ABRUPTIO PLACENTA

Definition:
- Premature separation of the placenta from the uterine wall.
- Common cause of bleeding during the second half of pregnancy
- Usually occurs after 20 to 24 weeks of pregnancy but may occur as late as during
first or second stage of labor.

Risk factors:
- women with parity of 5 or more
- women over 30 years of age
- women with pre-eclampsia - eclampsia and renal or vascular disease.

Factors contributing to ABRUPTIO PLACENTA

- multiple gestations
- hydramnios
- cocaine use
- dec. blood flow to the placenta
- trauma to the abdomen
- dec. serum folic acid levels
- PIH

Cause: Unknown
Theories proposed relating it’s occurrence to dec. blood flow to the placenta
through the sinuses during the last trimester; Excessive intrauterine pressure caused by
hydramnios or multiple pregnancy may also be contributing factors.

Clinical manifestations:
Covert (severe)/ Mild separation/ Mild Abruptio Placenta
The placenta separates centrally and the blood is trapped between the placenta and
the uterine wall.
Signs and Symptoms:
1. no overt bleeding from vagina
2. rigid abdomen
3. acute abdominal pain
4. dec. BP
5. inc. pulse
6. uteroplacental insufficiency

Overt (partial)/ Moderate separation/ Moderate Abruptio Placenta

The blood passes between the fetal membranes and the uterine wall and escapes
vaginally. May develop abruptly or progress from mild to extensive separation with
external hemorrhage.
Signs and Symptoms:
1. vaginal bleeding
2. rigid abdomen
 3. acute abdominal pain
4. dec. BP
5. inc. pulse
6. uteroplacental insufficiency

Placental Prolapse/ Severe separation/ Severe Abruptio Placenta

Massive vaginal bleeding is seen in the presence of almost total separation with
possible fetal cardiac distress.
Signs and Symptoms:
1. massive vaginal bleeding
2. rigid abdomen
3. acute abdominal pain
4. shock
5. marked uteroplacental insufficiency

Management:
- monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions and
vaginal bleeding
- likelihood of vaginal delivery depends on the degree and timing of separation in
labor
- cesarean delivery indicated for moderate to severe placental separation
- evaluation of maternal laboratory values
- F & E replacement therapy; blood transfusion
- Emotional support

Nursing Interventions:
- Assess the patient’s extent of bleeding and monitor fundal height q 30 mins.
- Draw line at the level of the fundus and check it every 30 mins (if the level of the
fundus increases, suspect abruptio placentae)
- Count the number of pads that the patient uses, weighing them as necessary to
determine the amount of blood loss
- Monitor maternal blood pressure, pulse rate, respirations, central venous pressure,
intake and output and amount of vaginal bleeding q 10 – 15 mins
- Begin electronic fetal monitoring to continuously assess FHR
- Have equipment for emergency cesarean delivery readily available:
-prepare the patient and family members for the possibility of an
emergency CS delivery, the delivery of a premature neonate and the
changes to expect in the postpartum period
-offer emotional support and an honest assessment of the situation
- if vaginal delivery is elected, provide emotional support during labor
-because of the neonate’s prematurity , the mother may not receive an
analgesic during labor and may experience intense pain
-reassure the patient of her progress through labor and keep her informed
of the fetus’ condition
- tactfully discuss the possibility of neonatal death
 -tell the mother that the neonate’s survival depends primarily on
gestational age, the amount of blood lost, and associated hypertensive
disorders
-assure her that frequent monitoring and prompt management greatly
reduce the risk of death.
- encourage the patient and her family to verbalize their feelings
- help them to develop effective coping strategies, referring them for counseling if
necessary.

Goals of Care:
1. blood loss is minimized, and lost blood is replaced to prevent ischemic necrosis of
distal organs, including kidneys
2. DIC is prevented or successfully treated.
3. normal reproductive functioning is retained
4. the fetus is safely delivered
5. the woman retains a positive sense of self-esteem and self-worth.

Additional lab results:

Hgb- ↓
Platelet - ↓
Fibrinogen - ↓
Fibrin degradation products - ↑

Other possible nursing diagnosis:

• Impaired gas exchange: fetal related to insufficient oxygen supply secondary to

premature separation of the placenta.

• Pain related to bleeding between the uterine wall and the placenta secondary to
premature separation of the placenta.

• Fear related to perceived or actual grave threat to body integrity secondary to

excessive bleeding and threat to fetal survival.

• Grieving related to actual or threatened loss of infant.

• Powerlessness related to maternal condition and hospitalization.

• Risk for deficient fluid volume related to excessive losses secondary to premature
placental separation.
Female Reproductive System
Most species have 2 sexes: male and female. Each sex has its own unique reproductive
system. They are different in shape and structure, but both are specifically designed to
produce, nourish, and transport either the egg or sperm.
Unlike the male, the human female has a reproductive system located entirely in the
pelvis. The external part of the female reproductive organs is called the vulva, which
means covering. Located between the legs, the vulva covers the opening to the vagina
and other reproductive organs located inside the body.
The fleshy area located just above the top of the vaginal opening is called the mons
pubis. Two pairs of skin flaps called the labia (which means lips) surround the vaginal
opening. The clitoris, a small sensory organ, is located toward the front of the vulva
where the folds of the labia join. Between the labia are openings to the urethra (the canal
that carries urine from the bladder to the outside of the body) and vagina. Once girls
become sexually mature, the outer labia and the mons pubis are covered by pubic hair.
A female's internal reproductive organs are the vagina, uterus, fallopian tubes, and
ovaries.
The vagina is a muscular, hollow tube that extends from the vaginal opening to the
uterus. The vagina is about 3 to 5 inches (8 to 12 centimeters) long in a grown woman.
Because it has muscular walls, it can expand and contract. This ability to become wider
or narrower allows the vagina to accommodate something as slim as a tampon and as
wide as a baby. The vagina's muscular walls are lined with mucous membranes, which
keep it protected and moist. The vagina serves 3 purposes: It's where the penis is inserted
during sexual intercourse, and it's also the pathway that a baby takes out of a woman's
body during childbirth, called the birth canal, and it provides the route for the menstrual
blood (the period) to leave the body from the uterus.
A thin sheet of tissue with 1 or more holes in it called the hymen partially covers the
opening of the vagina. Hymens are often different from person to person. Most women
find their hymens have stretched or torn after their first sexual experience, and the hymen
may bleed a little (this usually causes little, if any, pain). Some women who have had sex
don't have much of a change in their hymens, though.
The vagina connects with the uterus, or womb, at the cervix (which means neck). The
cervix has strong, thick walls. The opening of the cervix is very small (no wider than a
straw), which is why a tampon can never get lost inside a girl's body. During childbirth,
the cervix can expand to allow a baby to pass.
The uterus is shaped like an upside-down pear, with a thick lining and muscular walls - in
fact, the uterus contains some of the strongest muscles in the female body. These muscles
are able to expand and contract to accommodate a growing fetus and then help push the
baby out during labor. When a woman isn't pregnant, the uterus is only about 3 inches
(7.5 centimeters) long and 2 inches (5 centimeters) wide.
At the upper corners of the uterus, the fallopian tubes connect the uterus to the ovaries.
The ovaries are 2 oval-shaped organs that lie to the upper right and left of the uterus.
They produce, store, and release eggs into the fallopian tubes in the process called
ovulation. Each ovary measures about 1 1/2 to 2 inches (4 to 5 centimeters) in a grown
woman.
There are 2 fallopian tubes, each attached to a side of the uterus. The fallopian tubes are
about 4 inches (10 centimeters) long and about as wide as a piece of spaghetti. Within
each tube is a tiny passageway no wider than a sewing needle. At the other end of each
fallopian tube is a fringed area that looks like a funnel. This fringed area wraps around
the ovary but doesn't completely attach to it. When an egg pops out of an ovary, it enters
the fallopian tube. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help
push it down the narrow passageway toward the uterus.
The ovaries are also part of the endocrine system because they produce female sex
hormones such as estrogen and progesterone.

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 of Abruptio Placentae
Drug Action : Uses: Adverse Nursing Implications:
Effects:
Generic Name: Synthetic water soluble To initiate or fetal trauma Start flow charts to record maternal BP
Oxytocin polypeptide consisting of 8 improve uterine from too rapid and other v/s, I/O ration, weight,
amino acids identical contraction at propulsion strength, duration and frequency of
pharmacologically to the term only in through pelvis, contractions, as well as fetal heart tone
Classifications: oxytocic principle of post. carefully fetal death, and rate, before instituting treatment.
Hormones and Pituitary. selected patients anaphylactic
synthetic substitute; and all cervix is reactions, Monitor FHrate and maternal BP and
oxytocic dilate and postpartum pulse at least q 15 mins during infuson
presentation of hemorrhage, period;
Dosage: fetus has precordail pain,
Antepartum: occurred; used to edema, Monitor I&O during labor. If patient is
Adult: IV start at 1 stimulate let- cyanosis or receiving drug by prolonged IV
mU/min. down reflex in redness of skin infusion, waych out for water
May increase by 1 nursing mother intoxication. Report changed in
mU/min q15 min and to relieve orientation
(max:20mU/min.) pain from breast
engorgement. Check fundus frequently during first
Postpartum: Uses include few postpartum hours and several times
Adult: IV infuse a management of thereafter.
total of 10 U at a rate inevitable,
of 20-40 mU/min incomplete, or
after delivery missed abortion;
stimulation of
uterine
contractions
during third
stage of labor;
stimulation to
overcome
uterine inertia;
control of
postpartum
hemorrhage and
promotion of
postpartum
uterine
involution.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

O> Ineffective Tissue Goal: Client will • Assess patient’s • Assessment Patient’s blood
• estimated Perfusion related to maintain adequate condition provides pressure was
blood loss Excessive blood tissue perfusion by especially the baseline maintained(100/60)
loss secondary to (date/time). SaO2, BP, PR information
• FHR pattern premature placental and RR. about client’s Patient’s pulse was
separation Outcome: • Monitor for present at least 60 beats per
1. Client will restlessness, condition. minute.
• BP Rationale: maintain BP anxiety, air • S/Sx of the said
compared to 0ne of the and pulse hunger and condition
baseline symptoms of (specify: BP changes in provides
premature >100/60 and LOC. information of
separation of the pulse developing
• Pulse
placenta is uterine between 60- indications of
bleeding with a 90 beats per inadequate
• Severe small amount to minute),
abdominal cerebral tissue
moderate amount of warm skin • Monitor perfusion.
pain and dark-red vaginal and dry.
rigidity accurately input • Monitoring
bleeding in 80% to 2. Urine output and output. provides data
85% of cases. not less than Evaluate also about renal
• Pallor Bleeding may result 30cc/hour. blood loss by perfusion and
in maternal 3. Client will weighing pads. function and the
• Changes in hypovolemia remain alert extent of blood
LOC (shock, oliguria, and oriented,
• Continuously loss.
anuria) and FHR pattern
monitor FHR • The fetus may
• Decrease coaglulopathy. remains
pattern initially respond
urine output reassuring.
compare to reassuring to
baseline data decrease
from prenatal placental
 record. Inform perfusion by
other health raising the FHR
care team for above the
any signs of normal baseline.
non reassuring Non reassuring
changes. FHR is an
• Assess for indication for
uterine delivery.
irritability, • Assessment
abdominal pain, gives
rigidity and information
increase about the
abdominal severity of
girth. placental
abruption.
Bleeding may
be occult
• Assess client’s causing
skin color, abdominal
temperature, rigidity and
moisture, turgor pain.
and capillary • Assessment
refill. provides
information
about peripheral
tissue perfusion.
Hypovolemia
results in
shunting of
• Initiate IV blood away
 access with from peripheral
gauge 18 circulation to
catheter and the brain and
provide fluids, vital organs.
blood products, • Intervention
or blood as provides venous
ordered. access to replace
• Monitor fluids.
laboratory
results (Hgb,
Hct, Clotting
studies). • Laboratory
studies provide
information on
• Observe client extent of blood
for signs of loss and signs of
spontaneous impeding DIC.
bleeding. • This provides
information
about the
• Keep client and depletion of
significant clotting factors
others informed and
of the condition development of
and plan of DIC.
care. • Information of
the condition of
• Notify the client will
caregivers and promote
prepare for understanding
immediate and cooperation.
delivery and • Continued blood
neonatal loss or
resuscitation development of
for maternal DIC may lead to
and fetal. maternal or fetal
injury or death.