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PLACENTA PREVIA

OBJECTIVES:
At the end of the presentation of the case study, the students will be able to:
Understand what Placenta Previa is.
Describe the types, etiology, risk factors contributing to the cause of Placenta Previa.
Learn what are the signs and symptoms and possible complications of Placenta Previa.
Describe and understand the general medical and surgical management, pharmacologic
management, and as well as the nursing responsibilities for patients with Placenta Previa.
Understand the anatomy and physiology of placenta.
Discuss the general and specific pathophysiology of Placenta Previa.
Understand the patients health history, patterns of functioning, levels of competencies, and
developmental tasks and relate this on the contribution or development to the patients condition.
Discuss the specific medical management done to the patient and as well as the nursing
management appropriate to the patients condition.
Identify the drugs given to the patient, understand its mode of action, and provide appropriate
nursing interventions in relation to the drug to ensure patients safety and to potentiate the effect
of the drug.
Identify nursing diagnosis appropriate to the patient and discuss nursing care plans to provide
holistic care to the patient.

BASIS FOR CHOOSING THE CASE:


We have chosen this case to be studied and to be presented because:
It is a rare case and we want to enhance our knowledge about this case.
One of the causes of mortality and morbidity during 3rd trimester of pregnancy.

PLACENTA PREVIA
-Is a condition of pregnancy in which the placenta is implanted abnormally in the uterus. It is the
most common cause of painless vaginal bleeding in the third trimester of pregnancy.
THREE TYPES OF PLACENTA PREVIA:

LOW-LYING OR MARGINAL PLACENTA PREVIA


- Low-lying placenta is near the cervical opening but not covering it. It will often move upward in
the uterus as your due date approaches. (30%)
-mode of delivery: NSD
PARTIAL PLACENTA PREVIA
-an implantation that occludes a portion of the cervical os (70%)
-mode of delivery: CS
COMPLETE/TOTALIS PLACENTA PREVIA
-totally obstructs or totally covered the cervical os (100%)
-mode of delivery: CS

INCIDENCE RATE:
-The incidence is approximately 5 per 1000 of all pregnancies.

*Exact etiology of placenta previa is unknown. It is hypothesized to be related to abnormal


vascularization of the endometrium caused by scarring or atrophy from previous trauma, surgery, or
infection. These factors may reduce differential growth of lower segment, resulting in less upward shift in
placental position as pregnancy advances.

PROGNOSIS:
- The majority of women with placenta previa in developed countries will deliver healthy babies,
and the maternal mortality (death) rate is less than 1%. In developing countries where medical
resources may be lacking, the risks for mother and fetus may be higher.

MODIFIABLE FACTORS:
Lifestyle
Illicit drugs or cocaine use
Smoking
Alcoholism
NON-MODIFIABLE FACTORS:
Age (older than 35 years old and younger than 18 years old)
Race is a controversial risk factor, with some studies finding that people from Asia and Africa are
at higher risk and others finding no difference.
Previous CS
Increased parity (80%)
Prior to abortion and past uterine curettage
Multiple gestation
Congenital anomalies
Heredity
Previous placenta previa

CLINICAL MANIFESTATIONS:
Painless vaginal bleeding during 1st trimester; bright red in color associated with stretching and
thinning of the lower uterine segment that occurs in 3rd trimester.
Decreasing urinary output.
Medium to severe vaginal bleeding during first trimester.
Symptoms of early labor, such as regular contractions and aches or pains in lower back or belly.

DIAGNOSTIC EXAMINATIONS

I. ULTRASOUND
Description:
Ultrasound is a painless test that uses sound waves to create images of organs and structures
inside your body. It is a very common used test. As it uses sound waves and not radiation, it is not
thought to be harmless.
An ultrasound examination is used to establish the diagnosis of placenta previa. Either a
transabdominal (using a probe on the abdominal wall) or transvaginal (with a probe inserted inside the
vagina but away from the cervical opening) ultrasound evaluation may be performed, depending upon the
location of the placenta. Sometimes both types of ultrasound examination are necessary

PURPOSES
1. To know, fetal and pregnancy abnormalities.
2. To know the amount of amniotic fluid and fetal position.
3. Doctor may order an ultrasound if you are experiencing pain, swelling, or other symptoms that
require an internal view of your organs.
PROCEDURES
1. The client will change into a hospital gown.
2. The client will most likely be lying down on a table with a section of the body exposed for the
test.
3. An ultrasound technician, called a sonographer, will apply a special lubricating jelly to the area of
the skin. The transducer sends high-frequency sound waves through the body.
4. The waves echo as they hit a dense object, such as an organ or bone. Those echoes are then
reflected back into a computer.
5. The sound waves are at too high of a pitch for the human ear to hear. Depending on the area
being examined, you may need to change positions so the technician can have better access.
6. After the procedure, the gel will be cleaned off abdomen. The whole procedure typically lasts less
than 30 minutes.

NURSING RESPONSIBILITIES:

1. Explain the procedure is painless and safe and that no radiation exposure is involved.
2. Emphasized the importance of remaining still during the scan to prevent distorted image.
3. Assist the patient into a supine position; if possible use pillows to support the area to be
examined. Put a water soluble jelly to the target area.

NORMAL FINDINGS
Normal result: Placental implantation visualized in fundus of uterus.
Abnormality with condition: Placental implantation visualized in lower uterine segment.
Explanation: visualization of placenta determines location and can rule out other causes of
bleeding.

TYPES:
TRANSVAGINAL ULTRASOUND
-A small tube placed inside the vagina to look for the uterus its usually show how close the
placenta in the edge or top of the cervix. It is beneficial for those patients with posterior placenta
previa because of increased clarity of diagnosis, decreased time of scanning, and no increased
incidence of hemorrhage.

TRANSABDOMINAL ULTRASOUND
-A small device use to show the picture of the uterus, it is usually done in full bladder test.

DOPPLER ULTRASOUND
-A Doppler ultrasound usually done to check if the placenta has grown into the wall of the uterus.
LABORATORY EXAMINATIONS

COMPLETE BLOOD COUNT


Description:

A Complete Blood Count (CBC), also known as Full Blood Count (FBC) or Full Blood
Exams (FBE) or blood panel, is a test panel requested by a doctor or other medical professional
that gives information about the cells in a patients blood.

Purpose:
This test was done to evaluate overall health and detect a wide range of disorders, including
anemia or presence of infection.
Routine laboratory examination.

Procedures:
The patient is usually assigned in sitting position with the left or right hand stretch on a platform
or table with the palm facing upward.
A venipuncture site will be chosen on where to get the blood specimen.
A tourniquet is applied around the arm.
The skin overlying the vein will be cleaned using cotton and an antiseptic.
A needle is inserted through the area of cleansed skin into the vein below where the tourniquet is
applied.
Blood is pulled from the vein via the needle by gently pulling the plunger of the syringe.
After that, tourniquet is removed to facilitate venous return.
A dry cotton ball is taped in the insertion site upon the removal of the needle.
The blood sample is then sent to the laboratory for analysis.

Nursing Responsibilities:
Check doctors order.
Explain the procedure to the patient and its rationale.
Use aseptic technique by cleansing the venipuncture site with cotton and alcohol.
Inform patient what he/she may feel.
There are no food, fluid, or medication restrictions unless by medical direction.
Evaluate the venipuncture site and pressure if there is continuous bleeding.
Report any result to the requesting HCP, who will discuss the results with the patient.

EXAMINATION NORMAL VALUES


Hemoglobin F: 12-16 g/dl
M: 13.8-18 g/dl
Hematocrit F: 37-47%
M: 42-52%
WBC 5,000- 10,000/mm3
Neutrophils 40- 60%
Lymphocytes 20-40%
Monocytes 2-6%
Eosinophils 1-3%
Basophils 0-2%

Platelet Count 150- 450 x 10/ L


BLOOD TYPING AND CROSS MATCHING
Description:
-Blood typing is a method to tell what specific type of blood you have. To determine the blood type of the
patient
-To check compatibility of the donor and the patient before blood transfusion, in case severe blood loss
during surgery.

Blood is often grouped according to the ABO blood typing system. This method breaks blood types down
into four categories:
Type A
Type B
Type AB
Type O

PROCEDURES:
Blood is drawn from a vein, usually from the inside of the elbow or the antecubital area.
The puncture site is cleaned with an antiseptic solution.
An elastic band is placed around the upper arm to apply pressure, which causes the vein to swell
with blood.
A needle is inserted into the vein, and the blood is collected into a tube.
During the procedure, the elastic band is removed to restore circulation.
Once the blood has been collected, the needle is removed, and a band-aid or gauze is applied.

NURSING RESPONSIBILITIES:
Explain the procedure to the patient and its rationale.
Use aseptic technique by cleansing the venipuncture site with cotton and alcohol.
Evaluate the venipuncture site and pressure if there is continuous bleeding.
Report any result to the requesting Health care provider, who will discuss the results with the
patient.

MEDICAL MANAGEMENT

Monitor maternal vital signs and fetal heart tone.


Administer IVF as ordered.
Oxygen therapy as ordered.
Complete bed rest.
Left lateral position
Delivery of viable neonate.
With fetus of less than 36 weeks gestation, careful observation to determine safety of
continuing pregnancy or need for preterm delivery.
INTRAVENOUS (IV) FLUID THERAPY
- It is essential when clients are unable to take food and fluid orally.
- It is an efficient and effective method of supplying fluids directly into the intravascular fluid
compartment and replacing electrolyte losses.
- IVF therapy is usually ordered by the physician.

CLASSIFICATIONS:
ISOTONIC SOLUTION- having the same concentration of solutes as blood plasma. Isotonic
solutions are often used to restore vascular volume.
HYPERTONIC SOLUTION- has a greater concentration of solutes than plasma.
HYPOTONIC SOLUTION- has a lesser concentration of solutes.

PURPOSES:
Used to maintain the patients hydration.
Serves as a route for medication.

NURSING MANAGEMENT:
Verify the Doctors order.
Inform the client and explain the purpose of IV therapy.
Instruct the patient that the procedure may cause a little bit pain upon insertion.
Practice aseptic technique.
Regulate IVF at prescribed rate.
Check IV patency.
Observe for potential complications.

TYPE PURPOSE NSG. RESPONSIBILITIES


ISOTONIC SOLUTIONS
-0.9% NaCl (normal saline) -NS and lactated Ringers -Caution must be exercised in the
initially remain in the vascular administration of parenteral fluids.
-Lactated Ringers (a compartment, expanding -Assess clients carefully for signs of
balanced electrolyte vascular volume. hypervolemia such as bounding
solution) pulse and shortness of breath.

-5% dextrose in water -D5W on initial administration -D5W is avoided in clients at risk for
(D5W) but provides free water when increased intracranial pressure (IICP)
dextrose is metabolized, because it can increase cerebral
expanding intracellular and edema.
extracellular fluid volumes.
HYPOTONIC SOLUTION
-0.45% NaCl (half normal -Hypotonic solutions are used to -Caution must be exercised in the
saline) provide free water and treat administration of parenteral fluids
cellular dehydration. These
-0.33% NaCl (one-third solutions promote waste -Do not administer to clients at risk
normal sline) elimination by the kidneys. for IICP or third-space fluid shift.

HYPERTONIC SOLUTION
-5% dextrose in normal -Hypertonic solutions draw fluid -Caution must be exercised in the
saline (D5NS) out of the intracellular and administration of parenteral fluids
interstitial compartments into the -Do not administer to clients with
-5% dextrose in 0.45% vascular compartment, kidney or heart disease or clients
NaCl (D5 1/2NS) expanding vascular volume. who are dehydrated.
-Watch for signs of hypervolemia.
-5% dextrose in lactated -For persons needing extra -Solution containing dextrose should
Ringers (D5LR) calories who cannot tolerate be used with caution.
fluid overload. -Discard unused portion

PHARMACOLOGIC MANAGEMENT
CORTICOSTEROIDS
BETAMETHASONE (CELESTONE)
- Steroids may be given if patient need to deliver her baby earlier than expected. These
medicines help the baby's lungs to mature and prevent breathing problems after he is
born.
REPRESENTATIVE THERAPEUTIC INDICATIONS ADVERSE NURSING
DRUGS ACTIONS REACTIONS RESPONSIBILITY
AND SIDE
EFFECTS
Generic name: >In >used systemically Adverse >Assess involved
BETAMETHASONE pharmacologic and locally in a wide reactions/side systems before and
Brand name: does, agents variety of chronic effects are much periodically during
CELESTONE suppress diseases including: more common therapy.
inflammation and -inflammatory with high- >Assess pt. for
CLASSIFICATION(S): the normal -allergic dose/long-term signs of adrenal
Therapeutic: immune -hematologic therapy. insuffiency before
corticosteroids response. -neoplastic CNS: and periodically
>agents have -autoimmune Depression, during therapy.
Pharmacologic: numerous intense disorders euphoria, >monitor intake and
Corticosteroids metabolic effects. -with other headache, output.
(systemic) >suppress - increased >observe for
adrenal function mmunosuppressants intracranial peripheral edema,
Pregnancy Category C at chronic doses in the prevention of pressure (children steady weight gain
(prednisolone) of organ rejection in only), personality and dyspnea.
betamethasone--- transplantation changes, >notify physician or
0.6 mg/day. surgery psychoses, other health
Route and Dosage: >have negligible restlessness professional if these
>PO(Adults): 0.6mg- mineralocorticoid EENT: occur.
7.2 mg/dy as a single activity. Cataracts,
daily dose or in divided Therapeutic increased
doses Effects: intraocular
>IM, IV (Adults): Up -suppression of pressure
to 9 mg of inflammation and CV:
betamethasone sodium modification of Hypertension
phosphate or 0.5-9 mg the normal GI:
IM as betamethasone immune response Peptic ulceration,
sodium -replacement anorexia, nausea,
phosphate/acetate therapy in vomiting,
suspension. Prevention adrenal DERM:
of respiratory distress insufficiency Acne, decreased
syndrome in newborn- wound healing,
12 mg 12 daily for 2-3 ecchymoses,
days before delivery fragility, petichiae
(unlabeled). ENDO:
Adrenal
suppression,
hyperglycemia
F and E:
Fluid
retension(long-
term high doses),
hypokalemia,
hypokalemic
alkalosis
HEMAT:
thromboembolism,
thrombophlebitis
METAB:
Weight gain,
weight loss
MS:
Muscle wasting,
osteoporosis,
aseptic necrosis of
joints, muscle pain
TOCOLYTICS
Tocolytics are medicines that attempt to stop labor. They are used if labor begins before term.
Tocolytics can stop labor or delay labor to give the baby's lungs time to mature. If started early in
premature labor, they may be effective. They are not as successful later in labor, if the
membranes have broken, or if your cervix is already dilated beyond 2 centimeters. When taking
this medication, you may need hospitalization or home therapy.

MAGNESIUM SULFATE
This medicine can be used to stop contractions as well as in the treatment and prevention
of seizures in a patient with preeclampsia. It can be taken as a pill or through an IV.
REPRESENTATIVE THERAPEUTIC INDICATIONS ADVERSE NURSING
DRUGS ACTIONS REACTIONS RESPONSIBILITY
AND SIDE
EFFECTS
MAGNESIUM >Essential for the >Treatment/prevention CNS: >Explain purposes
SULFATE [IV] (9.9% activity of many of hypomagnesemia drowsiness of medication to
Mg; 8.1 mEq Mg/g) enzymes >Anticonvulsant in RESP: patient and family
CLASSIFICATION(S): >Plays an severe eclampsia or decreased >monitor maternal
Mineral and electrolyte important role in preeclampsia respiratory vital signs and fetal
replacements/supplements neurotransmission >unlabeled uses: rate heart rate
and muscular -preterm labor CV: >assess for deep
PHARMACOLOGIC: excitability -treatment of Torsades arrhythmias, tendon reflex
Minerals/electrolytes Therapeutic de pointes bradycardia, >check for LOC
effects: hypotension
Pregnancy Category D -Replacement in GI: diarrhea
deficiency states DERM:
Route and Dosage: -Resolution of flushing,
>IM (Adults): severe eclampsia sweating
deficiency-250 mg/kg METAB:
over 4 hr; mild hypothermia
deficiency-1 g q 6 hr for 4 > Magnesium
doses. sulfate can
>IV (Adults): severe affect
deficiency-5g. reflexes.

TERBUTALINE (BRETHINE)
- Acts directly on beta2-receptors to relax uterine contractions.
This medicine is used to stop preterm labor. It is also known as Brethine. It can be taken
as a pill, through an IV (through a catheter directly into your vein), as an injection, or
through a controlled infusion pump. A pump is used to give a continuous low dose of the
terbutaline. Additional amounts of the medication can be administered if uterine activity
increases.
REPRESENTATIVE THERAPEUTIC INDICATIONS ADVERSE NURSING
DRUGS ACTIONS REACTIONS RESPONSIBILITY
AND SIDE
EFFECTS
Generic name: >Result in the >Management of CNS: >Explain purposes
TERBUTALINE accumulation of reversible airway nervousness, of medication to
(BRETHINE) cyclic adenosine disease due to restlessness, patient and family
monophosphate asthma or tremor, >assess lung sounds,
CLASSIFICATION(S): (cAMP) at beta- COPD; headache, respiratory pattern,
Therapeutic: adrenergic inhalation and insomnia pulse and blood
bronchodilators receptors subcut used for RESP: pressure before
Pharmacologic: >Produces short-term paradoxical administrations and
adrenergics bronchodilation control and oral bronchospasm during peak of
>inhibits the agent as long- (excessive use medication.
Pregnancy Category B\ release of term control. of inhalers) >check for LOC
mediators of >Unlabeled uses: CV: angina,
Route and Dosage: immediate -Management of arrhythmias,
>Subcut (Adults): 20 hypersensitivity preterm labor hypertension,
mcg once daily reactions from (tocolytic). tachycardia
:Pre-Filled pen delivery mast cells GI: nausea and
device (FORTEO pen): Therapeutic vomiting
delivers 20 mcg/day. effects: ENDO:
Bronchodilation. hyperglycemia

SPINAL AND EPIDURAL ANESTHESIA


DESCRIPTION
These two types of anesthesia numb your body from the chest down to the legs. The medication is
placed directly into the spine area.

Spinal anesthesia (or spinal anesthesia), also called spinal analgesia, spinal block or sub-
arachnoid block (SAB), is a form of regional anesthesia involving injection of a local anesthetic
into the subarachnoid space, generally through a fine needle, usually 9 cm long (3.5 inches). For
extremely obese patients longer needles are available (12.7 cm / 5 inches). The tip of the spinal
needle has a point or small bevel. Recently, pencil point needles have been made available
(Whitacre, Sprotte, Gertie Marx & others)

Epidural anesthesia is a technique whereby a local anesthetic drug is injected through


a catheter placed into the epidural space. This technique has some similarity to spinal anesthesia.

PURPOSES:
Spinal and epidural anesthesia is frequently given for surgeries involving:
Pelvis, hips, and legs
Childbirth
Advantages of these types of anesthesia include:
The ability to be awake during the operation
POSSIBLE COMPLICATIONS:
Severe headache or back pain
Drop in blood pressure
Nerve damage
Infection
Allergic reaction to the anesthetic used
Longer labor during childbirth with an epidural anesthesia

PRIOR TO PROCEDURE:

Make sure that your doctor is aware of:

Your drug allergies


Medications you are taking
Any heart or lung conditions you have
Any previous reactions that you or other family members have had to anesthesia
Any bleeding problems you have had in the past

PROCEDURE:
An area on your back above the spinal cord will be cleaned.
A local anesthetic will be injected into the skin to numb the area.
If you are getting spinal anesthesia, the doctor will give you one injection.
The medication will be sent directly into the sac of fluid that surrounds the spinal cord.
If you are getting epidural anesthesia, it may be delivered the same way. But, if you need more
than one dose, you will have a tiny, flexible tube in place just outside of the fluid sac. This allows
the doctor to give you more medication if you need it.
After the surgery, a bandage will be placed over the injection spot.

NURSING RESPONSIBILITY:
Monitor vital signs.
Assess for level of consciousness.
Check for urine output.
Ensure safety.

EPIDURAL INJECTION
SPINAL INJECTION

SURGICAL MANAGEMENT

CESAREAN SECTION
A cesarean section is an operation that delivers a baby through a cut in abdomen and uterus.
Cesarean birth happens through an incision in the abdominal wall and uterus rather than through
the vagina.
Cesarean delivery takes about 45 to 60 minutes. It takes place in an operating room. So if you
were in a labor and delivery room, you will be moved to an operating room.

PURPOSE: Surgical treatment for placenta previa to prevent further blood loss that could occur with
disruption of the placenta during vaginal bleeding.

PROCEDURE:
PREOPERATIVE
You will have an IV for fluids and medicines as ordered.
Before surgery, you will be given an anesthetic (general, spinal, or epidural) if you have not
already been given one earlier in your labor.
A general anesthetic is normally only used for emergency cesareans because it works quickly
and the mother is sedated.
The spinal and epidural anesthesia will numb the area from the abdomen to below the waist
(sometimes the legs can be numb also), so that nothing can be felt during the procedure.
In this procedure you will probably receive a catheter to collect urine while your lower body
is numb.
Your abdomen will be cleaned and prepped.
A nurse will insert a catheter to drain urine from your bladder.
Your heart rate, blood pressure, and breathing also will be monitored.
INTRAOPERATIVE
The health care provider will make an incision in the abdomen wall first.
The doctor will make an incision that is about 6 inches long and goes through the skin, fat,
and muscle.
In an emergency cesarean this will most likely be a vertical incision (from the navel to the
pubic area) which will allow the health care provider to deliver the baby faster.
The most common incision is made horizontally (often called a bikini cut), just above the
pubic bone.
The muscles in your stomach will not be cut. They will be pulled apart so that the health care
provider can gain access to the uterus.
An incision will then be made into the uterus, horizontally or vertically. The same type of
incision does not have to be made in both the abdomen and uterus.
The classical incision made vertically, is usually reserved for complicated situations such as
placenta previa, emergencies, or for babies with abnormalities.

A vaginal birth after cesarean (VBAC) is not recommended for women with the classical
incision. Another type of incision that is rarely used is the lower segment vertical incision.
This would only be used in cases where problems with the uterus would not allow another
type of incision to be made.
The most common incision is the low transverse incision. This incision has fewer risks and
complications than the others and allows most women to attempt a VBAC in their next
pregnancy with little risk of uterine rupture.
The health care provider will then suction out the amniotic fluid and then deliver the baby.
The babys head will be delivered first so that the mouth and nose can be cleaned out to allow
it to breathe.
Once the whole body is delivered, the health care provider will lift up and show you your
baby.
Most health care providers will then pass the baby on to the nurse for evaluation.
Finally, your placenta will be delivered (you may feel some tugging) after which the surgical
team will begin the close up process.

POST OPERATIVE
After the surgery, you might begin to experience some nausea and trembling. This can be caused
by the anesthesia, by the effects of your uterus contracting or from an adrenaline let down. These
symptoms usually pass quickly and can be followed by drowsiness.
If your baby is healthy, this is normally when the baby can rest on your chest and you can start
breastfeeding and bonding. You and your baby will continually be monitored for any potential
complications.
When you are discharged from the hospital you will be advised on the proper post-operative care
for your incision and yourself.
NURSING MANAGEMENT FOR CS:
PREOPERATIVE
1. Verify the patients identity.
2. Obtain an informed consent.
3. Monitor maternal Vital signs and fetal heart tone.
4. Ensure cardio pulmonary clearance.
5. Perform hand hygiene and apply antiseptic or alcohol (70%).
6. Inform the patient of what is happening and provide support.
7. Position the patient for the skin preparation and placement of the indwelling catheter.
8. Insert the indwelling catheter and position the drain tube of the catheter under the patients leg. If
a catheter is already in place, confirm its patency and the colour and amount of urine currently in
the drainage bag, and then place the bag near the head of the table.
9. Place the padding around the area of skin to be prepare for the incision to prevent the pooling of
solutions under the patient. This padding should be removed after preparation is complete and
before sterile drapes are applied.
10. Perform surgical counts of sponges, sharps, and instruments per institutional policy and
procedure. A count is conducted before the start of the procedure and before the closure of the
uterus, peritoneum, and skin incision. A count is also performed when a change in surgical staff
takes place.
11. Perform a sterile abdominal skin preparation.
12. Continue monitoring the FHR until abdominal sterile preparation has been started and abdominal
preparation is complete.
13. Alleviate patient anxiety

INTRAOPERATIVE:
1. Verify that all required documentation is completed.
2. Correct informed surgical consent, with patients signature.
3. Completed records for health history and physical examination.
4. Verify details, provide explanations, and answer questions to provide a sense of professionalism
and friendliness that can help the patient feel secured.
5. Give attention to physical comfort of the client.
6. Inform the patient who else will be present in the OR, how long the procedure is expected to take
and other details that helps the patient prepare for the experience and gain a sense of control.
7. Position patient according to the surgical procedure to be performed and as well as to the physical
condition of the patient.
8. Precautions for patient safety must observe particularly with thin, elderly, or obese patients and
those with physical deformities.
9. Monitor and manage potential complications that may occur.
10. Add additional sponges, sharps, and instrument to the operating room as requested. Count
additions with the scrub person and add them to the count sheet.
11. Bring any medication, fluids, or surgical supplies as requested to the operating field using sterile
technique.
12. Monitor conditions in the OR. Any break in sterile technique must be reported and corrected.
13. Perform surgical counts of sponges, sharps, and instruments per institutional policy before closure
of the uterus, peritoneum, and skin incision. A count is also conducted when a change in surgical
staff takes place.
14. Notify the practitioner immediately if the surgical count is not correct.

POST-OPERATIVE
1. Monitor airway and level of consciousness.
2. Monitor vital signs every 15 minutes for the first hour, every 30 minutes for the next hour and
every 1 hour for the next 2 hours, if stable, every shift.
3. Administer pain reliever as ordered.
4. Encourage also deep breathing exercise.
5. Check for complications of surgery. (e.g. Bleeding, haemorrhage, infection, wound dehiscence,
evisceration, palpable lymph nodes, increase WBC count, presence of malodorous vaginal
discharge, etc.)

6. Assess for signs and symptoms of respiratory depression and altered level of consciousness due to
effect of anesthesia.
7. Assess patients pain scale.
8. Promote relaxation techniques such as listening to music, diversion of activities, splinting, etc.
9. Verify whether the infant is being transferred to the nursery or will remain with the patient to be
cared for in a family-centered environment.
10. Check for skin integrity.
11. Maintain aseptic technique when dressing and caring wound.
12. Emphasize the importance of proper hand washing.
13. Administer antibiotics and analgesics as ordered.
14. Document the procedure in the patient's record.

GENERAL NURSING MANAGEMENT FOR PATIENT WITH PLACENTA PREVIA


Monitor maternal vital signs and fetal heart tone.
Monitor patients condition and measure amount of vaginal bleeding.
Monitor patients intake and output. Weigh the patient daily. (Best way to monitor I & O).
Monitor for presence of severe bleeding and for signs and symptoms of shock (e.g. hypotension,
tachycardia, tachypnea, etc.) and evaluate changes.
Assess for patients capillary refill- to determine effective tissue perfusion.
Monitor for signs and symptoms of fetal distress (e.g. decrease or absence of FHT, bradycardia,
tachycardia, late or available decelerations, etc.)
Monitor laboratory results for signs and symptoms of infection (e.g. elevated WBC count,
presence of malodorous vaginal discharge, etc.)
Oxygen readily available at bedside. Administer oxygen as ordered.
Administer IVF or blood transfusions as ordered.
Administer medications as ordered (Magnesium Sulfate, Tocolytics, Corticosteroids,etc.)
Institute complete bed rest.
Position the patient at left lateral position.
If the patient is Rh negative, administer Rh (0) immune globulin (RhoGAm) after every bleeding
episode.
Provide information about labor progress and the condition of the fetus.
Prepare the patient and her family for a possible cesarean section delivery and the birth of a
preterm neonate, and provide thorough instructions for postpartum care.
Encourage the patient and her family to verbalize their feelings to help reduce anxiety and
develop effective coping strategies
Provide health teaching to the patient such as proper perineal hygiene - to decrease the risk of
ascending infection.
During the postpartum period, monitor the patient for signs of early and late postpartum
hemorrhage and shock.

POSSIBLE NURSING DIAGNOSIS


1. Fluid volume deficit r/t active blood loss secondary to disrupted placental implantation.
2. Fear r/t threat to maternal and fetal survival secondary to excessive blood loss.
3. Risk for impaired fetal gas exchange r/t disruption of placental implantation.
4. Active blood loss (hemorrhage) r/t disrupted placental implantation.
5. Activity intolerance r/t enforced bed rest during pregnancy secondary to potential for
hemorrhage.
6. Altered diversional activity r/t inability to engage in usual activities secondary to enforced bed
rest and inactivity during pregnancy.

COMPLICATIONS:
COMPLICATIONS FOR THE MATERNAL INCLUDE:
Antepartum hemorrhage
Malpresentation
puerperal sepsis
Death

COMPLICATIONS FOR THE FETUS INCLUDE:


Problems for the baby secondary to acute blood loss.
Intrauterine growth retardation due to poor placental perfusion (15% incidence)
Increased incidence of congenital anomalies
Premature delivery
Death
Note:
- In writing nursing responsibilities, wag masyado mahaba. Rephrase it in a way na andun yung
thought.
- Do not include RATIONALES sa presentation, better if nasa back up notes mo sya para may
masabi ka habang nageexplain.
- Read more. Especially sa mga procedures.
- Lahat ng causes, risk factors, s/sx, complications, medical or nursing responsibilities, may
RATIONALE.
- Prepare for back up notes
- Bawal magdala ng libro sa harapan
- Be familiar sa mga normal values, normal findings, etc.

THERAPEUTIC MANAGEMENT
*IMMEDITE CARE MEASURES
To ensure an adequate blood supply to a woman and fetus, place the woman immediately on bed
rest in a side-lying position. Be sure to assess:
Duration of pregnancy
Time the bleeding began
Womans estimation of the amount of bloodask her to estimate in terms of cups or tablespoon
(a cup is 240mL; a tablespoon is 15mL)
Whether there was accompanying pain
Color of blood (red blood indicates bleeding is fresh or is continuing)
What she has done for the bleeding (if she inserted a tampon to halt the bleeding, there may be
hidden bleeding)
Whether there were prior episodes of bleeding during the pregnancy
Whether she had prior cervical surgery for premature cervical dilatation

Inspect the perineum for bleeding. Estimate the present rate of blood loss.
Weighing perineal pads before and after use and calculating the difference by subtraction is a
good method to determine vaginal blood loss.
An Apt or Kleihauer- Betke test (test strip procedures) can be used to detect whether the blood is
of fetal or maternal origin
Never attempt of fetal or rectal examination with painless bleeding late in pregnancy because any
agitation of the cervix when there is a placenta previa may initiate massive hemorrhage, possibly
fatal to both mother and child.
Obtain baseline vital signs to determine whether symptoms of s hock are present.
Continue to assess blood pressure every 5-15 min or continuously with an electronic cuff.
An internal monitor for either fetal or uterine assessment that requires invasion of the cervix is
contraindicated.
Typically a woman remains in the hospital on bed rest for close observation for 48 hrs.
If the bleeding stops, she can be sent home with a referral for bed rest and home care
Careful assessment of fetal heart sounds is made and laboratory test, such as hemoglobin or
hematocrit, are frequently obtained.
Betamethasone, a steroid that hasten fetal lung maturity, may be prescribed for the mother to
encourage the maturity of fetal lungs if the fetus is less than 34 weeks of gestation.

MODE OF DELIVERY
In minor degrees (30%), vaginal delivery possible or NSD.
In cases of fetal distress and major degrees (75-100%) a cesarean section is indicated.
COLLABORATIVE MANAGEMENT
If both the mother and the fetus are stable and the fetus is immature (less than 37 weeks), delivery
may be put off and an intravenous (IV) infusion started with lactated Ringers solution.
The patient is maintained on bed rest with continues EFM.
Closely monitor the fetal heart rate.
If any signs of fetal distress are noted (flat variability, late decelerations, bradycardia,
tachycardia), turn the patient to her left side, increase the rate of IV infusion, administer oxygen
via face mask at 10L/min, and notify the physician.
Once the bleeding has ceased for 24 to 48 hrs. the patient may be discharged to her home on bed
rest before delivery. This conservative treatment gives the preterm fetus time to mature.
If the patient is in labor and the marginal placenta previa is prevent, the physician allows her to
labor and deliver vaginally, with careful surveillance of maternal and fetal throughout the labor.
Postpartum, the patient will require oxytocin to prevent hemorrhaging, owing to the poor ability
of the lower uterine segment to contract.
If fetal distress is present or if the patient has lost a significant amount of blood, an immediate
cesarean section and possibly blood transfusion are indicated.
If the patient delivers (vaginally or by cesarean), monitor her for postpartum hemorrhage because
contraction of the lower uterine segment is sometimes not effective in compressing the uterine
vessels that are exposed at the placental site.
Although medication is not given to treat a previa, pharmacologic treatment may be indicated to
stop preterm labor (if it is occurring and if bleeding is under control), enhance fetal lung maturity
if delivery is expected prematurely, or prevent RH disease, if the patient delivers.
Women with placenta previa have an increased chance of complications and hysterectomy.

(Do not include these anymore. But you can use it as back up notes, in case you need this pag nagtanong
sila. Just dont include it in your presentation and output.)