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Exam (elaborations) Concepts Of Maternal-Child Nursing And Families (NUR4130)
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lOMoARcPSD|1 209657 5OB Final Review
Concepts Of Maternal-Child Nursing And Families (Nova South-eastern University)
, lOMoARcPSD|1209657 5
1. Placenta Previa
The two most clinically significant causes of bleeding in the second half of CAUSE OF PLACENTA PREVIA IS UNKNOWN
pregnancy are: placenta previa and placentae Women at higher risk are:
In placenta previa, the placenta is implanted in the lower uterine segment rather Women of African descent
than the upper portion of the uterus Women who have undergone prior C-section
The placenta is implanted in the lower segment of the uterus or over the internal Other risk factors:
cervical os. High gravidity
Bleeding begins – may be either scanty or perfused High parity
Placenta previa is categorized as being: Advanced maternal age o
Low lying – placenta is in the lower uterine segment but DOES NOT COVER Previous miscarriage
THE OS Previous induced abortion o
Partial – internal os is partially covered Cigarette smoking
o Marginal – edge of placenta is covered Male fetus o
Complete – internal os is covered
Fetal/Neonatal Implications
o Prognosis for fetus depends on the extent of placenta previa
o Woman may be allowed to labor with: marginal and low-lying placenta previa o
Fetus may have changes in: FHR and meconium staining of the aminotic fluid -
FHR monitoring is imperative
o Porfuse bleeding: fetus is compromised and suffers some hypoxia o
If nonreassuring fetal status occurs C-section is indicated
o Woman with complete or partial previa C-section because of high risk for
hemmoraging!!!
o Postpartum: blood sampling to check for anemia in the newborn
Clinical Therapy Expectant Management
Goal of medical care is to identify the cause of bleeding and to • Bed rest
provide treatment that will ensure birth of a mature newborn • Bathroom privileges as long as woman is not bleeding •
Transabdominal ultrasound scan to localized placenta • Performing no vaginal exams
• Until placenta previa is ruled out: VAGINAL EXAMINATIONS • Monitoring blood loss, pain, and uterine contractility
ARE NEVER DONE WITH WOMAN WITH BLEEDING • Evaluating FHR with an external fetal monitor
o Examiners fingers can perforate placenta if • Monitoring maternal v/s
cervical dilation has occurred • Labs: H&H, Rh factor and urinalysis o
Once r/o then examiner can perform vaginal • IV (LR solution)
exam with speculum to determine cause of • 2 units of cross-matched blood available for transfusion
bleed • If frequent, recurrent or profuse bleeding persists or if fetal well-•
Differential diagnosis of placental or cervical bleeding takes being appears threatened a C-section is needed
careful consideration Clinical Signs
• Partial separation: painless bleeding • Most accurate diagnostic sign of placenta previa: PAINLESS, •
True placenta previa: may not demonstrate overt bleeding BRIGHT-RED VAGINAL BLEEDING
until labor begins • First bleeding episode is generally light, scanty
• Confusion between partial and true placental is an issue • If no vaginal examinations are performed it often subsides when
diagnosis spontaneously, however each subsequent hemorrhage is more
• Care of woman with painless late-gestational bleeding perfuse
depends on: • Uterus remains soft
st
1. week of gestation during which the 1 bleeding • If labor begins, the uterus relaxes during contractions episode
occurs • FHR remains stable unless profuse hemorrhage and maternal
2. The amount of bleeding shock occur
• If pregnancy is less than 37 weeks’, expectant management • Fetal presenting part is often unengaged and transverse lie is is
used to delay birth until about 37 weeks’ to allow the common
fetus time to mature
Nursing Prevent or treat complications
Management • Nurse should assess blood loss, pain and uterine contractility (subjective and objective) •
Maternal V/S and the result of blood loss and urine test
• Monitor maternal vital signs every 15 min in the absence of hemorrhage and every 5 mins with active
hemorrhage
• Evaluate the FHR w/continuous external fetal monitoring
• Observe and verify family’s ability to cope with the anxiety associated with an unknown outcome •
Record, I&O’s, V/S, prepare whole-blood setup to be ready for IV infusion, establish IV site,
• Fluid volume deficit due to excessive blood loss
• Impaired gas exchange of fetus r/t decreased blood volume and maternal hypotension •
Anxiety related to concern for own personal status and baby’s safety
• Check newborns Hgb, cell volume and erythrocyte count STAT and monitor it loosely, baby may require O2 and O
2. Abruptio Placentae
• Abruptio placentae - is the premature separation of a normally implanted placenta from the uterine wall
, lOMoARc PSD|120 96575
• Leading cause of perinatal mortality
• Catastrophic event because of the severity of resulting hemorrhage •
CAUSE IS LARGELY UNKNOWN
• Risk factors:
o Maternal age over 35 or under 20 years old o
Increased parity
o Cigarette smoking o
Alcohol use
o Cocaine abuse o
Trauma
o Maternal HTN and many more
• Abruptio placentae is subdivided into 3 types:
o Marginal – placenta separates at its edges, blood escapes through the vagina
o Central – placenta separates centrally, blood is trapped between placenta and uterine wall
o Complete – massive vaginal bleeding seen in the presence of total separation
Abruptio placentae grading: Maternal Implications
1. Grade 1 (mild) Risk for DIC – serious and can cause death!!!
Mild separation with slight vaginal bleeding • Because of damage to uterine wall and cloting, large thromboplastin
FHR pattern and maternal BP unaffected are released into the maternal blood.
Accounts for 40% of abruptions • Thromboplastin trigger DIC
2. Grade 2 (moderate) • Fibrogen levels decrease (which are normally elevated during
Partial abruption with moderate bleeding pregnancy)
Significant uterine irritability is present • Fibrogen levels drop to the point at which blood will no longer
(irritability in uterine is due to the blood that coagulate
invades the tissues between the muscle fibers) • Hypofibrogenemia - an acute hemorrhagic state brought about by
Maternal pulse may be elevated inability of the blood to clot, with massive hemorrhages
Blood pressure of mother is stable • Can result in hemorrhagic shock
FHR – signs of fetal compromise • Fatal to mother if not treated STAT
Accounts for 45% of abruptions • Postpartum:
3. Grade 3 (severe) o Risk for hemorrhage and renal failure due to shock
Large or complete separation with moderate to o Vascular spasm
severe bleeding o Intravascular cloting
Maternal shock and painful uterine Fetal/Neonatal Implications
contractions present • When placenta has separated the infant mortality rate is near 100%
Fetal death • In less severe separation, fetal outcome depends on level of maturity
om
c mon
Accounts for about 15% of abruptions and length of time to birth
• Mo t erious ation :
• If hemorrhaging continues eventually the uterus turns o Preterm
so s Anemia
labor complic s
entirely blue because muscle fibers are filled with blood
• Couvelaire
w uterus is a condition that occurs after birth o Hypoxia – if fetal hypoxia is unchecked it can lead to
hen irreversible brain damage or fetal demise
the uterus contracts poorly
Clinical Therapy Mild Placental Separation
• DIC - there is abnormal coagulation and abnormal bleeding • Vaginal labor may be induced if baby is late preterm
in o If induced labor or oxytocin don’t work C-section is required
the skin, GI and respiratory system o The longer they delay birth the more risk for increased
• The DIC cascade leads to microclots that disrupt normal hemorrhage
blood flow to major organs and can lead to organ failure Moderate to Severe placental Separation
• Coagulation test results are imperative!!! • Treat hypofibrinogemia 1st by IV cryoprecipitate or fresh frozen •
fibrinogen levels and platelet counts are decreased pl a s m a
• PT and P T are prolonged (longer to clot) • Then after treatment of hypofibrinogemia then C-Section is done •
T
Maintain cardiovascular status of mother and baby t
• Va g i n a l b i r h i s I M PO S S I B LE
• C-section is the safest option Nursing Management
• Type and cross-match for blood transfusion (at least 3 units) • Electronic monitoring of uterine contractions •
•IV fluids Resting tone btwn contractions
•Evaluate cloting mechanism • Evaluate uterine resting tone for increased tone (frequently
• CVP is monitored hourly to evaluate IV fluid replacement. increased tone with abruptio placentae)
• High CVP may in i ate fluid e load and p lmon y dema • Abdominal girth measurement hourly (at level of umbilicus)
•Lab exams: H&H andd coagulation
c ovstatus
r u ar e
• Uterine size increases with bleeding
• HYPOVOLEMIA – with s ere place tae pt s life • To measure uterine size from top of fundus to symphysis pubis
threatening and is combated
ev with whole
n blood io i
abru
•
• Over distension of uterus can lead to a ruptured uterus (life
threatening)
If fetus is under stress C-section is done!
• With still birth fetus, vaginal birth is preferred if bleeding has
been stabilized
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