Pregnancy Complications - 2

Vaginal Bleeding (after 20 weeks’ gestation)

The complications may be related to placenta previa or abruptio placentae.

Placenta Previa

It is a low-lying position of placenta in the uterus that partially or completely covers the cervical os. Clinical Findings:

• Painless bright red vaginal bleeding
• Bleeding may be reported after intercourse
• Uterine tone soft upon palpation
• Interventions dependent on amount of bleeding and labor status
• If partial placenta previa is noted in early gestation, then repeat ultrasound later in pregnancy (may demonstrate absence of previa as uterus grows)
• If labor active and os is covered, then cesarean birth necessary
• If bleeding controlled and labor absent, then conservative management is applied

Patient Teaching (Conservative Management)

• No tampon use
• No sexual intercourse
• Monitor and report bleeding
• Patient instructed to report placenta placement when admitted to hospital
• Cesarean preparation class
• Count fetal movements

Abrupto Placentae

Clinical Findings

• Abdominal pain (sudden onset, intense and localized)
• Fundus firm, boardlike, with little relaxation
• Vaginal bleeding
• Bleeding may be concealed within the uterine cavity
• Fetal heart tones may be non-reassuring

Nursing Care (vaginal bleeding/late pregnancy)

1. Monitor amount of bleeding
2. Check vital signs
3. Observe for signs of shock
4. Evaluate fetal heart tones
5. Palpate uterine tone
6. Apply electronic fetal monitor (EFM)
7. REPORT alterations in fetal heart rate pattern
8. REPORT hypertonic contractions with poor resting tone
9. Do not attempt vaginal exam until placenta placement verified
10. Initiate IV fluids
11. Report laboratory and ultrasound findings
12. Prepare staff for possible cesarean birth
13. Attend to patient’s emotional needs

Placenta Previa

Placenta previa is a condition in which the placenta implanted improperly in the lower uterine segment near or over the internal cervical os.

Types of Placenta Previa:

1. Total: the internal os is covered entirely by the placenta when the cervix is dilated fully
2. Partial: the internal os is covered incompletely
3. Marginal: only an edge of the placenta extends to the internal os
4. Low-lying placenta: the placenta is implanted in the lower uterine segment but does not reach the internal os

Signs and Symptoms:

• Painless red vaginal bleeding occur in the last half of pregnancy
• Uterus is soft, relaxed, and non-tender
• Fundal height may be greater than expected for gestational age

Nursing Interventions:

• Interventions depend on the classification of the previa and gestational age of the fetus
• Monitor maternal vital signs, fetal heart rate, and fetal activity
• Prepare for ultrasound
• Avoid vaginal examination
• Bed rest in a left leteral position
• Monitor amount of bleeding (shock)
• Administer IV fluids, blood products, or tocolytic medication as prescribed
• Cesarean section may be performed if bleeding is heavy
• Administer Rh immune globulin if the mother is Rh-negative and has not been given the injection at 28 weeks of gestation