Abruptio Placenta

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

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acute abdominal pain dec. BP inc. pulse 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

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-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.

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

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Fear related to perceived or actual grave threat to body integrity secondary to excessive bleeding and threat to fetal survival.

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Grieving related to actual or threatened loss of infant.

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Powerlessness related to maternal condition and hospitalization.

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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 :

Generic Name: Oxytocin

Synthetic water soluble polypeptide consisting of 8 amino acids identical pharmacologically to the oxytocic principle of post. Pituitary.

Classifications: Hormones and synthetic substitute; oxytocic Dosage: Antepartum: Adult: IV start at 1 mU/min. May increase by 1 mU/min q15 min (max:20mU/min.) Postpartum: Adult: IV infuse a total of 10 U at a rate of 20-40 mU/min after delivery

Uses:

Adverse Effects: To initiate or fetal trauma improve uterine from too rapid contraction at propulsion term only in through pelvis, carefully fetal death, selected patients anaphylactic and all cervix is reactions, dilate and postpartum presentation of hemorrhage, fetus has precordail pain, occurred; used to edema, stimulate letcyanosis or down reflex in redness of skin nursing mother and to relieve pain from breast engorgement. Uses include management of inevitable, incomplete, or missed abortion; stimulation of uterine contractions during third stage of labor; stimulation to overcome

Nursing Implications: Start flow charts to record maternal BP and other v/s, I/O ration, weight, strength, duration and frequency of contractions, as well as fetal heart tone and rate, before instituting treatment. Monitor FHrate and maternal BP and pulse at least q 15 mins during infuson period; Monitor I&O during labor. If patient is receiving drug by prolonged IV infusion, waych out for water intoxication. Report changed in orientation Check fundus frequently during first few postpartum hours and several times thereafter.

uterine inertia; control of postpartum hemorrhage and promotion of postpartum uterine involution.

Assessment O> •

estimated blood loss

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FHR pattern

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BP compared to baseline

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Pulse

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Severe abdominal pain and rigidity

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Pallor

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Changes in LOC

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Decrease urine output

Diagnosis Ineffective Tissue Perfusion related to Excessive blood loss secondary to premature placental separation Rationale: 0ne of the symptoms of premature separation of the placenta is uterine bleeding with a small amount to moderate amount of dark-red vaginal bleeding in 80% to 85% of cases. Bleeding may result in maternal hypovolemia (shock, oliguria, anuria) and coaglulopathy.

Planning Goal: Client will maintain adequate tissue perfusion by (date/time). Outcome: 1. Client will maintain BP and pulse (specify: BP >100/60 and pulse between 6090 beats per minute), warm skin and dry. 2. Urine output not less than 30cc/hour. 3. Client will remain alert and oriented, FHR pattern remains reassuring.

Intervention •

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Rationale

Assess patient’s • condition especially the SaO2, BP, PR and RR. Monitor for restlessness, • anxiety, air hunger and changes in LOC.

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Monitor accurately input • and output. Evaluate also blood loss by weighing pads.

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Continuously monitor FHR pattern compare to baseline data from prenatal

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Assessment provides baseline information about client’s present condition. S/Sx of the said condition provides information of developing indications of inadequate cerebral tissue perfusion. Monitoring provides data about renal perfusion and function and the extent of blood loss. The fetus may initially respond reassuring to decrease placental

Evaluation Patient’s blood pressure was maintained(100/60) Patient’s pulse was at least 60 beats per minute.

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record. Inform other health care team for any signs of non reassuring changes. Assess for uterine • irritability, abdominal pain, rigidity and increase abdominal girth.

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Assess client’s skin color, temperature, moisture, turgor • and capillary refill.

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Initiate IV

perfusion by raising the FHR above the normal baseline. Non reassuring FHR is an indication for delivery. Assessment gives information about the severity of placental abruption. Bleeding may be occult causing abdominal rigidity and pain. Assessment provides information about peripheral tissue perfusion. Hypovolemia results in shunting of blood away

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access with gauge 18 catheter and provide fluids, blood products, or blood as ordered. Monitor laboratory results (Hgb, Hct, Clotting studies). Observe client for signs of spontaneous bleeding.

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Keep client and significant others informed of the condition and plan of care. •

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Notify caregivers and prepare for

from peripheral circulation to the brain and vital organs. Intervention provides venous access to replace fluids.

Laboratory studies provide information on extent of blood loss and signs of impeding DIC. This provides information about the depletion of clotting factors and development of DIC. Information of the condition of the client will promote understanding

immediate delivery and neonatal resuscitation for maternal and fetal.

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and cooperation. Continued blood loss or development of DIC may lead to maternal or fetal injury or death.