Introduction:

The placenta is implanted in the lower uterine segment near or over the internal cervical os. The degree to
which the internal cervical os is covered by the placenta has been used to classify four types of placenta
previa; total, partial, marginal and low–lying. In total previa the internal os is entirely covered by the placenta.
Partial placenta previa implies incomplete coverage of theinternal os. Marginal placenta previa indicates that
only an edge of the placenta extends to the margin of the internal os. And the last is the low – lying placenta
has been used when the placenta is implanted in the lower uterine segment but not reach the os. The more
descriptive classification that includes placenta previa is in the third trimester.
The incidence of placenta previa is approximately 0.5% of births. The most important risk factors are
previous placenta previa, previous cesarean birth, and suction curettage for miscarriage or induced abortion,
possible related to endometrial scarring. The risk also increases with multiple gestations because of
the larger placental area, closely spaced pregnancies, advanced maternal age older than 34 years, African
or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and tobacco use.
Classification of Placenta Previa:
1. Total Previa- the placenta 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 during dilatation.
4. Low-lying placenta- the placenta is implanted in the lower uterine segment but does not reach to
the internal os of the cervix.

Predisposing Factors:
1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years old in 33% of cases
3. Multiple gestation
4. Previous Cesarean birth
5. Uterine Incisions
6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa)
Complications for the baby include:
 Problems for the baby, secondary to acute blood loss
 Intrauterine growth retardation due to poor placental perfusion
 Increased incidence of congenital anomalies
Clinical Manifestations:
 Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated with
the stretching and thinning of the lower uterine segment that occurs in third trimester.
 Adequately contract and stop blood flow from open vessels.
 Stop blood flow from open vessels
 Decreasing urinary output
Normal Placenta During Childbirth
Process of placental growth and uterine wall changes during pregnancy
1. The placenta grows with the placental site during pregnancy.
2. During pregnancy and early labor the area of the placental site probably changes little, even during
uterine contractions.
3. The semirigid, noncontractile placenta cannot alter its surface area.
Anatomy of the uterine/placental compartment at the time of birth
1. The cotyledons 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 uterus to the placental area.
3. The placental site is usually located on either the 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
No specific cause of placenta previa has yet been found but it is hypothesized to be related to abnormal
vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or
infection.
In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a
normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the
lower segment, it may shear off and a small section may bleed.
Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often
starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if
there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender
and relaxed. Leopold’s Maneuvers may find the fetus in an oblique or breech position or lying transverse as
a result of the abnormal position of the placenta. Praevia can be confirmed with an ultrasound.[3] In parts of
the world where ultrasound is unavailable, it is not uncommon to confirm the diagnosis with an examination
in the surgical theatre.
The proper timing of an examination in theatre is important. If the woman is not bleeding severely she can
be managed non-operatively until the 36th week. By this time the baby’s chance of survival is as good as at
full term.

Diagnostic Evaluation:
Placenta previa is diagnosed using transabdominal ultrasound.
- transabdominal scans with fewer false positive results
Transvaginal ultrasound
 If a woman is bleeding she is usually placed in the labor and birth unit or for cesarean birthbecause
profound hemorrhage can occur during the examination. This type of vaginal examination knows as the
double- setup procedure
Ultrasonographic scan
 If ultrasonographic scanning reveals a normally implanted placenta, an examination may be
performed to rule out local causes of bleeding and a coagulation profile is obtained to rule out other
 causes of bleeding management of placenta previa depends of the gestational age and condition of
the fetus and the amount and cesarean birth.
Complete blood count (CBC)
 To monitor mother’s blood volume
Fetoscope
 To monitor fetal heart rate and conditions
Medical Management:
 Maternal stabilization and fetal monitoring
 Control of blood loss, blood replacement
 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
 Hospitalization with complete bed rest until 36 weeks gestation with complete placenta previa
 Possible vaginal delivery with minimal bleeding or rapidly progressing labor
Nursing Interventions:
1. If continuation of the pregnancy is deemed safe for patient and fetus administer magnesium sulfate
as ordered for premature labor
2. Obtain blood samples for complete blood count and blood type and cross matching
3. Institute complete bed rest
4. If the patient and placenta previa is experiencing active bleeding, continuously monitor her blood
pressure, pulse rate, respiration, central venous pressure, intake and output, and amount of vaginal
bleeding as well as the fetal heart rate and rhythm
5. Assist with application of intermittent or continuous electronic fetal monitoring as indicated by
maternal and fetal status.
6. Have oxygen readily available for use should fetal distress occur, as indicated by bradycardia,
tachycardia, late or available decelerations, pathologic sinusoidal pattern, unstable baseline, or loss of
variability.
7. If the patient is Rh-negative and not sensitized, administer Rh (D) immune globulin (RhoGAM) after
every bleeding episode.
8. Administer prescribed IV fluids and blood products.
9. Provide information about labor progress and the condition of the fetus.
10. Prepare the patient and her family for a possible caesarian delivery and the birth of a preterm
neonate, and provide thorough instructions for postpartum care.
11. If the fetus less than 36 weeks gestation expect to administer an initial dose of betamethasone:
explain that additional doses may be given again in 24 hours and possibly for the next 2 weeks to help
mature the neonates lungs.
12. Explain that the fetus survival depends on gestational age and amount of maternal blood loss.
Request consultation with a neontologist or pediatrician to discuss a treatment plan with the patient and
her family.
13. Assure the patient that frequent monitoring and prompt management greatly reduce the risk of
neonatal death.
14. Encourage the patient and her family to verbalize their feelings helps them to develop effective
coping strategies, and refer them for counseling, if necessary.
15. Anticipate the need for a referral for home care if the patient bleeding ceases and she’s to return
home in bed rest.
16. During the postpartum period, monitor the patient for signs of early and late postpartum
hemorrhage and shock.
 17. Monitor VS for elevated temperature, pulse, and blood pressure, monitor laboratory results for
elevated WBC count, differential shift; check for urine tenderness and malodorous vaginal discharge to
detect early signs of infection resulting from exposure of placental tissue.
18. Provide or teach perineal hygiene to decrease the risk of ascending infection.
19. Observe for abnormal fetal heart rate patterns such as loss of variability, decelerations tachycardia
to identify fetal distress.
20. Position the patient in side lying position and wedge for support to maximize placental perfusion.
21. Assess fetal movement to evaluate for possible fetal hypoxia.
22. Teach woman to monitor fetal movement to evaluate well being
23. Administer oxygen as ordered to increase oxygenation to mother and fetus.

Predisposing Factors:
1. Multiparity (80% of affected clients are multiparous)
2. Advanced maternal age (older than 35 years old in 33% of cases
3. Multiple gestation
4. Previous Cesarean birth
5. Uterine Incisions
6. Prior placenta previa ( incidence is 12 times greater in women with previous placenta previa)

Nursing Management
1. Ensure the physiologic well-being of the client and fetus
a. Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh perineal
pads before and after use to estimate blood loss.
b. Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin and a drop in blood
pressure
c. Monitor the FHR
d. Enforce strict bed rest to minimize risk to the fetus
e. Observe for additional bleeding episodes.
2. Provide client and family teaching
a. Explain the condition and management options. To ensure an adequate blood supply to the mother and
fetus, place the woman at bed rest in a side-lying position. Anticipate the order for a sonogram to localize
the placenta. If the condition of mother or fetus deteriorates, a cesarean birth will be required.
b. Prepare the client for ambulation and discharge ( may be within 48 hours of last bleeding episode)
c. Discuss the need to have transportation to the hospital available at all times.
d. Instruct the client to return to the hospital if bleeding recurs and to avoid intercourse until after the birth.
e. Instruct the client on proper handwashing and toileting to prevent infection.
3. Address emotional and psychosocial needs
a. Offer emotional support to facilitate the grieving process, if needed
b. After birth of the newborn, provide frequent visits with the newborn so that the mother can be certain of
the infant’s condition
Discharge Plan:
Medication
 Betamethasone (Celestone) is a corticosteroid that acts as an anti-inflammatory and
immunosuppressive agent.
 Assess for contraindications of Betamethasone administration. Obtain reports of urine and cervical
cultures and fibronectin.
Exercise
 Needs to adequate her time with her child to be certain he or she is all right, and nurse can states
hearing fetal heart beat helps to reassure her about baby’s health.
 Attach contraction and fetal heart rate monitoring for continuous evaluation of contractions of fetal
response.
Treatment
 Used of drugs
 Catheterization
Health Teaching
 Maintain a bed rest
 Maintain a 8 glasses of water
Ongoing Assessment
 Assess client’s home surrounding to determine whether they are appropriate for bed rest and
continuing monitoring at home. Administer oral dose and home monitoring requires professional
supervision.
Diet
 She might to begin to neglect her diet or her supplementary vitamins because “It doesn’t matter
anymore”.
Spiritual
 Assess anxiety level of client over preterm labor possible feelings.
 Determine whether client wants a support person to be wit her, to the presence of a support person
can offer additional comfort to a client.

Possible Nursing Diagnosis for Placenta Previa:

 Risk for Impaired Fetal Gas Exchange r/t Disruption of Placental Implantation
 Fluid Volume Deficit r/t Active Blood Loss Secondary to Disrupted Placental Implantation
 Active Blood Loss (Hemorrhage) r/t Disrupted Placental Implantation
  Fear r/t Threat to Maternal and Fetal Survival Secondary to Excessive Blood Loss
 Activity Intolerance r/t Enforced Bed Rest During Pregnancy Secondary to Potential for
Hemorrhage
 Altered Diversional Activity r/t Inability to Engage in Usual Activities Secondary to Enforced Bed
Rest and Inactivity During Pregnancy

References:
 Maternal & Child Nursing Seventh Edition Vol.1 page 413.
 Maternity nursing, Lowdermilk Perry, seventh edition, chapter 23, page 751.
 Maternal Neonatial Nursing Lippincott manual of Nursing Practice
 http://wikipedia.org
 Pregnancy care
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
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“Bigla na lang gas is the nursing • Assess vital baseline data of
akong dinugo exchange development of interventions, signs on maternal nursing
(I’m related placenta in the the patient will (pulse, blood loss. interventions,
bleeding)” as to altered verbalize respirations, and • Systemic the
lower uterine
verbalized by blood understanding blood pressure rest is patient was able
the flow and
segment, of every 15 mandatory and to verbalize
patient. decreased partially or causative minutes). understanding
important
Objective: surface area of completely factors • Maintain bed throughout all of
• Changes in gas exchange covering the and rest phases of causative
fetal heart at internal cervical appropriate or chair rest when disease to factors
rate or fetal site of os. The cause interventions. indicated. Provide reduce fatigue, and appropriate
activity. placental is unknown, but frequent rest and improve interventions
• Release of detachment. a possible periods and strength.
meconium. theory states uninterrupted • Provide
• V/S taken as that the embryo night time sleep. objective
follows: will implant in • Monitor amount evidence of
T: 36.9 the lower and type of bleeding.
P: 96 uterine bleeding. • To promote
R: 22
segment if the • Position mother placental
Bp: 100/80 on her left side. perfusion.
deciduas in the
• Restrict vaginal • Prevents
uterine fundus
examination. tearing of
is not
• Monitor uterine placenta if
favorable. contractions and placenta previa
Complications fetal heart rate by is the cause of
are immediate external monitor. bleeding.
hemorrhage, • Maintain • Assess
shock, and positive whether
maternal death; attitude toward labor is present
fetal mortality; about fetal and fetal status
and post outcome. and external
 partumhemorrhage Collaborative: system avoids
. • Administer cervical
oxygen as trauma.
indicated. • Supports
mother and
child bonding.
• Provides
adequate fetal
oxygenation
despite of
lowered
maternal
circulating
volume.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

• After 8 hours
of
nursing
interventions,
the
patient was able
to verbalize
understanding of
causative factors
and appropriate
interventions