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Nursing Diagnosis

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Nursing Diagnosis
Ineffective tissue perfusion (placental) related toexcessive bleeding, hypotension, and decreased cardiacoutput, causing fetal compromise

Administer oxygen through a snug face mask at 8-12L per minute if maternal or fetal compromise is evident AcutePain related to increase uterine activity

to augment analgesics Administer pain medications as needed and as prescribed Fluid volume deficit related to excessive bleeding -bore IV line, as prescribedand draw blood for type and screen for bloodreplacement ontractions Monitor vaginal bleeding and evaluate fundalheight to detect an increase in bleeding Risk for infection related to excessive blood loss

Evaluate WBC and differential count each perinealcare and hand washing techniques Assess odor of all vaginal bleeding or lochia Fear related excessive bleeding procedures andunknown outcome herself and the fetus performed Answer questions in a calm manner, using simple terms

Abruptio placenta is premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage. Two types of abruption placentae: Concealed hemorrhage - the placenta separation centrally, and a large amount of blood is accumulated under the placenta. External hemorrhage – the separation is along the placental margin, and blood flows under the membranes and through cervix. Risk Factors: 1. 2. 3. 4. 5. 6. 7. 8. 9. Uterine anomalies Multiparity Preeclampsia Previous cesarean delivery Renal or vascular disease Trauma to the abdomen Previous third semester bleeding Abnormally large placenta Short umbilical cord

Common Clinical Manifestations: 1. 2. 3. 4. 5. 6. 7. Intense, localized uterine pain, with or without vaginal bleeding Concealed or external dark red bleeding Uterus firm to boardlike, with severe continuous pain Uterine contractions Uterine outline possibly enlarged or changing shape FHR present or absent Fetal presenting part may be engaged

Nursing Management: 1. Continuous evaluate maternal and fetal physiologic status, particularly: o Vital Signs o Bleeding o Electronic fetal and maternal monitoring tracings o Signs of shock – rapid pulse, cold and moist skin, decrease in blood pressure o Decreasing urine output o Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity. 2. Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated. 3. Provide appropriate management.

On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava. o Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level. o Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask. o Prepare for cesarean section, which is the method of choice for the birth 4. Provide client and family teaching. 5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the separation, amount of fetal hypoxia and amount of bleeding.

o

Abruptio Placenta
What is abruptio placenta?
Abruptio Placenta Care Guide


Abruptio placenta is a condition that can occur in your uterus (womb) before your baby is born. With abruptio placenta, all or part of your placenta pulls away from the wall of your uterus. The placenta forms during pregnancy and brings oxygen and nutrition from the mother to the fetus (unborn baby). The placenta also removes waste products from the fetus. Normally, your placenta stays attached to the wall of your uterus until your baby is born.

When your placenta pulls away during pregnancy, you may have vaginal bleeding or bleeding inside your uterus. Abruption of your placenta can be painful and may be life-threatening for both you and your baby. Treatment may help to resolve your bleeding and pain. Treatment may decrease your risk for having your baby earlier than he is ready to be born. Treatment may also save yours and your baby's life.

What causes abruptio placenta?
The exact cause of abruptio placenta is not clear. Caregivers believe damage to the placenta's blood vessels may cause bleeding and blood clots to form. The blood clots may then push the placenta away from the wall of your uterus. Caregivers also believe there may be an inflammatory (swelling) condition that causes the placenta to pull away.

What increases my risk for abruptio placenta?
Your risk for abruptio placenta increases as you get older. Past pregnancies that resulted in an abortion or miscarriage may also lead to abruptio placenta. The following may also increase your risk:


Alcohol, smoking, and street drug use: Drinking alcohol and smoking during pregnancy increases your risk of placental abruption. Examples of alcohol are beer, wine, whiskey, and vodka. The more cigarettes you smoke, the greater your risk. Your risk also increases if your partner smokes around you. Use of street drugs such as cocaine also may lead to abruption of your placenta.

 Bleeding: Bleeding during the first trimester (before the 12th week) of your pregnancy may increase your risk for abruption. You risk increases more if you have bleeding during both your first and second trimester (weeks 12 to 28).  Medical conditions: The following medical conditions may increase your risk for abruptio placenta:
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Abnormally shaped uterus Asthma or a lung infection Blood clotting disorders High blood pressure Infection in your uterus or placenta Lack of nutrition and vitamins Too much or too little fluid in your uterus



Pregnancy: The more times you have been pregnant, the higher your risk is for the condition. Your risk also increases if you had abruptio placenta during a past pregnancy. Being pregnant with more than one baby such as twins, also increases your risk. Early rupture (break) of the fluid filled sac that holds your unborn baby may also lead to abruptio placenta. Past C-section: A C-section is surgery to deliver your baby through a cut in your lower abdomen (stomach) and uterus. A past C-section may cause changes in your uterine tissue. The tissue changes may increase your risk for an abruption. Trauma: Motor vehicle accidents are a common trauma that may lead to abruptio placenta. You are also at risk if you are injured or attacked by another person while pregnant.





What are the signs and symptoms of abruptio placenta?
You may have no signs and symptoms when you have abruptio placenta. When your placenta pulls away from the uterine wall you may have bleeding that becomes trapped inside. Trapped blood may cause the fluid filled sac holding your unborn baby to weaken and break open. You may have any of the following signs and symptoms:
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Bleeding from your vagina that may be very light to very heavy. Abdominal pain or tenderness. Back pain. Contractions (cramping of your uterus). Dizziness and feeling like you are going to faint (pass out). Feeling like your heart is beating much faster than what is normal for you.

How is abruptio placenta diagnosed?
Your caregiver will ask you about your signs and symptoms. Tell your caregiver about any previous pregnancies and problems you may have had. If you have vaginal bleeding, your caregiver may do an exam to check where the bleeding is coming from. Your caregiver may also put a fetal monitor on your stomach to check your unborn baby's heartbeat. You may also need the following:


Blood tests: You may need blood taken to give caregivers information about how your body is working. The blood may be taken from your hand, arm, or IV. Ultrasound: An ultrasound uses sound waves to show pictures of your uterus on a TVlike screen. The pictures help show the amount of fluid inside your uterus. The ultrasound



can show the location of your placenta and if you have any blood clots. Your baby's position inside your uterus may also be seen. You may need to have more than one ultrasound when you have abruptio placenta.

How is abruptio placenta treated?
Treatment will depend on how far along you are in your pregnancy. You may need any of the following:


Bed rest: You may need to be on bed rest until your baby is ready to be born. You may be able to rest at home or you may need to stay in the hospital. If you are in the hospital, your caregiver may keep you on a monitor. A monitor is used to watch your vital signs (heart rate, breathing, and blood pressure). You may also need to wear a fetal monitor. Talk to your caregiver about what activities are OK while you are on bed rest. Medicine:
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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. Steroids: Steroid medicine may be given if you need to deliver your baby earlier than expected. Steroids help your baby's lungs to function and prevent breathing problems after he is born.

o



Delivery of your baby: Early delivery of your baby may be needed when you have abruptio placenta. If your due date is close, and you have a partial abruption, you may be able to give birth vaginally. If your abruption is severe or complete, a C-section is commonly done. A C-section may also be done if you have heavy bleeding, or you or your baby is in danger. Blood transfusion: You may need a blood transfusion if you lose a large amount of blood. During a blood transfusion, donated blood is given to you through an IV. An IV is a tube that is put into your vein for given medicines or fluids such as blood.



What are the risks to my health with abruptio placenta?
Risks to your health may depend on how severe your abruption is. Do not ignore any signs and symptoms you have, as they could mean you are in danger. Having abruptio placenta may increase your risk for blood clotting and bleeding problems. You may have vaginal bleeding that cannot be stopped or controlled. Your kidneys may fail, and your heart may not work as it should. Abruptio placenta can be a very serious condition, and you may die. Having abruptio placenta may make you feel worried and scared. Talk to your caregiver, family, and friends about your feelings. Ask your caregiver if you have questions or concerns about your condition, treatment, or care.

What are the risks to my unborn baby with abruptio placenta?
If you have abruptio placenta, your unborn baby may not get the oxygen and nutrition it needs to grow and survive. Your unborn baby may have problems with his heart rate. Your baby may be born too early, and his lungs may not function properly. If your baby is born too early, he may be very small, and he may die. Your baby may also be at an increased risk for Sudden Infant Death Syndrome (SIDS). Talk to your caregiver about any concerns you have about your unborn baby's health.

When should I call my caregiver?
Call your caregiver if:
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You are having contractions. You have blood spotting from your vagina. You have a fever (high body temperature). Your heart is beating faster than what is normal for you.

When should I seek immediate care?
Seek care immediately or call 911 if:
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Your unborn baby is moving less than usual, or not at all. You have a large amount of vaginal bleeding. You are leaking fluid from your vagina, or a large amount of fluid comes out of your vagina. You are having severe abdominal pain or contractions. You have new and sudden chest pain or trouble breathing. You are urinating less than what is normal for you, or not at all. You fainted or feel too weak to stand up.

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Care Agreement

You have the right to help plan your care. Learn about your health condition and how it may be treated. Discuss treatment options with your caregivers to decide what care you want to receive. You always have the right to refuse treatment. Copyright © 2012. Thomson Reuters. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes. The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Clinical Manifestation
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Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Class 1: mild and represents approximately 48% of all cases. Characteristics include the following: o No vaginal bleeding to mild vaginal bleeding o Slightly tender uterus o Normal maternal BP and heart rate o No coagulopathy o No fetal distress Class 2: moderate and represents approximately 27% of all cases. Characteristics include the following: o No vaginal bleeding to moderate vaginal bleeding o Moderate-to-severe uterine tenderness with possible tetanic contractions o Maternal tachycardia with orthostatic changes in BP and heart rate o Fetal distress o Hypofibrinogenemia (i.e., 50–250 mg/dL) Class 3: severe and represents approximately 24% of all cases. Characteristics include the following: o No vaginal bleeding to heavy vaginal bleeding o Very painful tetanic uterus

o o o o

Maternal shock Hypofibrinogenemia (i.e., <150 mg/dL) Coagulopathy Fetal death

Pathophysiology
Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death. Abruptions are classified according to severity in the following manner:
   

Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring. Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

Intervention
Placental abruption is suspected when a pregnant mother has sudden localized abdominal pain with or without bleeding. The fundus may be monitored because a rising fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative. Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus is in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress. Blood volume replacement to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress. Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.

INTRODUCTION
Abruptio placentae (ie, placental abruption) refers to separation of the normally located placenta after the 20th week of gestation and prior to birth. Pathophysiology: Bleeding into the decidua basalis leads to separation of the placenta. Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus. Retroplacental blood may penetrate through the thickness of the uterine wall into the peritoneal cavity, a phenomenon known as Couvelaire uterus. The myometrium in this area becomes weakened and may rupture with increased intrauterine pressure during contractions. A myometrium rupture immediately leads to a life-threatening obstetrical emergency. Severity of fetal distress correlates with the degree of placental separation. In near-complete or complete abruption, fetal death is inevitable unless an immediate cesarian delivery is performed.


Abruptio placentae occurs in about 1% of all pregnancies throughout the world.

Maternal and fetal death may occur because of hemorrhage and coagulopathy. The fetal perinatal mortality rate is approximately 15%.

CLINICAL
History:


Patients usually present with the following symptoms:
o o o o o o

Vaginal bleeding Abdominal or back pain and uterine tenderness Fetal distress Abnormal uterine contractions (eg, hypertonic, high frequency) Idiopathic premature labor Fetal death

Placental abruption is mainly a clinical diagnosis based on findings of vaginal bleeding, abdominal pain, uterine tenderness, uterine contractions, and fetal distress. Severe uterine pain and tenderness with mild vaginal bleeding in a patient with hypertension (HTN) indicates placental abruption. Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). Clinical characteristics include the following:


Class 0 is asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Class 1 is mild and represents approximately 48% of all cases. Characteristics include the following:
o o o o o



No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress



Class 2 is moderate and represents approximately 27% of all cases. Characteristics include the following:
o o

No vaginal bleeding to moderate vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenemia (ie, 50-250 mg/dL)

o

o o 

Class 3 is severe and represents approximately 24% of all cases. Characteristics include the following:
o

No vaginal bleeding to heavy vaginal bleeding

o o o o o

Very painful tetanic uterus Maternal shock Hypofibrinogenemia (ie, Coagulopathy Fetal death

Causes:


Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all cases Maternal trauma (eg, motor vehicle accidents [MVA], assaults, falls) - Causes 1.5-9.4% of all cases Cigarette smoking Alcohol consumption Cocaine use Sudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin) Retroplacental fibromyoma Retroplacental bleeding from needle puncture (ie, postamniocentesis) Advanced maternal age
Idiopathic (probable abnormalities of uterine blood vessels and decidua) Folic Acid deficiency.



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    

DIFFERENTIALS
Abdominal Trauma, Blunt Appendicitis, Acute Disseminated Intravascular Coagulation Ovarian Cysts Ovarian Torsion Placenta Previa Pregnancy, Delivery

Pregnancy, Ectopic > Pregnancy, Preeclampsia Pregnancy, Trauma Shock, Hemorrhagic Shock, Hypovolemic Vaginitis

Laboratory Studies
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Hemoglobin Hematocrit

Platelets
    

Prothrombin time/activated partial thromboplastin time Fibrinogen Fibrin/fibrinogen degradation products D-dimer Blood type

Imaging Studies:


Ultrasonography helps determine the location of the placenta. (Location is used to exclude previa.) Ultrasonography is not very useful in diagnosing placental abruption.
o

Retroplacental hematoma may be recognized in 2-25% of all abruptions. Recognition of retroplacental hematoma depends on the degree of hematoma and on the operator's skill level.

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TREATMENT
Provide emergency care to all patients with suspected placental abruption. This care includes the following:
  

Continuous monitoring of vital signs Continuous, high-flow, supplemental oxygen One or 2 large-bore IV lines with normal saline (NS) or lactated Ringer (LR) solution Monitor amount of vaginal bleeding Treatment of hemorrhagic shock, if needed. Closely observe the patient.. Perform fetal monitoring. Perform aggressive fluid resuscitation to maintain adequate perfusion, if needed. Monitor vital signs and urine output. Transfuse, if necessary. Crossmatch 4 units of packed red blood cells. Perform amniotomy to decrease intrauterine pressure, extravasation of blood into the myometrium, and entry of thromboplastic substances into the circulation. Immediately deliver the fetus by cesarean delivery if the mother or fetus becomes unstable. Treatment of coagulopathy or disseminated intravascular coagulation (DIC) may be necessary. Some degree of coagulopathy occurs in about 30% of severe cases of placental abruption. The best treatment for DIC as a complication of placental abruption is immediate delivery..

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Further Inpatient Care:
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Labor, delivery, and postpartum care Further management of the complications of abruptio placentae

Prevention:
   

Treat maternal hypertension. Prevent maternal trauma/domestic violence. Prevent smoking and substance abuse. Diagnose placental abruption at an early stage in high-risk groups (eg, maternal hypertension, maternal trauma, association with domestic violence, smoking habit, substance abuse, advanced maternal age, premature ruptured membranes, uterine fibromyomas, amniocentesis). Folic Acid supplementation from early Pregnancy.



Complications:


Maternal complications
o o o o o

Hemorrhagic shock Coagulopathy/DIC Uterine rupture Renal failure Ischemic necrosis of distal organs (eg, hepatic, adrenal, pituitary)



Fetal complications
o
o o o o

Hypoxia
Anemia Growth retardation CNS anomalies Fetal death

Pitfalls:


Some patients may not have the classic presentation of abruption, especially with posterior implantation.



Consider a diagnosis of placental abruption for every patient in premature labor. Carefully monitor patients to exclude or establish this diagnosis. Absence of vaginal bleeding does not exclude placental abruption. DIC/coagulopathy may occur even if clotting factors initially are within reference ranges. Continue to monitor clotting factors Normal ultrasound findings do not exclude placental abruption.

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Source: http://www.indiandoctors.com/OBGYN/obst%20disorder/obst%20disorde-1.htm

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