- Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage.
- The cause of abruptio placenta is unknown.
- Risk factors include:
- Uterine anomalies
- Previous cesarean delivery
- Renal or vascular disease
- Trauma to the abdomen
- Previous third trimester bleeding
- Abnormally large placenta
- Short umbilical cord
- The placenta detaches in whole or in par from the implantation site. This occurs in the area of the deciduas basalis.
- 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.
- Continuously evaluate maternal and fetal physiologic status, particularly:
- Vital signs
- 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.
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Nursing Care Plan
Ineffective Tissue Perfusion
- Excessive blood loss
Possibly evidenced by:
- Loss of blood
- FHR pattern
- Altered BP compared to baseline
- Altered PR Severe abdominal pain and rigidity
- Changes in LOC
- Decrease urine output
- Delay in wound healing
- Positive Homan’s sign
- Skin temperature changes
|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
- 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
- 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.
|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.|
- 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
- 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.
|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.|