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 hypertonus, and fetal distress. It can occur during the prenatal or intrapartum period. In a marginal abruption, separation begins at the periphery and bleeding accumulates between the membranes and the uterus and eventually passes through the cervix, becoming an external hemorrhage. In a central abruption, the separation occurs in the middle, and bleeding is trapped between the detached placenta and the uterus, concealing the hemorrhage. Frank vaginal bleeding also does not occur if the fetal head is tightly engaged. Since bleeding can be concealed, note that the apparent bleeding does not always indicate actual blood loss. If the placenta completely detaches, massive vaginal bleeding is seen. Abruptions are graded according to the percentage of the placental surface that detaches. Visual inspection of an abrupted placenta reveals circumscribed depressions on its maternal surface and is covered by dark, clotted blood. Destruction and loss of function of the placenta result in fetal distress, neurological deficits such as cerebral palsy, or fetal death.
Causes of Abruptio placenta
The cause of abruptio placenta is unknown; however, any condition that causes vascular changes at the placental level may contribute to premature separation of the placenta. Hypertension, preterm premature rupture of membranes, smoking, and 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 caval compression are other predisposing factors.
Physical Assessment and Examination
Obtain an obstetric history. Determine the date of the last menstrual period to calculate 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). When obtaining a history from a patient with an abruption, recognize that it is possible for her to be disoriented from blood loss and/or cocaine or other drug usage. Generally, patients have one of the risk factors, but sometimes no clear precursor is identifiable.
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 resting 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. 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 umbilicus. Maintain continuous fetal monitoring.
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.
Primary nursing diagnosis: Fluid volume deficit related to blood loss.
The goal of this nursing care plan is to maintain Fluid balance; Hydration; Circulation status; Bleeding reduction; Blood product administration; Intravenous therapy; Shock management
Nursing Care Plan/Intervention and Treatment
If the fetus is immature (37 weeks) and the abruption is mild, conservative treatment may be indicated. However, conservative treatment is rare because the benefits of aggressive treatment far outweigh the risk of the rapid deterioration that can result from an abruption. Conservative treatment includes bedrest, tocolytic (inhibition of uterine contractions) therapy, and 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, aggressive, expedient, and frequent assessments of blood loss, vital signs, and fetal heart rate pattern and variability are performed. Give lactated Ringer’s solution intravenously (IV) via a large-gauge peripheral catheter. At times, two intravenous catheters are needed, especially if a blood transfusion is anticipated and the fluid loss has been great. If there has been an excessive blood loss, blood transfusions and central venous pressure (CVP) monitoring may be ordered. A normal CVP of 10 cm H2O is the goal. CVP readings may indicate fluid volume deficit (low readings) or fluid overload and possible pulmonary edema following treatment (high readings).
If the mother or fetus is in distress, an emergency cesarean section is indicated. If any signs of fetal distress are noted (flat variability, late decelerations, bradycardia, tachycardia), turn the patient to her left side, increase the rate of her IV infusion, administer oxygen via face mask, and notify the physician. If a cesarean section is planned, see that informed consent is obtained in accordance with unit policy, prepare the patient’s abdomen for surgery, insert a Foley catheter, administer preoperative medications as ordered, and notify the necessary personnel to attend the operation.
After delivery, monitor the degree of bleeding and perform fundal checks frequently. The 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).
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 placenta 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. The labor, therefore, may be more painful than most mothers experience; provide support during labor. Keep the patient and the significant others informed of the progress of labor, as well as the condition of the mother and fetus. Monitor the fetal heart rate for repetitive late decelerations, decreased variability, and bradycardia. If noted, turn the patient on her left side, apply oxygen, increase the rate of the IV and notify the physician immediately.
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.
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 placenta.