labor are much higher.
During the last trimester, and especially in the last month, the lower uterine s
egment thins appreciably and pulls up a bit, which is what causes cervical effac
ement (thinning) and early dilatation. If the placenta is impinging on the lower
segment and is not up in the fundus where it is supposed to be, then part of th
e placenta may dislodge and hemorrhage may occur. This condition is called PLACE
NTA PREVIA.
PLACENTA PREVIA is an abnormal low implantation of the placenta in proximity to
the internal cervical os. Placenta previa is a condition in which the placenta a
ttaches to the uterine wall in the lower portion of the uterus and covers all or
part of the cervix. Classification of Placenta Previa 1. Total Previa- the plac
enta completely covers the internal cervical os. 2. Partial Previa- the placenta
covers a part of the internal cervical os. 3. Marginal Previa- the edge of the
placenta lies at the margin of the internal cervical os and may be exposed durin
g dilatation. 4. Low-lying placenta- the placenta is implanted in the lower uter
ine segment but does not reach to the internal os of the cervix.
Mothers who are above 35 years old and below 18 years old as well as to those mu
ltiparous mothers are at risk in developing placenta previa. In addition to that
, mothers who have previous uterine surgery, large placenta that would include m
ultiple gestation and erythroblastosis, and maternal smoking will also likely to
develop placenta previa. When true placenta previa at term is very serious. Com
plications for the baby include (1) Problems for the baby, secondary to acute bl
ood loss, (2) Intrauterine growth retardation due to poor placental perfusion, (
3) Increased incidence of congenital anomalies. The siigns and symptoms of place
nta previa vary, but the most common symptom is painless bleeding during the thi
rd trimester. Other reasons to suspect placenta previa would be include (a) Prem
ature contractions, (b) Baby is breech, or in transverse position, (c) Uterus me
asures larger than it should according to gestational age. Some of the nursing a
ctions that would manage the occurrence of placenta previa is to give drugs that
can prevent premature labor or birth example is progesterone. Ultrasound exams
to determine migration of an early diagnosed previa or classification of the pre
via as total, partial, marginal, or low-lying would also help in managing placen
ta previa. When the client experience a small first bleed, client may sent home
on bed rest if she can return to hospital quickly and if bleeding is more profus
e client is required to be hospitalized on bed rest with BRP, IV access; labs: H
gb and Hct, urinalysis, blood group and type and cross match for 2 units of bloo
d hold, possible transfusions; goal is to maintain the pregnancy fetal maturity.
No vaginal exams are performed except under special conditions requiring a doub
le set-up for immediate cesarean birth should hemorrhage result. Instruct patien
t to position herself in a low lying or marginal previas to allow vaginal delive
ry if the fetal head acts as tamponade to prevent hemorrhage. In some cases, pro
cedure of Cesarean birth, often with vertical uterine incision, is used for tota
l placenta previa. Steroid shots may be given to help mature the baby's lungs.
II. Goals and Objectives:
GOAL:
We, the student nurses of Capitol University, aim to develop essential as well a
s skillful maternal nursing care which is based on the better and effective appr
oach ---that will serve as a catalyst to promote health, reduce illness and/or c
ompletely eliminate such diseases. We are also up to in knowing the nature of th
e disease and on how to manage it in such a way that it would be therapeutic to
both mother and child.
Objectives:
By the end of this whole rotation, we, the student nurses of Capitol University,
will be able to:
1. Enhance our ability to manage the said disease in regards to their cultural b
eliefs and lifestyle. 2. Develop an independent and collaborative work together
with the medical health team members. 3. Prioritize things which are essential i
n assessing and developing proper interventions in treating or alleviating the i
llness. 4. Improve the use of the nursing process that would include assessment,
diagnosis, planning, implementation and
evaluation into a more useful and more effective in doing the patient’s care. 5.
Apply the core and fundamental systematic approach of the nursing profession in
promoting health unto the clients.
III. Client’s Profile
A. Socio-demographic data Patient X is a 37- year old Filipina female who is liv
ing with her family at Look, Salay, Misamis Oriental. She is from Quitoan, Bacol
od. Her religion is Iglesia ni Cristo. She is a high school graduate, non-smoker
, non –alcoholic, and no allergies reported. Patient has placenta previa with bl
eeding during her delivery. Patient X was admitted last Novemer 29, 2009 at NNMC
–DR because of abnormal separation of the placenta. With that, patient X underg
one cesarean section. Patient X is multigravida. She delivered a post term opera
tive baby boy 43 weeks of gestation 3.4 kg with an APGAR score of 3,6,7 vertex,
placenta previa, accreta with anemia. Patient X has two full term baby weighing
5 lbs and 6 lbs. Patient is referred to NNMC from Balingasag, Provincial Hospita
l. B. Vital signs The patient vital signs are one of the most important data tha
t should be given a direct attention because it will serve as basis in determini
ng any risk factors towards the patient. The increase and decreased of the vital
sign of the patient must be monitored in order to determined whether the patien
t is at risk or not. The patient had the following vital signs upon admission: B
P- 120/90 mmHg, PR80 bpm ; RR-22 cpm; and temp- 36°c .
IV. Physical Assessment
These portions of the chapter will present the normal and regressed health funct
ion of patient X arranged in a cephalocaudal approach to present a more organize
d and convenient documentation. • Health perception and management pattern (pre-
hospitalization) She has 3 children and her medical and dental check-ups are onl
y done when needed. She does not smoke and drink alcoholic beverages. Her previo
us hospitalization was only when she delivered her previous babies. She had no o
ther health problems except the headache during her pregnancy period, and also t
here family believes in quack doctors or the so called “albularios” and uses of
herbal plants and medicines. • Nutrition-Metabolic Pattern (MGH – still in)
The patient is having her diet as diet as tolerated during her confinement in th
e hospital. • Elimination pattern (pre-hospitalization) A patient usually defeca
tes once a day with no other problems during defecations. She urinates approxima
tely 4-6 times a day also with no other problems in voiding process. • Activitie
s of daily living (ADL) (pre-hospitalization) The patient verbalized that, she c
an eat independently and can dress herself properly without a need of any assist
ance as well as in bathing. She usually sleeps around ten o’clock in the evening
and awake at five o’clock in the morning.
•
Self-perception and self-concept pattern (while confined)
The patient had a fighting spirit that she will overcome all the trials that may
come to her life. She had an overviewed that she will get soon and may go home
to see her family, love ones and friends. • Activities Tolerance-Exercise patter
n (while confined) Patient was able to ambulate around and able to make walking
wxercises, she was able to take bathe, dress and eat on her own and walk without
any assistance on her side. • Sleep rest pattern (while confined) She had a dif
ficulty in sleeping during the first day of admission because had a wound from h
er C/S operation and for the fact that she is surrounded with many people who ar
e literally noisy. The patient also verbalize that the environment is not soothi
ng for her but after a day she was able to adjust and adapt gradually in the env
ironment. • Cognitive-Perception (while confined) The patient can speak fluently
and understand fully in Cebuano and Tagalog, but she had low comprehension in E
nglish language. She is oriented with the time, people surround her and place. H
er memory is good and answer the question that was given to her, she is also nic
e to the co-patient in the ward and interact to her surroundings. • Role-Relatio
nship Pattern (while confined) The patient is happily married in 5 years with he
r husband. She is also good and nice mother to her children that provides their
basic needs even though she’s experiencing difficulty in most of the time. And a
lso a good influence to the people within the community where she belongs. • Val
ues – Belief Pattern The client is a member of Iglesia ni Cristo and verbalized
that she is always attending worship sessions and seldom missed it. She also act
ively participates in
the activities within her church.
V. Neurological Assessment
Orientation Appropriate behavior/communication Level of Consciousness Emotional
State Skin General Color Texture Turgor Temperature Moisture Pinkish Smooth Supp
le Warm Dry Oriented to time, person, and place Cooperative; Responsive Consciou
s Calm
Head Facial Movements Fontanels Hair Scalp Eyes Lids Preorbital Region Conjuncti
va Sclera Reaction to light Reaction to accommodation Visual Acuity Peripheral V
ision Symmetrical Intact/full Pink Anicteric R- Brisk L- Brisk Uniform constrict
ion / Convergence Grossly Normal Intact/full Symmetrical Closed Fine Clean
Nose
Septum Mucosa Patency Gross Smell Sinuses Ears External Pinnae Tympanic Membrane
Gross Hearing Mouth Lips Mucosa Tongue Teeth Gums Neck Trachea Thyroids Others
Pharynx Uvula Tonsils Posterior Pharynx Mucosa
Midline Pinkish Both patent Normal/symmetrical Non-tender
Normoset; Symmetrical Intact Decreased
Pinkish Pinkish Midline Complete Pinkish
Midline Non-palpable Normal ROM
Midline Not Inflamed Not Inflamed Pinkish
Abdomen General Configuration Bowel Sounds Percussion Back and Extremities Range
of Motion Decreased ROM Post-operative Wound Symmetrical Normoactive Tympanitic
Muscle tone and strength Spine Gait Cardiovascular Status
Fair Midline Coordinated
Precordial Area Point of Maximal Impulse (PMI) Heart Sounds Peripheral Pulses Ca
pillary Refill Respiratory Status Breathing Pattern Shape of Chest Lung Expansio
n Vocal/Tactile Fremitus Percussion Breath Sounds Cough Reproductive Status Labi
a Urethra Breasts
Flat Regular Regular 2 seconds
Regular AP:L:1:2 Symmetrical Symmetrical Resonant Vesicular Non-productive
Symmetrical Pinkish Equal; smooth
VI. Anatomy and Physiology
At conception: One very lucky spermatozoon out of hundreds of millions ejaculate
d by the man will penetrate the outside layer of the ovum and fertilize it. This
happens typically in the outer third of one of the woman s Fallopian tubes. The
surface of the ovum changes its electrical characteristics and normally prevent
s additional sperm from entering. A genetically unique entity is formed shortly
thereafter, called a zygote. This is commonly referred to as a "fertilized ovum.
" However that term is not really valid because the ovum ceases to exist after c
onception. Half of the zygote s 46 chromosomes come from the egg s 23 chromosome
s and the other half from the spermatozoon s 23. It has a unique DNA structure,
different from that of the ovum and the spermatozoon. The zygote "...is biologic
ally alive. It fulfills the four criteria needed to establish biological life:
1. metabolism, 2. growth, 3. reaction to stimuli, and 4. reproduction." It can r
eproduce itself through twinning at any time up to about 14 days after conceptio
n; this is how identical twins are caused. Conception is the point that most, or
all, pro-life groups and conservative Christians define as the beginning of pre
gnancy. When conception occurs, most of these groups define the start of a human
person as occurring at conception. The medical definition of the start of pregn
ancy is about 10 days later, at implantation. The zygote divides into two cells,
called blastomeres. They subdivide once every 12 to 20 hours as the zygote slow
ly passes down the fallopian tubes.
About 3 days after conception: The zygote now consists of 16 cells and is called
a 16 cell morula (a.k.a. preembryo). It has normally reached the junction of th
e fallopian tube and the uterus.
5 days or so after conception: A cavity appears in the center of the morula. The
grouping of cells are now called a blastocyst. It has an inner group of cells w
hich will become the fetus and later the newborn; it has an outer shell of cells
which will "become the membranes that nourish and protect the inner group of ce
lls." It has traveled down the fallopian tubes and has started to attach itself
to the endometrium, the inside wall of the uterus (a.k.a. womb). The cells in th
e inside of the blastocyst, called the embryoblast, start forming the embryo. Th
e outer cells, called the trophoblast, start to form the placenta. It continues
to be referred to as a pre-embryo.
9 or 10 days after conception: The blastocyst has fully attached itself to endom
etrium. Primitive placental blood circulation has begun. This blastocyst has bec
ome one of the lucky ones. Most never make it this far in the process.
12 days or so after conception: The blastocyst has started to produce hormones w
hich can be detected in the
woman s urine. This is is the event that all (or almost) all pro-choice groups a
nd almost all physicians (who are not conservative Christians) define to be the
start of pregnancy. If instructions are followed exactly, a home-pregnancy test
may reliably detect pregnancy at this point, or shortly thereafter.
13 or 14 days after conception: A "primitive streak" appears. It will later deve
lop into the fetus central nervous system. This is the point at which spontaneo
us division of the blastocyst -- an event that sometimes generates identical twi
ns -- is not longer possible. The pre-embryo is now referred to as an embryo. It
is a very small blob of undifferentiated tissue at this stage of development.
3 weeks: The embryo is now about 1/12" long, the size of a pencil point. It most
closely resembles a worm - long and thin and with a segmented end. Its heart be
gins to beat about 18 to 21 days after conception. Before this time, the woman m
ight have noticed that her menstrual period is late; she might suspect that she
is pregnant and conduct a pregnancy test. If it is an unwanted pregnancy, she mi
ght have already arranged and carried through with an abortion.
4 weeks: The embryo is now about 1/5" long. It looks something like a tadpole. T
he structure that will develop into a head is visible, as is a noticeable tail.
The embryo has structures like the gills of a fish in the area that will later d
evelop into a throat.
5 weeks: Tiny arm and leg buds have formed. Hands with webs between the fingers
have formed at the end of the arm buds. Fingerprints are detectable. The face "h
as a distinctly reptilian aspect." 1 "...the embryo still has a tail and cannot
be distinguished from pig, rabbit, elephant, or chick embryo."
6 weeks: The embryo is about 1/2" long. The face has two eyes on each side of it
s head; the front of the face has "connected slits where the mouth and nose even
tually will be."
7 weeks: The embryo has almost lost its tail. "The face is mammalian but somewha
t piglike." Pain sensors appear. Many conservative Christians believe that the e
mbryo can feel pain. However, the higher functions of the brain have yet to deve
lop, and the pathways to transfer pain signals from the pain sensors to the brai
n have not developed at this time.
2 months: The embryo s face resembles that of a primate but is not fully human i
n appearance. Some of the brain begins to form; this is the primitive "reptilian
brain" that will function throughout life. The embryo will respond to prodding,
although it has no consciousness at this stage of development. The brain s high
er functions do not develop until much later in pregnancy.
10 weeks: The embryo is now called a fetus. Its face looks human; its gender may
be detectable via ultrasound.
13 weeks or 3 months: The fetus is about 3 inches long and weighs about an ounce
. Fingernails and bones can be seen. Over 90% of all abortions are performed bef
ore this stage.
17 weeks or 3.9 months: It is 8" long and weighs about a half pound. The fetus
movements may begin to be felt. Its heartbeat can usually be detected.
22 weeks or 5 months: 12" long and weighing about a pound, the fetus has hair on
its head. Its movements can be felt. An abortion is usually unavailable at this
gestational age
because of state and province medical society regulations, except under very unu
sual circumstances. Half-way through the 22nd week, the fetus lungs may be deve
loped to the point where it would have a miniscule chance to live on its own. St
ate laws and medical association regulations generally outlaw almost all abortio
ns beyond 20 or 21 weeks gestation. "A baby born during the 22nd week has a 14.8
percent chance of survival. And about half of these survivors are brain-damaged
, either by lack of oxygen (from poor initial respiration) or too much oxygen (f
rom the ventilator). Neonatologists predict that no baby will ever be viable bef
ore the 22 nd week, because before then the lungs are not fully formed." Of cour
se, if someone develops an artificial womb, then this limit Fetal survival rate:
"Most babies at 22 weeks are not resuscitated because survival without major di
sability is so rare. A baby s chances for survival increases 3-4% per day betwee
n 23 and 24 weeks of gestation and about 2-3% per day between 24 and 26 weeks of
gestation. After 26 weeks the rate of survival increases at a much slower rate
because survival is high already." could change suddenly.
26 weeks or 6 months: The fetus 14" long and almost two pounds. The lungs bronc
hioles develop. Interlinking of the brain s neurons begins. The higher functions
of the fetal brain turn on for the first time. Some rudimentary brain waves can
be detected. The fetus will be able to feel pain for the first time. It has bec
ome conscious of its surroundings. The fetus has become a sentient human life fo
r the first time. 7 months: 16" long and weighing about three pounds. Regular br
ain waves are detectable which are similar to those in adults. 8 months: 18" lon
g and weighing about 5 pounds. 9 months: 20" long and with an average weight of
7 pounds, a full-term fetus is typically born about this time.
Normal Placenta During Childbirth
Process of placental growth and uterine wall changes during pregnancy The placen
ta grows with the placental site during pregnancy. During pregnancy and early la
bor the area of the placental site probably changes little, even during uterine
contractions. The semirigid, noncontractile placenta cannot alter its surface ar
ea. Anatomy of the uterine/placental compartment at the time of birth 1. The cot
yledons of the maternal surface of the placenta extend into the decidua basalis,
which forms a natural cleavage plane between the placenta and the uterine wall.
2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils,
around the branches of the uterine arteries that run through the wall of the ut
erus to the placental area. 3. The placental site is usually located on either t
he anterior or the posterior uterine wall. 4. The amniotic membranes are adhered
to the inner wall of the uterus except where the placenta is located
PATHOPHYSIOLOGY OF PLACENTA PREVIA
VII.
XI. Discharge Planning
AFTER YOU LEAVE: Medicines:
•
Keep a written list of the medicines you take, the amounts, and when and why you
take them. Bring the list of your medicines or the pill bottles when you see yo
ur caregivers. Learn why you take each medicine. Ask your caregiver for informat
ion about your medicine. Do not use any medicines, over-the-counter drugs, vitam
ins, herbs, or food supplements without first talking to caregivers.
•
Always take your medicine as directed by caregivers. Call your caregiver if you
think your medicines are not helping or if you feel you are having side effects.
Do not quit taking your medicines until you discuss it with your caregiver. If
you are taking medicine that makes you drowsy, do not drive or use heavy equipme
nt.
•
Tocolytics: Tocolytics are given to stop contractions if your baby is not ready
to be born. Contractions are when the muscles of your uterus tighten and loosen.
•
Antibiotics: Antibiotics may be given to help treat or prevent an infection caus
ed by germs called bacteria. Antibiotics may be needed before giving birth if yo
u have an infection in your uterus. You may also need antibiotics after your bab
y has been born.
•
Blood thinners: Blood thinners prevent clots from forming in your blood. They ma
y be given if you are at risk for deep vein thrombosis (DVT). DVT is a condition
where clots form inside your blood vessels.
Follow-up visits: Ask your caregiver when to return for a follow-up visit. If yo
u have not given birth yet, you may need to return for repeat ultrasounds. Keep
all appointments. Write down any questions you may have. This way you will remem
ber to ask these questions during your next visit. Activity: If you have not giv
en birth yet, you may need to rest more often. You may also need to be on bed re
st until your baby is born. If you have given birth, your caregiver may also wan
t you to limit your activity for a period of time. Talk to your caregiver about
what activities are OK for you. Having sex: With placenta previa, you will not b
e able to have sex in your third trimester. Even after your baby is born, you ma
y need to avoid having sex for a period of time. Talk to your caregiver about an
y questions you may have. Safety plan: When you have placenta previa, you will n
eed to have a safety plan until your baby is born. Make sure you live, or are st
aying a short distance away from the hospital. You will also need to make sure s
omeone is ready to take you to the hospital if needed. Talk to your caregiver ab
out other ways to make sure you and your unborn baby are safe. CONTACT A CAREGIV
ER IF:
• • • •
You have abdominal cramps, pressure, or tightening. Your heart is beating faster
then what is normal for you. You have a fever (high body temperature). You have
any questions or concerns about your pregnancy, condition, or care.
SEEK CARE IMMEDIATELY IF:
•
You have any bleeding from your vagina.
• • •
You are having severe (very bad) abdominal pain or contractions. You have new an
d sudden chest pain or trouble breathing. You fainted or feel too weak to stand
up.