Prepared by: Claire Alvarez Ongchua, RN

Abruptio Placenta Is the premature separation of the normally implanted placenta after the 20th week of pregnancy, typically with sever hemorrhage. Also known Placental abruption is an obstetric catastrophe (complication of pregnancy)

Hemorrhage can be: a.Occult An occult hemorrhage, the placenta usually separates centrally, and a large amount of blood is accumulated under the placenta. b. Apparent With apparent hemorrhage , the separation is along the placental margin, and blood flows under the membranes and through the cervix.

If the placenta begins to detach during pregnancy, there is bleeding from these vessels. The larger the area that detaches, the greater the amount of bleeding

PATHOPHYSIOLOGY

PREDISPOSING FACTORS Age Race Previous Placenta Abruption Thrombophilia

PRECIPITATIONG FACTORS Smoking (cigarette,tobacco,cocaine0 Trauma Chorioamnionitis PIH

Damage in small arterial vessels in the basal layer of decidua Splits decidua, leaving a thin layer attached to the placenta

Bleeding Occult Apparent

Hematoma formation

Compression of the basal layer

Obliteration of the intervillous space

Destruction of the placental tissues

Concealed Bleeding

Visible Bleeding

Impaired exchange of respiratory gases and nutrients Blood reaches the edge of the placenta

Blood passes through the membranes of amniotic sac

Port wine discoloration of discharges ( PATHOGNOMONIC SIGN)

TYPES OF ABRUPTIO PLACENTA

Concealed hemorrhageThe placenta separation centrally, and a large amount of blood is accumulated under the placenta.

External HemorrhageThe separation is along the placental margin, and blood flows under the membranes and through cervix.

Degrees of Separation:Grade Criteria No symptoms of separation were apparent from 0 maternal or fetal signs; the diagnosis that a slight separation did occur is made after birth, when the placenta is examined and a segment of the placenta shows a recent adherent clot on the maternal surface. 1 Minimal separation, but enough to cause vaginal bleeding and changes in the maternal vital signs; no fetal distress or hemorrhagic shock occurs, however.

Grade Criteria 2 Minimal separation, but enough to cause vaginal bleeding and changes in the maternal vital signs; no fetal distress or hemorrhagic shock occurs, however. Extreme separation; without immediate interventions, maternal shock and fetal death will result.

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Laboratory ExaminationsBlood Test Workup: a. CBC b. Blood Typing c. Fibrinogen d. PT and aPTT e. BUN f. Creatinine g. Rh Type h. Thrombophilia workup

OTHER TEST: 1. Imaging Studies 2. Nonstress test 3. Biophysical Profile 4. Histologic findings

Maternal AssessmentSigns Increase Abdominal girth Board like rigidity Uterine tetany Cold extremities Tachypnea, Pallor Decreased Urine output Increase discharges Symptoms Confusion Abdominal/ back pain

Fetal AssessmentSigns And Symptoms Fetal thrashing Signs And Symptoms Fetal Acidosis Increase FHR

ManagementI. Patient Stable (Grade I) A. General1. Obstetrics Consultation 2. RhoGAM if Maternal blood Rh Negative

B. Criteria1. Reassuring Fetal Heart Tracing 2. Coagulopathy 3. Normotensive without Preeclampsia 4. Nontender uterus 5. Negative ultrasound with normal AFI

C. Preterm gestation1. Consider Tocolysis with Magnesium Sulfate 2. Contraindicated in all but mild abruption Normal saline >Lactated Ringers

4. Call for immediate Obstetric and neonatal support 5. Delivery within 20 minutes if Fetal Distress a. Cesarean Section unless imminent Vaginal Delivery 6. RhoGAM if Maternal blood Rh Negative

iii. Monitoring1. Orthostatic Blood Pressure and pulse 2. Monitor Intake and output a. Keep Urine Output over 30cc per hour

3. Monitor Hemoglobin or Hematocrit q1-2 hours a. Keep Hemoglobin >10 g/dl or Hematocrit >30% b. Packed Red Blood Cell transfusion as needed 4. Monitor coagulation studies (see labs above) a. Fresh Frozen plasma transfusion as needed b. Platelet transfusion as needed

NURSING MANAGEMENT1. Continuous evaluate maternal and fetal physiologic status, particularly: a. Vital signs b. Bleeding c. Electronic fetal and maternal monitoring tracings.

d. Signs of shock rapid pulse, cold and moist skin, decrease in blood pressure e. Decreasing urine output f. Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.

2. Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated. 3. Provide appropriate management a. On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.

b. Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a blood sample for fibrinogen level. c. Measure maternal vital signs every 5 to 15 by Monitor the FHR externally and mask. d. Prepare for cesarean section, which is the method of choice for the birth

4. Provide client and family teaching. 5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the separation, amount of fetal hypoxia and amount of bleeding.

Nursing Diagnosis

Ineffective tissue perfusion (placental) related to excessive bleeding, hypotension, and decreased cardiac output, causing fetal compromiseEvaluate amount of bleeding by weighing all pads. Monitor CBC results and VS Position in the left lateral position, with the head elevated to enhance placental perfusion Administer oxygen through a snug face mask at 8-12L per minute Evaluate fetal status with continuous external fetal monitoring Prepare for possible CS delivery if maternal or fetal compromise is evident

Acute Pain related to increase uterine activityInstruct patient on the cause of pain to decrease anxiety Instruct and encourage the use of relaxation technique to augment analgesics Administer pain medications as needed and as prescribed

Fluid volume deficit related to excessive bleedingEstablish and maintain a large-bore IV line, as prescribed and draw blood for type and screen for blood replacement Evaluate coagulation studies Monitor maternal VS and contractions Monitor vaginal bleeding and evaluate fundal height to detect an increase in bleeding

Risk for infection related to excessive blood lossUse aseptic technique when providing care Evaluate temperature q4h unless elevated; then evaluate q2h Evaluate WBC and differential count Teach perineal care and hand washing techniques Assess odor of all vaginal bleeding or lochia

Fear related excessive bleeding procedures and unknown outcomeInform the woman and her family about the status of herself and the fetus Explain all procedures in advance when possible or as they are performed Answer questions in a calm manner, using simple terms Encourage the presence of a support person

Determine the amount and type of bleeding and the presence or absence of pain. Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and FHR variability. Palpate the abdomen >Note the presence of contractions and relaxations between contractions (if contractions are present) >If contractions are not present assess the abdomen for firmness Measure and record fundal height to evaluate the presence of concealed bleeding.

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