I.

Introduction:

The upper part of the uterus is the most favorable area for placental implantation
because it is rich in blood and, therefore, nutrients and oxygen. The lower uterine
segment is not and, therefore, it is possible that if the baby implants too low (low-lying
placenta), risks of intrauterine growth restriction and preterm labor are much higher.

During the last trimester, and especially in the last month, the lower uterine
segment thins appreciably and pulls up a bit, which is what causes cervical effacement
(thinning) and early dilatation. If the placenta is impinging on the lower segment and is
not up in the fundus where it is supposed to be, then part of the placenta may dislodge
and hemorrhage may occur. This condition is called PLACENTA PREVIA.

PLACENTA PREVIA is an abnormal low implantation of the placenta in proximity

to the internal cervical os. Placenta previa is a condition in which the placenta attaches
to the uterine wall in the lower portion of the uterus and covers all or part of the cervix.

Classification of Placenta Previa

1. Total Previa- the placenta completely covers the internal cervical os.
2. Partial Previa- the placenta covers a part of the internal cervical os.
3. Marginal Previa- the edge of the placenta lies at the margin of the internal
cervical os and may be exposed during dilatation.
4. Low-lying placenta- the placenta is implanted in the lower uterine segment but
does not reach to the internal os of the cervix.
 Mothers who are above 35 years old and below 18 years old as well as to those
multiparous mothers are at risk in developing placenta previa. In addition to that,
mothers who have previous uterine surgery, large placenta that would include multiple
gestation and erythroblastosis, and maternal smoking will also likely to develop placenta
previa.

When true placenta previa at term is very serious. Complications for the baby
include (1) Problems for the baby, secondary to acute blood loss, (2) Intrauterine growth
retardation due to poor placental perfusion, (3) Increased incidence of congenital
anomalies. The siigns and symptoms of placenta previa vary, but the most common
symptom is painless bleeding during the third trimester. Other reasons to suspect
placenta previa would be include (a) Premature contractions, (b) Baby is breech, or in
transverse position, (c) Uterus measures larger than it should according to gestational
age.

Some of the nursing actions that would manage the occurrence of placenta
previa is to give drugs that can prevent premature labor or birth example is
progesterone. Ultrasound exams to determine migration of an early diagnosed previa or
classification of the previa as total, partial, marginal, or low-lying would also help in
managing placenta previa. When the client experience a small first bleed, client may
sent home on bed rest if she can return to hospital quickly and if bleeding is more
profuse client is required to be hospitalized on bed rest with BRP, IV access; labs: Hgb
and Hct, urinalysis, blood group and type and cross match for 2 units of blood hold,
possible transfusions; goal is to maintain the pregnancy fetal maturity. No vaginal
exams are performed except under special conditions requiring a double set-up for
immediate cesarean birth should hemorrhage result. Instruct patient to position herself
in a low lying or marginal previas to allow vaginal delivery if the fetal head acts as
tamponade to prevent hemorrhage. In some cases, procedure of Cesarean birth, often
with vertical uterine incision, is used for total placenta previa. Steroid shots may be
given to help mature the baby's lungs.
II. Goals and Objectives:

GOAL:

We, the student nurses of Capitol University, aim to develop essential as well as

skillful maternal nursing care which is based on the better and effective approach ----

that will serve as a catalyst to promote health, reduce illness and/or completely

eliminate such diseases. We are also up to in knowing the nature of the disease and on

how to manage it in such a way that it would be therapeutic to both mother and child.

Objectives:

By the end of this whole rotation, we, the student nurses of Capitol University, will

be able to:

1. Enhance our ability to manage the said disease in regards to

their cultural beliefs and lifestyle.

2. Develop an independent and collaborative work together

with the medical health team members.

3. Prioritize things which are essential in assessing and

developing proper interventions in treating or alleviating the

illness.

4. Improve the use of the nursing process that would include

assessment, diagnosis, planning, implementation and

evaluation into a more useful and more effective in doing the

patient’s care.

5. Apply the core and fundamental systematic approach of the

nursing profession in promoting health unto the clients.

III. Client’s Profile

A. Socio-demographic data

Patient X is a 37- year old Filipina female who is living with her family at Look, Salay,
Misamis Oriental. She is from Quitoan, Bacolod. Her religion is Iglesia ni Cristo. She is a
high school graduate, non-smoker, non –alcoholic, and no allergies reported. Patient
has placenta previa with bleeding during her delivery.

Patient X was admitted last Novemer 29, 2009 at NNMC –DR because of abnormal
separation of the placenta. With that, patient X undergone cesarean section.

Patient X is multigravida. She delivered a post term operative baby boy 43 weeks of
gestation 3.4 kg with an APGAR score of 3,6,7 vertex, placenta previa, accreta with
anemia.

Patient X has two full term baby weighing 5 lbs and 6 lbs. Patient is referred to
NNMC from Balingasag, Provincial Hospital.

B. Vital signs
The patient vital signs are one of the most important data that should be given a
direct attention because it will serve as basis in determining any risk factors towards the
patient. The increase and decreased of the vital sign of the patient must be monitored in
order to determined whether the patient is at risk or not.

The patient had the following vital signs upon admission: BP- 120/90 mmHg, PR-
80 bpm ; RR-22 cpm; and temp- 36°c .
IV. Physical Assessment

These portions of the chapter will present the normal and regressed health
function of patient X arranged in a cephalocaudal approach to present a more organized
and convenient documentation.

• Health perception and management pattern (pre-hospitalization)

She has 3 children and her medical and dental check-ups are only done when
needed. She does not smoke and drink alcoholic beverages. Her previous
hospitalization was only when she delivered her previous babies. She had no other
health problems except the headache during her pregnancy period, and also there
family believes in quack doctors or the so called “albularios” and uses of herbal plants
and medicines.

• Nutrition-Metabolic Pattern (MGH – still in)

The patient is having her diet as diet as tolerated during her confinement in the
hospital.

• Elimination pattern (pre-hospitalization)

A patient usually defecates once a day with no other problems during

defecations. She urinates approximately 4-6 times a day also with no other problems in
voiding process.

• Activities of daily living (ADL) (pre-hospitalization)

The patient verbalized that, she can eat independently and can dress herself
properly without a need of any assistance as well as in bathing. She usually sleeps
around ten o’clock in the evening and awake at five o’clock in the morning.
 • Self-perception and self-concept pattern (while confined)

The patient had a fighting spirit that she will overcome all the trials that may come to
her life. She had an overviewed that she will get soon and may go home to see her
family, love ones and friends.

• Activities Tolerance-Exercise pattern (while confined)

Patient was able to ambulate around and able to make walking wxercises, she
was able to take bathe, dress and eat on her own and walk without any assistance on
her side.

• Sleep rest pattern (while confined)

She had a difficulty in sleeping during the first day of admission because had a
wound from her C/S operation and for the fact that she is surrounded with many people
who are literally noisy. The patient also verbalize that the environment is not soothing
for her but after a day she was able to adjust and adapt gradually in the environment.

• Cognitive-Perception (while confined)

The patient can speak fluently and understand fully in Cebuano and Tagalog, but
she had low comprehension in English language. She is oriented with the time, people
surround her and place. Her memory is good and answer the question that was given to
her, she is also nice to the co-patient in the ward and interact to her surroundings.

• Role-Relationship Pattern (while confined)

The patient is happily married in 5 years with her husband. She is also good and
nice mother to her children that provides their basic needs even though she’s
experiencing difficulty in most of the time. And also a good influence to the people within
the community where she belongs.

• Values – Belief Pattern

The client is a member of Iglesia ni Cristo and verbalized that she is always
attending worship sessions and seldom missed it. She also actively participates in
 the activities within her church.

V. Neurological Assessment

Orientation Oriented to time, person, and place

Appropriate behavior/communication Cooperative; Responsive
Level of Consciousness Conscious
Emotional State Calm

Skin

General Color Pinkish

Texture Smooth
Turgor Supple
Temperature Warm
Moisture Dry

Head

Facial Movements Symmetrical

Fontanels Closed
Hair Fine
Scalp Clean

Eyes

Lids Symmetrical
Preorbital Region Intact/full
Conjunctiva Pink
Sclera Anicteric
Reaction to light R- Brisk
L- Brisk
Reaction to accommodation Uniform constriction / Convergence
Visual Acuity Grossly Normal
Peripheral Vision Intact/full

Nose
Septum Midline
Mucosa Pinkish
Patency Both patent
Gross Smell Normal/symmetrical
Sinuses Non-tender

Ears

External Pinnae Normoset; Symmetrical

Tympanic Membrane Intact
Gross Hearing Decreased

Mouth

Lips Pinkish
Mucosa Pinkish
Tongue Midline
Teeth Complete
Gums Pinkish

Neck

Trachea Midline
Thyroids Non-palpable
Others Normal ROM

Pharynx

Uvula Midline
Tonsils Not Inflamed
Posterior Pharynx Not Inflamed
Mucosa Pinkish

Abdomen

General Post-operative Wound

Configuration Symmetrical
Bowel Sounds Normoactive
Percussion Tympanitic

Back and Extremities

Range of Motion Decreased ROM

Muscle tone and strength Fair
Spine Midline
Gait Coordinated

Cardiovascular Status

Precordial Area Flat

Point of Maximal Impulse (PMI)
Heart Sounds Regular
Peripheral Pulses Regular
Capillary Refill 2 seconds

Respiratory Status

Breathing Pattern Regular

Shape of Chest AP:L:1:2
Lung Expansion Symmetrical
Vocal/Tactile Fremitus Symmetrical
Percussion Resonant
Breath Sounds Vesicular
Cough Non-productive

Reproductive Status

Labia Symmetrical
Urethra Pinkish
Breasts Equal; smooth
VI. Anatomy and Physiology

At conception:

One very lucky spermatozoon out of hundreds of millions ejaculated by the man will

penetrate the outside layer of the ovum and fertilize it. This happens typically in the

outer third of one of the woman's Fallopian tubes. The surface of the ovum changes its

electrical characteristics and normally prevents additional sperm from entering. A

genetically unique entity is formed shortly thereafter, called a zygote. This is commonly

referred to as a "fertilized ovum." However that term is not really valid because the

ovum ceases to exist after conception. Half of the zygote's 46 chromosomes come from

the egg's 23 chromosomes and the other half from the spermatozoon's 23. It has a

unique DNA structure, different from that of the ovum and the spermatozoon. The

zygote "...is biologically alive. It fulfills the four criteria needed to establish

biological life:
 1. metabolism,
2. growth,
3. reaction to stimuli, and
4. reproduction."

It can reproduce itself through twinning at any time up to about 14 days after
conception; this is how identical twins are caused.
Conception is the point that most, or all, pro-life groups and conservative Christians
define as the beginning of pregnancy. When conception occurs, most of these groups
define the start of a human person as occurring at conception. The medical definition of
the start of pregnancy is about 10 days later, at implantation. The zygote divides into
two cells, called blastomeres. They subdivide once every 12 to 20 hours as the zygote
slowly passes down the fallopian tubes.

About 3 days after conception:

The zygote now consists of 16 cells and is called a 16 cell morula (a.k.a. pre-
embryo). It has normally reached the junction of the fallopian tube and the uterus.

5 days or so after conception:

A cavity appears in the center of the morula. The grouping of cells are now
called a blastocyst. It has an inner group of cells which will become the fetus and later
the newborn; it has an outer shell of cells which will "become the membranes that
nourish and protect the inner group of cells." It has traveled down the fallopian tubes
and has started to attach itself to the endometrium, the inside wall of the uterus (a.k.a.
womb). The cells in the inside of the blastocyst, called the embryoblast, start forming
the embryo. The outer cells, called the trophoblast, start to form the placenta. It
continues to be referred to as a pre-embryo.

9 or 10 days after conception:

The blastocyst has fully attached itself to endometrium. Primitive placental blood
circulation has begun. This blastocyst has become one of the lucky ones. Most never
make it this far in the process.

12 days or so after conception:

The blastocyst has started to produce hormones which can be detected in the
woman's urine. This is is the event that all (or almost) all pro-choice groups and almost
all physicians (who are not conservative Christians) define to be the start of pregnancy.
If instructions are followed exactly, a home-pregnancy test may reliably detect
pregnancy at this point, or shortly thereafter.

13 or 14 days after conception:

A "primitive streak" appears. It will later develop into the fetus' central nervous
system. This is the point at which spontaneous division of the blastocyst -- an event that
sometimes generates identical twins -- is not longer possible. The pre-embryo is now
referred to as an embryo. It is a very small blob of undifferentiated tissue at this stage of
development.

3 weeks:

The embryo is now about 1/12" long, the size of a pencil point. It most closely
resembles a worm - long and thin and with a segmented end. Its heart begins to beat
about 18 to 21 days after conception. Before this time, the woman might have noticed
that her menstrual period is late; she might suspect that she is pregnant and conduct a
pregnancy test. If it is an unwanted pregnancy, she might have already arranged and
carried through with an abortion.

4 weeks:

The embryo is now about 1/5" long. It looks something like a tadpole. The
structure that will develop into a head is visible, as is a noticeable tail. The embryo has
structures like the gills of a fish in the area that will later develop into a throat.

5 weeks:

Tiny arm and leg buds have formed. Hands with webs between the fingers have
formed at the end of the arm buds. Fingerprints are detectable. The face "has a
distinctly reptilian aspect." 1 "...the embryo still has a tail and cannot be distinguished

from pig, rabbit, elephant, or chick embryo."

6 weeks:

The embryo is about 1/2" long. The face has two eyes on each side of its head;
the front of the face has "connected slits where the mouth and nose eventually will be."

7 weeks:

The embryo has almost lost its tail. "The face is mammalian but somewhat pig-
like." Pain sensors appear. Many conservative Christians believe that the embryo can
feel pain. However, the higher functions of the brain have yet to develop, and the
pathways to transfer pain signals from the pain sensors to the brain have not developed
at this time.

2 months:

The embryo's face resembles that of a primate but is not fully human in
appearance. Some of the brain begins to form; this is the primitive "reptilian brain" that
will function throughout life. The embryo will respond to prodding, although it has no
consciousness at this stage of development. The brain's higher functions do not develop
until much later in pregnancy.

10 weeks:

The embryo is now called a fetus. Its face looks human; its gender may be
detectable via ultrasound.

13 weeks or 3 months:

The fetus is about 3 inches long and weighs about an ounce. Fingernails and
bones can be seen. Over 90% of all abortions are performed before this stage.

17 weeks or 3.9 months:

It is 8" long and weighs about a half pound. The fetus' movements may begin to
be felt. Its heartbeat can usually be detected.

22 weeks or 5 months:

12" long and weighing about a pound, the fetus has hair on its head. Its
movements can be felt. An abortion is usually unavailable at this gestational age
because of state and province medical society regulations, except under very unusual
circumstances. Half-way through the 22nd week, the fetus' lungs may be developed to
the point where it would have a miniscule chance to live on its own. State laws and
medical association regulations generally outlaw almost all abortions beyond 20 or 21

weeks gestation. "A baby born during the 22nd week has a 14.8 percent chance of
survival. And about half of these survivors are brain-damaged, either by lack of oxygen
(from poor initial respiration) or too much oxygen (from the ventilator). Neonatologists

predict that no baby will ever be viable before the 22 nd week, because before then the
lungs are not fully formed." Of course, if someone develops an artificial womb, then this
limit could change suddenly.

Fetal survival rate:

"Most babies at 22 weeks are not resuscitated because survival without major
disability is so rare. A baby's chances for survival increases 3-4% per day between 23
and 24 weeks of gestation and about 2-3% per day between 24 and 26 weeks of
gestation. After 26 weeks the rate of survival increases at a much slower rate because
survival is high already."

26 weeks or 6 months:

The fetus 14" long and almost two pounds. The lungs' bronchioles develop.
Interlinking of the brain's neurons begins. The higher functions of the fetal brain turn on
for the first time. Some rudimentary brain waves can be detected. The fetus will be able
to feel pain for the first time. It has become conscious of its surroundings. The fetus has
become a sentient human life for the first time.

7 months:

16" long and weighing about three pounds. Regular brain waves are detectable
which are similar to those in adults.

8 months:

18" long and weighing about 5 pounds.

9 months:

20" long and with an average weight of 7 pounds, a full-term fetus' is typically
born about this time.

Normal Placenta During Childbirth

Process of placental growth and uterine wall changes during pregnancy

The placenta grows with the placental site during pregnancy. During pregnancy
and early labor the area of the placental site probably changes little, even during uterine
contractions. 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 PLACENTA PREVIA

VII.
XI. Discharge Planning

AFTER YOU LEAVE:

Medicines:

• Keep a written list of the medicines you take, the amounts, and when and why
you take them. Bring the list of your medicines or the pill bottles when you see
your caregivers. Learn why you take each medicine. Ask your caregiver for
information about your medicine. Do not use any medicines, over-the-counter
drugs, vitamins, herbs, or food supplements without first talking to caregivers.

• Always take your medicine as directed by caregivers. Call your caregiver if you
think your medicines are not helping or if you feel you are having side effects. Do
not quit taking your medicines until you discuss it with your caregiver. If you are
taking medicine that makes you drowsy, do not drive or use heavy equipment.

• Tocolytics: Tocolytics are given to stop contractions if your baby is not ready to
be born. Contractions are when the muscles of your uterus tighten and loosen.
 • Antibiotics: Antibiotics may be given to help treat or prevent an infection caused
by germs called bacteria. Antibiotics may be needed before giving birth if you
have an infection in your uterus. You may also need antibiotics after your baby
has been born.

• Blood thinners: Blood thinners prevent clots from forming in your blood. They
may be given if you are at risk for deep vein thrombosis (DVT). DVT is a
condition where clots form inside your blood vessels.

Follow-up visits: Ask your caregiver when to return for a follow-up visit. If you have not
given birth yet, you may need to return for repeat ultrasounds. Keep all appointments.
Write down any questions you may have. This way you will remember to ask these
questions during your next visit.

Activity: If you have not given birth yet, you may need to rest more often. You may also
need to be on bed rest until your baby is born. If you have given birth, your caregiver
may also want you to limit your activity for a period of time. Talk to your caregiver about
what activities are OK for you.

Having sex: With placenta previa, you will not be able to have sex in your third
trimester. Even after your baby is born, you may need to avoid having sex for a period
of time. Talk to your caregiver about any questions you may have.

Safety plan: When you have placenta previa, you will need to have a safety plan until
your baby is born. Make sure you live, or are staying a short distance away from the
hospital. You will also need to make sure someone is ready to take you to the hospital if
needed. Talk to your caregiver about other ways to make sure you and your unborn
baby are safe.

CONTACT A CAREGIVER IF:

• You have abdominal cramps, pressure, or tightening.

• Your heart is beating faster then what is normal for you.

• You have a fever (high body temperature).

• You have any questions or concerns about your pregnancy, condition, or care.

SEEK CARE IMMEDIATELY IF:

• You have any bleeding from your vagina.

• You are having severe (very bad) abdominal pain or contractions.

• You have new and sudden chest pain or trouble breathing.

• You fainted or feel too weak to stand up.