Abruptio Placenta Nursing Care Plan and Management

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Notes

Description

Abruptio placenta is premature separation of a normally implanted placenta after the 20th week of pregnancy, typically with severe hemorrhage.

Etiology

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:
1. Renal failure
2. Disseminated intravascular coagulation
3. Maternal and fetal death
Common clinical manifestation include:
1. Intense, localized uterine pain, with or without vaginal bleeding.
2. Concealed or external dark red bleeding
3. Uterus firm to boardlike, with severe continuous pain
4. Uterine contractions
5. Uterine outline possibly enlarged or changing shape
6. FHR present or absent.
7. 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

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Question 1

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placentae is present. Based on these findings, the nurse would prepare the client for:

A	Complete bed rest for the remainder of the pregnancy
B	Delivery of the fetus
C	Strict monitoring of intake and output
D	The need for weekly monitoring of coagulation studies until the time of delivery

Question 1 Explanation:

The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

Question 2

A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias?

A	Thrombocytopenia.
B	Idiopathic thrombocytopenic purpura (ITP).
C	Disseminated intravascular coagulation (DIC).
D	Heparin-associated thrombosis and thrombocytopenia (HATT).

Question 2 Explanation:

Abruptio placentae is a cause of DIC because it activates the clotting cascade after hemorrhage.

Option A: Thrombocytopenia results from decreased production of platelets.
Option B: ITP doesn’t have a definitive cause.
Option D: A patient with abruptio placentae wouldn’t get heparin and, as a result, wouldn’t be at risk for HATT.

Question 3

Which of the following would the nurse assess in a client experiencing abruptio placenta?

A	Bright red, painless vaginal bleeding
B	Concealed or external dark red bleeding
C	Palpable fetal outline
D	Soft and nontender abdomen

Question 3 Explanation:

A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.

Question 4

A maternity nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

A	Swelling of the calf in one leg
B	Prolonged clotting times
C	Decreased platelet count
D	Petechiae, oozing from injection sites, and hematuria

Question 4 Explanation:

DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

Question 5

A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client’s complaint of vaginal bleeding?

A	Placenta previa
B	Abruptio placentae
C	Ectopic pregnancy
D	Spontaneous abortion

Question 5 Explanation:

The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruptio placentae.

Question 6

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

A	Absence of abdominal pain
B	A soft abdomen
C	Uterine tenderness/pain
D	Painless, bright red vaginal bleeding

Question 6 Explanation:

In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by the failure of the uterus to relax in an attempt to constrict blood vessels and control bleeding.

Question 7

Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?

A	Placenta previa
B	Ectopic pregnancy
C	Incompetent cervix
D	Abruptio placentae

Question 7 Explanation:

Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.

Question 8

Which of the following increases the risk of placental abruption?

A	Age < 35 years
B	Gestational diabetes
C	Previous placental abruption
D	Strenuous exercise

Question 8 Explanation:

Previous placental abruption. The risk of placental abruption is increased 15- to 20-fold if an earlier pregnancy had been complicated by placental abruption.6 Other risk factors include chronic hypertension, cocaine use, preeclampsia, age over 35 years, trauma, thrombophilia, cigarette smoking, preterm premature rupture of membranes, chorioamnionitis, and multiparity

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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.

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Notes

Description

Etiology

Pathophysiology

Assessment Findings

Nursing Management

Exam

Abruptio Placenta Practice Exam (PM)**

Nursing Care Plan

Ineffective Tissue Perfusion

Related to:

Possibly evidenced by:

Desired outcome:

Risk for Shock

Related to:

Possibly evidenced by:

Desired outcomes:

Acute Pain

Related to:

Possibly evidenced by:

Desired outcomes:

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