Notes
Description
- Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage.
Etiology![Abruptio placentae](data:image/gif;base64,R0lGODlhAQABAAAAACH5BAEKAAEALAAAAAABAAEAAAICTAEAOw==)
- The cause of abruptio placenta is unknown.
- Risk factors include:
- Uterine anomalies
- Multiparity
- Preeclampsia
- Previous cesarean delivery
- Renal or vascular disease
- Trauma to the abdomen
- Previous third trimester bleeding
- Abnormally large placenta
- Short umbilical cord
Pathophysiology
- The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas basalis.
Assessment Findings
- Associated findings. Severe abruption placentae may produce such complications as:
- Renal failure
- Disseminated intravascular coagulation
- Maternal and fetal death
- Common clinical manifestation include:
- 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.
- Laboratory and diagnostic study findings.
- Ultrasound may be able to identify the extent of abruption. However, the absence of an ultrasound finding does not rule out the presence of abruption.
Nursing Management
- Continuously evaluate maternal and fetal physiologic status, particularly:
- Vital signs
- Bleeding
- Electronic fetal and maternal monitoring tracings
- Signs of shock-rapid pulse, pallor, cold and most skin, decrease in blood pressure
- Decreasing urine output
- Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.
- Assess 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.
- Provide appropriate management.
- On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.
- Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level.
- Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask.
- Prepare for cesarean section, which is the method of choice for the birth.
- Provide client and family teaching.
- 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.
Exam
[mtouchquiz 673 title=off]
Nursing Care Plan
Ineffective Tissue Perfusion
Related to:
- Excessive blood loss
Possibly evidenced by:
- Loss of blood
- FHR pattern
- Altered BP compared to baseline
- Altered PR Severe abdominal pain and rigidity
- Pallor
- Changes in LOC
- Decrease urine output
- Edema
- Delay in wound healing
- Positive Homan’s sign
- Skin temperature changes
Desired outcome:
Nursing Interventions | Rationale |
---|---|
Assess patient’s vital signs, O2 saturation, and skin color. | For baseline data. |
Monitor for restlessness, anxiety, hunger and changes in LOC | These conditions may indicate decreased cerebral perfusion |
Monitor accurately I&O | To obtain data about renal perfusion and function and the extent of blood loss. |
Monitor FHT continuously | To provide information regarding fetal distress and/or worsening of condition |
Assess uterine irritability, abdominal pain and rigidity. | To determine the severity of the placental abruptio and bleeding |
Assess skin color, temperature, moisture, turgor, capillary refill | To determine peripheral tissue perfusion like hypervolemia. |
Elevate extremity above the level of the heart | Helps promote circulation. |
Teach patient not to apply uterine pressure | Uterine pressure can cause pooling of venous blood in lower extremities |
Instruct patient and/or SO to report immediately signs and symptoms of thrombosis: (1) pain in leg, groin (2) unilateral leg swelling (3) pale skin | To immediately provide additional interventions |
Risk for Shock
Related to:
- Significant blood loss of about 10% of the blood volume
- Separation of the placenta
- External or internal bleeding
Possibly evidenced by:
- Vaginal bleeding
- Couvelaire uterus or a tense and rigid uterus
- Increased pulse rate
- Decreased blood pressure
- Increased respiratory rate
- Decreased central venous pressure
- Decreased urine output
- Decreasing level of consciousness
- Cold, clammy skin
- Fetal bradycardia
Desired outcomes:
- Patient will display hemodynamic stability.
- Patient will regain vital signs within the normal range.
- Patient will be able to verbalize understanding of disease process, risk factors, and treatment plan.
- Patient will display a normal central venous pressure.
- Patient’s skin is warm and dry.
- Fetal heart rate is within normal range.
- Patient will exhibit an adequate amount of urine output with normal specific gravity.
- Patient will display the usual level of mentation.
Nursing Interventions | Rationale |
---|---|
Assess for history or presence of conditions leading to hypovolemic shock. | The condition may deplete the body’s circulating blood volume and the ability to maintain organ perfusion and function. |
Monitor for persistent or heavy fluid or blood loss. | The amount of fluid or blood loss must be noted to determine the extent of shock. |
Assess vital signs and tissue and organ perfusion. | For changes associated with shock states |
Review laboratory data. | To identify potential sources of shock and degree of organ involvement. |
Collaborate in prompt treatment of underlying conditions and prepare for or assist with medical and surgical interventions. | To maximize systemic circulation and tissue and organ perfusion. |
Administer oxygen by appropriate route. | To maximize oxygenation of tissues. |
Administer blood or blood products as indicated. | To rapidly restore or sustain circulating volume and electrolyte balance. |
Monitor uterine contractions and fetal heart rate by external monitor. | Assesses whether labor is present and fetal status; external system avoids cervical trauma. |
Withhold oral fluid. | Anticipates need for emergency surgery. |
Measure intake and output. | Enables assessment of renal function. |
Measure maternal blood loss by weighing perineal pads and save any tissue that has passed. | Provides objective evidence of amount bleeding. |
Maintain a positive attitude about fetal outcome. | Supports mother-child bonding. |
Provide emotional support to the woman and her support person. | Assists problem solving which is lessened by poor self-esteem. |
Acute Pain
Related to:
- Sudden separation of placenta from the uterine wall
- Pain accompanying labor contractions during initial separation
Possibly evidenced by:
- Sharp, stabbing pain high in the uterine fundus
- Uterine tenderness
Desired outcomes:
- Patient will report relief or control of pain.
- Patient will follow prescribed pharmacological regimen.
- Patient will verbalize non pharmacological methods that provide relief.
- Patient will demonstrate use of relaxation skills and diversional activities as indicated.
Nursing Interventions | Rationale |
---|---|
Assess for referred pain as appropriate. | To help determine the possibility of underlying condition or organ dysfunction requiring treatment. |
Note client’s locus of control. | Individuals with external locus of control may take little or no responsibility for pain management. |
Note and investigate changes from previous reports of pain. | To rule out worsening of underlying condition or development of complications. |
Acknowledge the client’s description of pain and convey acceptance of client’s response to pain. | Pain is a subjective experience and cannot be felt by others. |
Monitor skin color and temperature and vital signs. | These are usually altered in acute pain. |
Note when pain occurs. | To medicate as appropriate. |
Provide comfort measures, quiet environment, and calm activities. | To promote non pharmacological pain management. |
Administer analgesics as indicated. | To maintain an acceptable level of pain. |
Encourage adequate rest periods. | To prevent fatigue. |