Placenta previa is a condition in pregnancy characterized by the implantation of the placenta in the lower part of the uterus covering a part or all of the opening of the cervix. This condition can result in bleeding during pregnancy or during the delivery of the baby.
The placenta provides the growing fetus with nutrients and oxygen from the mother’s blood supply during pregnancy. It usually grows into the upper part of the uterus and stays there until the baby is born. After delivery, the placenta will separate from the uterine wall and is pushed out from the uterus. This is referred to as afterbirth.
Risk Factors
Risk factors for placenta previa include:
- Advanced maternal age
- Multiparity
- Scarring in the uterus due to previous surgery
- Previous C-section delivery
- Cocaine use
Many patients with placenta previa have no symptoms. Placenta previa is usually found during a routine ultrasound. If symptoms do occur, it is usually painless vaginal bleeding during the second or third trimester.
Complications of placenta previa include hemorrhage, fetal distress, shock from blood loss for the mother and baby, preterm labor and delivery, emergency cesarean delivery, and death.
Nursing Process
Placenta previa management includes interventions that prolong the pregnancy and prevent bleeding. Hospitalization may be required for close monitoring along with the administration of medications that help prevent early labor. Cesarean delivery is often indicated to reduce bleeding.
Nurses play a critical part in supporting women with placenta previa as they provide education, examinations, and medical interventions to prevent maternal and fetal mortality.
Nursing Assessment
Placenta previa is a significant obstetric condition characterized by the placenta implanting abnormally low in the uterus, covering or partially covering the cervix. This condition poses risks to both the mother and the baby, necessitating prompt and effective nursing assessment. The following sections outline the critical aspects of nursing care for placenta previa, aiming to ensure optimal outcomes for maternal and neonatal health.
Initial Assessment
History and Symptoms: Conduct a thorough medical history, focusing on previous pregnancies, cesarean sections, and any history of placenta previa. Assess for symptoms such as painless vaginal bleeding, which is a hallmark of placenta previa.
Physical Examination: Perform a gentle abdominal examination to assess uterine size and tenderness. Avoid digital vaginal examinations to prevent provoking hemorrhage.
Diagnostic Procedures
Ultrasound Examination: Utilize transabdominal and transvaginal ultrasound to confirm the diagnosis of placenta previa and determine the placenta’s location and extent.
Fetal Monitoring: Regularly monitor fetal heart rate and movements to assess fetal well-being and detect any signs of distress.
Ongoing Monitoring
Bleeding Assessment: Monitor the amount, color, and frequency of vaginal bleeding. Documenting these observations helps to predict the severity and progression of the condition.
Vital Signs: Regularly check maternal vital signs, including blood pressure, pulse, respiratory rate, and temperature, to identify signs of shock or infection.
Nursing Intervention
Nursing intervention in cases of placenta previa are crucial for safeguarding the health and well-being of both mother and baby. Through comprehensive assessment, vigilant monitoring, and timely interventions, nurses play a pivotal role in managing this complex condition. By providing education, emotional support, and personalized care, nurses contribute to positive health outcomes and enhance the overall experience of pregnancy and childbirth for women with placenta previa.
Immediate Care
Hospitalization: Admit the patient to the hospital for close monitoring, especially if bleeding is significant or recurrent.
Intravenous Access: Establish intravenous (IV) access to administer fluids, medications, and potential blood transfusions.
Medical Management
Medications: Administer corticosteroids to accelerate fetal lung maturity if preterm delivery is anticipated. Use tocolytics to manage preterm labor if necessary.
Blood Transfusion: Prepare for possible blood transfusions in cases of severe hemorrhage to manage maternal blood loss and maintain hemodynamic stability.
Preparation for Delivery
Delivery Planning: Collaborate with the healthcare team to plan the timing and mode of delivery. Cesarean section is often recommended in cases of complete placenta previa.
Preoperative Care: Provide preoperative education and support to the mother. Ensure informed consent is obtained for the planned surgical intervention.
Postpartum Care
Postoperative Monitoring: After delivery, closely monitor the mother for signs of postpartum hemorrhage, infection, and other complications.
Emotional Support: Offer psychological support and counseling to the mother and family, addressing any anxiety or concerns related to the condition and its management.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for placenta previa, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for placenta previa.
Decreased Cardiac Output
Since placenta previa can cause bleeding, the heart needs to work harder and faster to pump blood throughout the body to compensate for the blood loss.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Hemorrhaging
- Vaginal bleeding
- Complications of condition
- Hypovolemia
As evidenced by:
- Bradycardia
- Tachycardia
- Hypotension
- Fatigue
- ECG changes
- Cyanosis
- Pallor
- Decreased peripheral pulses
- Prolonged capillary refill
- Restlessness/anxiety
Expected outcomes:
- Patient will exhibit vital signs within normal limits.
- Patient will remain free from complications from decreased cardiac output, like poor tissue perfusion, organ failure, and shock.
Assessment:
1. Assess the patient’s blood pressure and other vital signs.
Blood pressure is closely related to cardiac output. It is approximated by blood flow and systemic vascular resistance. Cardiac output decreases when there is a decrease in blood pressure due to bleeding in patients with placenta previa.
2. Assess the patient’s level of consciousness.
Alterations in cardiac output due to bleeding cause blood vessel constriction, reduced cerebral blood flow, and increased arterial stiffness, leading to cognitive decline and mental status alterations.
3. Monitor the fetus.
Placenta previa, if left untreated, can have detrimental effects on the fetus. Decreased cardiac output can compromise the blood supply to the fetus, resulting in fetal growth retardation and fetal distress.
Interventions:
1. Prepare for inpatient admission.
Patients who are unstable with three or more bleeding episodes are recommended to remain hospitalized until delivery. Patients with one or two bleeding episodes may be discharged, but only if they can adhere to treatment guidelines and are in close proximity to a hospital.
2. Administer medications to prepare for delivery.
Magnesium sulfate offers neuroprotection for fetuses at <32 weeks gestation when delivery is imminent but not urgent. Corticosteroids are also administered when bleeding is present to support fetal lung maturity.
3. Administer blood transfusions as indicated.
Decreased cardiac output in patients with placenta previa is typically caused by active bleeding. Prompt blood transfusions can correct circulating blood volume and increase cardiac output, preventing fetal and maternal complications.
4. Provide a quiet and calm environment.
Bleeding while pregnant can cause intense anxiety in the pregnant patient. A calm and quiet environment relaxes the patient and reduces the release of stress-related catecholamines, which cause vasoconstriction, increased myocardial workload, and alterations in cardiac output.
5. Assist with surgical interventions as needed.
If hemorrhaging occurs, surgical interventions such as ligation of vessels, compression sutures, or balloon tamponade are necessary to control bleeding and preserve cardiac output. A hysterectomy may be necessary to prevent severe hypovolemia and hypoxia.
Deficient Fluid Volume
Deficient fluid volume occurs from bleeding because of disrupted placental implantation during pregnancy, leading to decreased intravascular, intracellular, or interstitial fluid.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Disease process
- Bleeding
- Disrupted placental implantation
- Hypovolemia
As evidenced by:
- Decreased blood pressure
- Decreased pulse pressure
- Altered mental status
- Increased heart rate
- Alteration in hemoglobin and hematocrit
- Vaginal bleeding
Expected outcomes:
- Patient will maintain normal fluid status, as evidenced by acceptable vital signs and adequate urinary output.
- Patient will adhere to recommendations on limiting exercise and exertion to prevent disrupting the placenta.
Assessment:
1. Assess for signs of bleeding and other factors contributing to fluid loss.
The main symptom of placenta previa is painless and bright red vaginal bleeding which usually occurs after 20 weeks gestation. Sometimes there is no identifiable cause of the bleeding, but it can be caused by strenuous activity, vaginal intercourse, and standing for long periods.
2. Assess and monitor the patient’s vital signs.
Baseline vital signs must be assessed and monitored to determine indications of hypovolemic shock. Signs of hypovolemic shock include tachycardia, tachypnea, and hypotension.
3. Assess lab values.
Decreases in hemoglobin and hematocrit signal blood loss and must be monitored to assess the efficacy of interventions or deconditioning. The goal is a hemoglobin level >10 g/dL.
Interventions:
1. Monitor the patient’s intake and output.
Monitoring the patient’s intake and output is vital in determining the patient’s fluid status and adequate blood volume perfusing the patient’s organs.
2. Quantify blood loss.
Measuring blood loss visually on soaked towels, pads, or gauze is difficult. Attempt to collect blood in graduated containers or measure the weight of bloody materials subtracted from their weight when dry. This weight in grams is approximately the volume of blood in mL. If possible, account for other sources of fluid loss, like amniotic fluid, irrigation fluid, or urine.
3. Monitor the fetal heart rate and contractions continuously.
Deficient fluid and blood volume can negatively affect and compromise fetal health. Bleeding from placenta previa can cause fetal hypoxia due to inadequate uteroplacental perfusion.
4. Administer IV fluids or blood products as indicated.
To ensure adequate fluid circulation, administer intravenous crystalloid fluids or blood products as indicated to allow prompt fluid replacement in cases of active bleeding.
5. Administer oxytocin.
In the postpartum phase, oxytocin may be administered to control heavy bleeding, as this medication causes the uterus to contract.
Impaired Physical Mobility
The American College of Obstetricians and Gynecologists (ACOG) does not recommend bed rest in most instances, but reduced activity and lifestyle changes may be required.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Activity restrictions
- Disease process
- Increased risk for bleeding
As evidenced by:
- Medical protocol requiring reduced activity
Expected outcomes:
- Patient will verbalize understanding and adhere to the prescribed activity restrictions.
- Patient will prevent loss of muscle strength and endurance during bed rest.
Assessment:
1. Assess usual activity levels.
Assess the patient’s current exercise and activity levels. Those who partake in strenuous exercise or weight-lifting will likely require reduced activity until after delivery.
2. Assess for a support system.
If bed rest or activity restrictions are instituted the mother may require help with other children or responsibilities. Assess for the presence of a partner or family member that can help.
Interventions:
1. Educate on the importance of reduced activity.
Reduced activity places less pressure on the cervix and may help the placenta function better to deliver nutrients and oxygen to the fetus.
2. Instruct on specific restrictions.
Complete bed rest is often not required. If it is, teach the mother that they should only partake in minimal activities such as walking to the bathroom, sitting at a desk, and standing or walking for less than 20 minutes.
3. Educate on other activities to maintain muscle strength.
Patients can usually partake in stretching of the extremities while in bed or other activities that promote circulation. Always discuss with a doctor first.
4. Left side-lying is recommended.
Lying on the left side is generally recommended during pregnancy to maximize blood flow to the uterus.
Risk for Bleeding
Pregnant women with placenta previa are at risk for bleeding and require monitoring and education on preventing bleeding.
Nursing Diagnosis: Risk for Bleeding
Related to:
- Disease process
- Low-lying placenta
- Sexual intercourse
- Vaginal examinations
- Labor
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient discusses and demonstrates precautions to prevent bleeding complications.
- Patient is able to deliver the fetus without excessive bleeding.
Assessment:
1. Assess vital signs.
Increased pulse rate and decreased blood pressure can signal bleeding. Vital signs should be closely monitored with placenta previa.
2. Assess and monitor diagnostic studies.
Transabdominal or transvaginal ultrasounds should be conducted to monitor the location of the placenta.
3. Assess coagulation studies.
Closely monitor PTT and hemoglobin levels for possible bleeding risks.
Interventions:
1. Type and cross.
To prepare for possible bleeding, ensure the patient is type and crossed for potential blood transfusions.
2. Administer blood transfusions as indicated.
A blood transfusion may be indicated for patients with placenta previa who have active heavy bleeding.
3. Educate on preventing bleeding.
Teach the patient that sexual intercourse or vaginal penetration can provoke bleeding. Instruct not to partake in strenuous activity or lift over 20 pounds.
4. Prepare the patient for Cesarean section.
Patients with placenta previa will usually require Cesarean section delivery at 36-37 weeks. Prepare the patient for what to expect pre and post-operatively.
Situational Low Self-Esteem
Pregnancy can be an emotional time and this can be aggravated when there are complications. Pregnant women diagnosed with placenta previa may feel stressed or anxious upon confirmation of diagnosis and may feel guilt that they did something wrong to contribute to their condition, especially if fetal or maternal harm occurs.
Nursing Diagnosis: Situational Low Self-Esteem
Related to:
- Change in health status
- Situational crisis
As evidenced by:
- Expresses helplessness
- Self-negating verbalizations
- Underestimates ability to deal with the situation
- Expresses guilt or shame
Expected outcomes:
- Patient will verbalize acceptance of the diagnosis and a positive outlook.
- Patient will adhere to the treatment plan to reduce risks to self and fetus.
Assessment:
1. Assess for any signs of depression.
Pregnancy itself can cause feelings of depression, especially if the patient has a history. Threats to the patient’s health as well as their fetus can increase these feelings.
2. Assess for thoughts of low self-esteem.
Assess how the patient is feeling in regards to their self-worth and if they place any blame on themselves for their diagnosis.
Interventions:
1. Help the patient focus on what they can control.
The patient may not be able to control the position of the placenta but they can be taught lifestyle modifications to prevent bleeding and preterm labor.
2. Educate the patient about the causes of placenta previa.
Often there is no cause for placenta previa or causes can be vague. Maternal age over 35 can be a contributor as well as simply being pregnant before. A past surgical procedure such as D&C which is often done after a miscarriage or abortion is a risk factor and may cause unnecessary feelings of guilt to the mother. Educate them that they are not to blame.
3. Provide emotional and psychological support.
Allow the patient to verbalize feelings and concerns about the current situation. Listen and remain nonjudgmental. Provide support and reassurance that the medical team is providing excellent care to prevent complications and ensure a safe delivery.
4. Refer the patient to support groups.
Knowing that she is not alone and that other pregnant women have gotten through this condition can help the mother cope with her pregnancy and delivery.
Nursing Diagnosis and Rationale for Placenta Previa
1. Risk for Haemorrhage
Rationale: Placenta previa is characterized by the abnormal placement of the placenta over or near the cervical opening. This condition poses a significant risk for hemorrhage, especially during labor when the cervix dilates and the placenta can detach. Nurses should closely monitor maternal vital signs, fetal heart rate, and signs of bleeding. Educating the patient about the importance of bed rest and avoiding activities that may trigger bleeding is crucial. Administering medications such as corticosteroids to promote fetal lung maturity if preterm delivery is anticipated, and ensuring that blood products are readily available in case of severe hemorrhage, are essential interventions.
2. Risk for Preterm Birth
Rationale: Due to the risk of bleeding and other complications associated with placenta previa, there is a heightened risk of preterm birth. Nurses should monitor for signs of preterm labor and educate the patient about recognizing these signs, such as regular contractions, back pain, and increased vaginal discharge. Coordination with obstetricians for timely interventions, such as the administration of tocolytics to delay labor or corticosteroids to accelerate fetal lung maturity, is essential.
3. Anxiety and Fear
Rationale: The diagnosis of placenta previa can be a source of significant anxiety and fear for the expectant mother due to the potential risks to herself and her baby. Nurses should provide emotional support, offer clear and accurate information about the condition and its management, and reassure the patient by discussing the planned approach to care. Referring the patient to counseling services or support groups may also be beneficial in managing anxiety.
4. Deficient Knowledge
Rationale: Patients with placenta previa may lack knowledge about the condition, its potential complications, and the necessary precautions to take. Nurses should provide comprehensive education on placenta previa, including the importance of adhering to activity restrictions, the signs and symptoms of complications, and when to seek immediate medical attention. Using visual aids, written materials, and one-on-one discussions can enhance the patient’s understanding and adherence to recommendations.
5. Impaired Physical Mobility
Rationale: Depending on the severity of placenta previa, patients may be advised to limit physical activity or remain on bed rest to prevent bleeding. This restriction can lead to impaired physical mobility and related complications such as muscle weakness or venous thromboembolism. Nurses should assist the patient in maintaining as much mobility as possible within the prescribed limits, encourage range-of-motion exercises, and monitor for signs of venous stasis. Educating the patient on safe mobility practices and the importance of hydration and leg exercises can help mitigate these risks.
REFERENCES
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Placenta Previa. Anderson-Bagga FM, Sze A. [Updated 2024]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539818/
- Placenta previa. Mayo Clinic. Updated May 11, 2024. From: https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768
- Placenta Previa. Reviewed by Arefa Cassoobhoy, MD, MPH. WebMD. Updated July 28, 2024. From: https://www.webmd.com/baby/guide/what-is-placenta-previa
- Placenta Previa. Ronan Bakker, MD. Medscape. Updated: Jan 08, 2024. From: https://emedicine.medscape.com/article/262063-overview
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