Abruptio Placentae

Prepared by: Crisanto T. Layos

• Abruptio placenta is the premature separation of a normally implanted placenta before the delivery of the baby.

• It is characterized by a triad of symptoms: vaginal bleeding, uterine hyper tonus, and fetal distress.

CAUSES

• Unknown• Hypertension• Preterm premature rupture of membranes• Smoking• Cocaine abuse are the most common

associated factors

• A short umbilical cord, thrombophilias, external trauma, fibroids (especially those located behind the placental implantation site), severe diabetes or renal disease, and vena cava compression are other predisposing factors.

Grading System for Abruptions

Grade 0 Less than 10% of the total placental surface has detached; the patient has no symptoms; however, a small retroplacental clot is noted at birth.

Grade I Approximately 10%–20% of the total placental surface has detached; vaginal bleeding and mild uterine tenderness are noted; however, the mother and fetus are in no distress.

Grade II Approximately 20%–50% of the total placental surface has detached; the patient has uterine tenderness and tetany; bleeding can be concealed or is obvious; signs of fetal distress are noted; the mother is not in hypovolemic shock.

Grade III More than 50% of the placental surface has detached; uterine tetany is severe; bleeding can be concealed or is obvious; the mother is in shock and often experiencing coagulopathy; fetal death occurs.

ASSESSMENT

HISTORY

• Obtain an obstetric history

• Determine the date of the last menstrual period to cal- culate the estimated day of delivery and gestational age of the infant

• Inquire about alcohol, tobacco, and drug usage, and any trauma or abuse situations during pregnancy

• Ask the patient to describe the onset of bleeding (the circumstances, amount, and presence of pain)

PHYSICAL EXAMINATION

• Assess the amount and character of vaginal bleeding; blood is often dark red in color, and the amount may vary, depending on the location of abruption.

• Palpate the uterus; patients complain of uterine tenderness and abdominal/back pain.

• The fundus is woodlike, and poor resting tone can be noted.

• With a mild placental separation, contractions are usually of normal frequency, intensity, and duration.

• If the abruption is more severe, strong, erratic contractions occur.

• Assess for signs of concealed hemorrhage: slight or absent vaginal bleeding; an increase in fundal height; a rigid, boardlike abdomen; poor rest- ing tone; constant abdominal pain; and late decelerations or decreased variability of the fetal heart rate.

• A vaginal exam should not be done until an ultrasound is performed to rule out placenta previa.

• Using electronic fetal monitoring, determine the baseline fetal heart rate and presence or absence of accelerations, decelerations, and variability.

• At times, persistent uterine hypertonus is noted with an elevated baseline resting tone of 20 to 25 mm Hg.

• Ask the patient if she feels the fetal movement.

• Using electronic fetal monitoring, determine the baseline fetal heart rate and presence or absence of accelerations, decelerations, and variability.

• At times, persistent uterine hypertonus is noted with an elevated baseline resting tone of 20 to 25 mm Hg.

• Ask the patient if she feels the fetal movement. Fetal position and presentation can be assessed by Leopold’s maneuvers.

• Assess the contraction status, and view the fetal monitor strip to note the frequency and duration of contractions.

• Throughout labor, monitor the patient’s bleeding, vital signs, color, urine output, level of consciousness, uterine resting tone and contractions, and cervical dilation.

• If placenta previa has been ruled out, perform sterile vaginal exams to determine the progress of labor.

• Assess the patient’s abdominal girth hourly by placing a tape measure at the level of the umbili- cus.

• Maintain continuous fetal monitoring.

PSYCHOSOCIAL

• Assess the patient’s understanding of the situation and also the significant other’s degree of anxiety, coping ability, and willingness to support the patient.

Diagnostic HighlightsGeneral Comments: Abruptio placentae is diagnosed based on the clinical symptoms, and the diagnosis is confirmed after delivery by examining the placenta.

Test Normal Result Abnormally with Condition

Explanation

Pelvic ultrasound Placenta is visualized in the fundus of the uterus

None; ultrasound is used to rule out a previa

If the placenta is in the lower uterine segment, a previa (not an abruption) exists

Other Tests: Complete blood count (CBC); coagulation studies; type and crossmatch; nonstress test and biophysical profile are done to assess fetal well-being

PRIMARY NURSING DIAGNOSIS

• Fluid volume deficit related to blood loss

INTERVENTIONS

OUTCOME

• Fluid balance; Hydration; Circulation status

• Bleeding reduction; Blood product administration; Intravenous therapy; Shock management

PLANNING AND IMPLEMENTATION

Conservative treatment

• Bedrest• tocolytic (inhibition of uterine contractions) therapy• constant maternal and fetal surveillance• If a vaginal delivery is indicated and no regular

contractions are occurring, the physician may choose to infuse oxytocin cautiously in order to induce the labor.

If the patient’s condition is more severe:• assessments of blood loss, vital signs, and fetal heart

rate pattern and variability are performed.

• Give LR solution IV

• Blood transfusions• Central venous pressure (CVP)

(A normal CVP of 10 cm H2O is the goal)• CVP readings may indicate:

fluid volume deficit (low readings)

fluid overload and possible pulmonary edema

(high readings).

• If the mother or fetus is in distress - emergency cesarean section

FETAL DISTRESS Flat variability Late decelerations Bradycardia Tachycardia

Management:• Turn the patient to her left side• Increase the rate of her IV infusion• Administer oxygen via face mask• Notify the physician.

If a cesarean section is planned: Informed consent is obtained Prepare the patient’s abdomen for surgery Insert a foley catheter Administer preoperative medications as ordered Notify the necessary personnel to attend the operation

After deliverymonitor the degree of bleedingperform fundal checks frequently

(fundus should be firm, midline, and at or below the level of the umbilicus.)

Determine the Rh status of the mother; if the patient is Rh-negative and the fetus is Rh-positive with a negative Coombs’test, administer

Rho(D) immune globulin (rhoGAM).

Independent

During prenatal visits, explain the risk factors and the relationship of alcohol and substance abuse to the condition.

Teach the patient to report any signs of abruption, such as cramping and bleeding.

• If the patient develops abruptio placentae and a vaginal delivery is chosen as the treatment option, the mother may not receive analgesics because of the fetus’s prematurity; regional anesthesia may be considered.

Keep the patient and the significant others informed of the progress of labor, as well as the condition of the mother and fetus.

Offer as many choices as possible to increase the patient’s sense of control.

Reassure the significant others that both the fetus and the mother are being monitored for complications and that surgical intervention may be indicated.

Provide the patient and family with an honest commentary about the risks.

Discuss the possibility of an emergency cesarean section or the delivery of a premature infant.

Answer the patient’s questions honestly about the risk of a neonatal death.

If the fetus does not survive, support the patient and listen to her feelings about the loss.

DOCUMENTATION GUIDELINES

• Amount and character of bleeding: Uterine resting tone; intensity, frequency, and duration of contractions and uterine irritability

• Response to treatment: Intravenous fluids, blood transfusion, medications, surgical interventions

• Fetal heart rate baseline, variability, absence or presence of accelerations or decelerations, bradycardia, tachycardia

MEDICATIONS Instruct the patient not to miss a dose of the tocolytic

medication; usually the medication is prescribed for every 4 hours and is to be taken throughout the day and night.

Tell her to expect side effects of palpitations, fast heart rate, and restlessness.

Teach the patient to notify the doctor and come to the hospital immediately if she experiences any bleeding or contractions.

Note that being on tocolytic therapy may mask contractions. Therefore, if she feels any uterine contractions, she may be developing abruptio placentae

POSTPARTUM• Give the usual postpartum instructions for avoiding

complications. • Inform the patient that she is at much higher risk of

developing abruptio placentae in subsequent pregnancies.

• Instruct the patient on how to provide safe care of the infant.

• If the fetus has not survived, provide a list of referrals to the patient and significant others to help them manage their loss.

Thank You

Kingsoft Office