JH CERILLES STATE COLLEGE

in consortium with

Western Mindanao State University

West Capitol Road, Balangasan District, Pagadian City

A CASE ANALYSIS ON PLACENTA PREVIA

In Partial Fulfillment

of the Requirements for NCM 109 A

MATERNAL AND CHILD NURSING

Submitted by

Aranding, Nicole

Catong, Warda

Submitted to

Odessa S. Bugarin, MAN

2nd Semester, A.Y. 2020

Introduction ……………………………………………………………………………… 1

Anatomy and Physiology ………………………………………….…………………….. 5

Review of Affected System ……………………………………………………………..14

Pathophysiology ………………………………………………………………………... 15

Laboratory and Diagnostic Results ………………………………….….………..…….. 16

Doctor’s Order ……………………………………………………….…….…….……. 18

Nursing Care Plan …………………………………………………………………..….. 20

Drug Study …………………………………………………………………...………… 25

Discharge Plan ………………………………………………………………................. 41

Nursing Management …………………………………………………………...…....…44

Medical Management……………………..…………………………………....………. 46

Reference ……………………………………………………………………....………. 47

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INTRODUCTION

Background of the Study

Throughout history, there has been uncountable issues about different diseases

that have unfortunately caught up with humans. This has happened quite frequently to an

extent that being educated, informed, and learning each process has become the a vital

part for the prosperity of every field of life. This accentuates the importance why all

people must have to pay attention on their everything that relates to them; Their

surroundings, communities, environments, and the continuous alterations in national and

global well-being and health conditions - especially their local health system. Being

informed to news reports and also being competent and efficient researchers are

significant for the development of wellness because, it is a key prerequisite and resource

for the development of the regulation of the impacts of both morbidity and mortality.

Such usually reach high levels due to the lack of information when it comes to

distinguishing and identifying the roots of health complications. Consequently, these lead

to the compromised well-being of individuals and communities and to a larger extent,

affect the co-existence beings. This scenario leads to the transformation and development

of this diseases resulting to death and calamitous situations.

Placenta previa is an obstetric complication that classically presents as painless

vaginal bleeding in the third trimester secondary to an abnormal placenta implantation

near or covering the internal cervical os. However, with the technologic advances in

ultrasonography, the diagnosis of placenta previa is commonly made earlier in

pregnancy.

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 Historically, there have been three defined types of placenta previa: complete,

partial, and marginal. More recently, these definitions have been consolidated into two

definitions: complete and marginal previa.

A complete previa is defined as complete coverage of the cervical os by the placenta. If

the leading edge of the placenta is less than 2 cm from the internal os, but not fully

covering, it is considered a marginal previa. Because of the inherent risk of hemorrhage,

placenta previa may cause serious morbidity and mortality to both the fetus and the

mother.

Physical Examination

Any pregnant woman beyond the first trimester who presents with vaginal

bleeding requires a speculum examination followed by diagnostic ultrasonography,

unless previous documentation confirms no placenta previa.

Because of the risk of provoking life-threatening hemorrhage, a digital

examination of the vagina is absolutely contraindicated until placenta previa is excluded.

Findings in a woman with placental previa may include profuse haemorrhage,

hypotension, tachycardia, soft and nontender uterus, and usually normal fetal heart tones.

Racial and Age-related Differences in Incidence

The significance of race in having a role in placenta previa is somewhat

controversial. Some studies suggest an increased risk among black and Asian women,

whereas other studies cite no difference.

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 Advanced maternal age has also been strongly associated with an increasing

incidence of placenta previa. The incidence of placenta previa after age 35 years reported

to be 2%. A further increase to 5% is seen after age 40 years, which is a 9-fold increase

when compared to females younger than 20 years.

Prognosis

Placenta previa complicates approximately 0.5% of all pregnancies.  Technologic

advances in ultrasonography have increased the early diagnosis of placenta previa, and

several studies have shown that a significant portion of these early diagnoses do not

persist until delivery. In fact, 90% of all placentas designated as “low lying” on an early

sonogram are no longer present on repeat examination in the third trimester.

However, maternal and fetal complications of placenta previa are well

documented. Preterm birth is highly associated with placenta previa, with 16.9% of

women delivering at less than 34 weeks and 27.5% delivering between 34 and 37 weeks

in a population-based study from 1989 to 1997.  There is a significant increase in the risk

of postpartum hemorrhage and need for emergency hysterectomy in women with placenta

previa. 

Symptoms

 Bright red, painless vaginal bleeding

In many women diagnosed with placenta previa early in their pregnancies, the placenta

previa resolves. As the uterus grows, it might increase the distance between the cervix

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and the placenta. The more the placenta covers the cervix and the later in the pregnancy

that it remains over the cervix, the less likely it is to resolve.

Causes

The exact cause of placenta previa is unknown.

Risk factors

Placenta previa is more common among women who: have had a baby, have scars on the

uterus (such as from previous surgery, including cesarean deliveries, uterine fibroid

removal, and dilation and curettage), had placenta previa with a previous pregnancy, are

carrying more than one fetus, are age 35 or older, are of a race other than white, smoke

and use cocaine

Complications

Maternal complications of placenta previa are summarized as follows:

hemorrhage,  including rebleeding (Planning delivery and control of hemorrhage is

critical in cases of placenta previa as well as placenta accreta, increta, and percreta),

higher rates of blood transfusion, placental abruption, preterm delivery, increased

incidence of postpartum endometritis, and having a mortality rate of (2-3%); in the US,

the maternal mortality rate is 0.03% (the great majority of which is related to uterine

bleeding and the complication of disseminated intravascular coagulopathy).

Complications of placenta previa in the neonate/infant are summarized as follows:

congenital malformations, fetal intrauterine growth retardation (IUGR) fetal anemia and

Rh isoimmunization, abnormal fetal presentation, low birth weight (< 2500 g), neonatal

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respiratory distress syndrome, jaundice, admission to the neonatal intensive care unit

(NICU), longer hospital stay, increased risk for infant neurodevelopmental delay

and sudden infant death syndrome (SIDS), and having a neonatal mortality rate: As high

as 1.2% in the United States.

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ANATOMY AND PHYSIOLOGY

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Female Reproductive System

The female reproductive system provides several functions. The ovaries produce

the egg cells, called the ova or oocytes. The oocytes are then transported to the fallopian

tube where fertilization by a sperm may occur. The fertilized egg then moves to the

uterus, where the uterine lining has thickened in response to the normal hormones of the

reproductive cycle. Once in the uterus, the fertilized egg can implant into thickened

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uterine lining and continue to develop. If implantation does not take place, the uterine

lining is shed as menstrual flow. In addition, the female reproductive system produces

female sex hormones that maintain the reproductive cycle.

During menopause, the female reproductive system gradually stops making the female

hormones necessary for the reproductive cycle to work. At this point, menstrual cycles

can become irregular and eventually stop. One year after menstrual cycles stop, the

woman is considered to be menopausal.

The female reproductive anatomy includes both external and internal structures. The

function of the external female reproductive structures (the genital) is twofold: To enable

sperm to enter the body and to protect the internal genital organs from infectious

organisms.

The External Structures of the Female Reproductive System

Labia Majora

The labia majora (“large lips”) enclose and protect the other external reproductive

organs. During puberty, hair growth occurs on the skin of the labia majora, which also

contain sweat and oil-secreting glands.

Labia Minora

The labia minora (“small lips”) can have a variety of sizes and shapes. They lie

just inside the labia majora, and surround the openings to the vagina (the canal that joins

the lower part of the uterus to the outside of the body) and urethra (the tube that carries

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urine from the bladder to the outside of the body). This skin is very delicate and can

become easily irritated and swollen.

Bartholin’s Glands

These glands are located next to the vaginal opening on each side and produce a

fluid (mucus) secretion.

Clitoris

The two labia minora meet at the clitoris, a small, sensitive protrusion that is

comparable to the penis in males. The clitoris is covered by a fold of skin, called the

prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the

clitoris is very sensitive to stimulation and can become erect.

The Internal Reproductive Organs

Vagina

The vagina is a canal that joins the cervix (the lower part of uterus) to the outside

of the body. It also is known as the birth canal.

The vagina is an elastic, muscular canal with a soft, flexible lining that provides

lubrication and sensation. The vagina connects the uterus to the outside world. The vulva

and labia form the entrance, and the cervix of the uterus protrudes into the vagina,

forming the interior end.

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 The vagina receives the penis during sexual intercourse and also serves as a

conduit for menstrual flow from the uterus. During childbirth, the baby passes through

the vagina (birth canal). The hymen is a thin membrane of tissue that surrounds and

narrows the vaginal opening. It may be torn or ruptured by sexual activity or by exercise.

Uterus (womb)

The uterus is a hollow, pear-shaped organ that is the home to a developing fetus.

The uterus is divided into two parts: the cervix, which is the lower part that opens into the

vagina, and the main body of the uterus, called the corpus. The corpus can easily expand

to hold a developing baby. A canal through the cervix allows sperm to enter and

menstrual blood to exit.

Each month in women of the reproductive age group the female body secretes

hormones that causes ovulation (release of an egg from the ovary) and periods

(menstruation). The lining of the uterus is called the endometrium. It is made of several

layers that include surface epithelium, blood vessels, glands and other tissues. Each

month the endometrium grows thicker to prepare for pregnancy. This is synchronized

with the ovulation. If a woman does not become pregnant, the top layers of the

endometrium with blood from the blood vessels are shed. These flow out through the

vagina in the monthly period. When a woman has her menopause the body stops

production of hormones that cause ovulation and periods.

Functions of the uterus include nurturing the fertilized ovum that develops into

the fetus and holding it till the baby is mature enough for birth. The fertilized ovum gets

implanted into the endometrium and derives nourishment from blood vessels which

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develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops

into a fetus and develops until childbirth.

Ovaries

The ovaries are small, oval-shaped glands that are located on either side of the

uterus. The ovaries produce eggs and hormones.

The ovaries form part of the female reproductive system. Each woman has two

ovaries. They are oval in shape, about four centimeters long and lie on either side of the

womb (uterus) against the wall of the pelvis in a region known as the ovarian fossa. They

are held in place by ligaments attached to the womb but are not directly attached to the

rest of the female reproductive tract, e.g. the fallopian tubes.

The ovaries have two main reproductive functions in the body. They produce

oocytes (eggs) for fertilization and they produce the reproductive hormones, estrogen and

progesterone. The function of the ovaries is controlled by gonadotrophin-releasing

hormone released from nerve cells in the hypothalamus which send their messages to the

pituitary gland to produce luteinizing hormone and follicle stimulating hormone. These

are carried in the bloodstream to control the menstrual cycle.

The ovaries release an egg (oocyte) at the midway point of each menstrual cycle.

Usually, only a single oocyte from one ovary is released during each menstrual cycle,

with each ovary taking an alternate turn in releasing an egg. A female baby is born with

all the eggs that she will ever have. This is estimated to be around two million, but by the

time a girl reaches puberty, this number has decreased to about 400,000 eggs stored in

her ovaries. From puberty to the menopause, only about 400–500 eggs will reach

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maturity, be released from the ovary (in a process called ovulation) and be capable of

being fertilized in the fallopian tubes/uterine tube/oviduct of the female reproductive

tract.

Fallopian Tubes

These are narrow tubes that are attached to the upper part of the uterus and serve

as pathways for the ova (egg cells) to travel from the ovaries to the uterus. Fertilization of

an egg by a sperm normally occurs in the fallopian tubes. The fertilized egg then moves

to the uterus, where it implants to the uterine lining.

The fallopian tube, also known as the oviduct or uterine tube, is responsible for

carrying the egg to the uterus. The fallopian tube has finger-like branches, called

fimbriae, which reach out into the pelvic cavity and pick up the released egg. The egg is

then brought into the fallopian tube where it will travel to the uterus. Not only does the

fallopian tube collect and transport the egg, it is also the location where fertilization

occurs. Sperm cells that enter the reproductive system through the vagina travel to the

fallopian tube where they fertilize the egg. The fertilized egg then continues its journey to

the uterus, where it will implant and safely develop into a baby.

Fetus in Utero

Amniotic Sac

A thin-walled sac that surrounds the fetus during pregnancy. The sac is filled

with liquid made by the fetus (amniotic fluid) and the membrane that covers the fetal side

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of the placenta (amnion). This protects the fetus from injury. it also helps to regulate the

temperature of the fetus.

Anus

The opening at the end of the anal canal.

Cervix

The lower part of the uterus that extends into the vagina. The cervix is made up of

mostly fibrous tissue and muscle. It is circular in shape.

The cervix is the lower third portion of the uterus. It forms the neck of the uterus

and opens into the vagina (which is also called the endocervical canal). It is a little over

an inch long, and just about an inch wide. Made up largely of muscle tissue, it plays a

minor role except during pregnancy or if a medical problem emerges. Because of its

location between the uterus and the vagina, the cervix is rarely seen. To see one's own

cervix requires a mirror and bright light. It is possible to feel the cervix with your finger;

if you do so you'll notice that it changes texture over the course of your cycle.

The narrow opening of the cervix is called the os. The cervical os allows

menstrual blood to flow out from the vagina during menstruation. The cervix is covered

by the epithelium which is made of a thin layer of cells. Epithelial cells are either

squamous or columnar (also called glandular cells). Squamous cells are flat and scaly,

while columnar cells appear, as indicated by their name, column-like.

The cervix produces cervical mucus. Cervical mucus changes in consistency over

the course of your menstrual cycle. At the point of greatest fertility, the cervix produces a

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good deal of clear mucus which helps to promote pregnancy. During pregnancy, the

mucus produced by the cervix thickens to create a cervical "plug." This shields the

growing embryo from infection. The cervical plug thins and is expelled when birth is

imminent.

During menstruation, the cervix opens a small amount to permit passage of

menstrual flow. During pregnancy, the cervical os closes to help keep the fetus in the

uterus until birth. Another important function of the cervix occurs during labor when the

cervix dilates (widens), to allow the passage of the fetus from the uterus to the vagina.

Fetus

An unborn baby from the 8th week after fertilization until birth.

Placenta

An organ shaped like a flat cake. It only grows during pregnancy. The fetus takes

in oxygen, nutrients, and other substances from the placenta and gets rid of carbon

dioxide and other wastes.

The placenta is an organ that develops in your uterus during pregnancy. This

structure provides oxygen and nutrients to your growing baby and removes waste

products from your baby's blood. The placenta attaches to the wall of your uterus, and

your baby's umbilical cord arises from it. The organ is usually attached to the top, side,

front or back of the uterus. In rare cases, the placenta might attach in the lower uterine

region (placenta previa).

Umbilical Cord

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 A rope-like cord connecting the fetus to the placenta. The umbilical cord contains

2 arteries and a vein. It carries oxygen and nutrients to the fetus and waste products away

from the fetus.

Uterus

The uterus, or womb, is a hollow, pear-shaped organ ln a woman's lower stomach

between the bladder and the rectum. It sheds its lining each month during menstruation.

A fertilized egg (ovum) becomes implanted in the uterus, and the fetus develops.

Vagina

The part of the female genitals behind the bladder and in front of the rectum that

forms a canal. This extends from the uterus to the vulva.

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Review of Affected System

The placenta is a structure that develops inside your uterus during pregnancy,

providing oxygen and nutrition to and removing wastes from your baby. The placenta

connects to your baby through the umbilical cord. In most pregnancies, the placenta

attaches at the top or side of the uterus.

Placenta previa occurs when a baby's placenta partially or totally covers the

mother's cervix — the outlet for the uterus. Placenta previa can cause severe bleeding

during pregnancy and delivery.

If you have placenta previa, you might bleed throughout your pregnancy and

during your delivery. Your health care provider will recommend avoiding activities that

might cause contractions, including having sex, douching, using tampons, or engaging in

activities that can increase your risk of bleeding, such as running, squatting, and jumping.

You'll need a C-section to deliver your baby if the placenta previa doesn't resolve.

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Pathophysiology

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Doctor’s Order

• Tests:

- Ultrasound scan

- Feeling the mother’s belly to establish the baby’s position (the baby is sideways or

presenting bottom-first in around one in three cases of placenta previa).

• Laboratory: CBC, Kleihauer-Betke test, Maternal Blood Type and Antibody screen,

APTT,PT, Fibrin degradation products – to rule out DIC (disseminated intravascular

coagulation)

• Determining the degree of placenta previa present, gestational age of the fetus and

presence and amount of vaginal bleeding.

• Digital vaginal examinations should be strictly avoided

• Activities:

- Bed rest.

• Close monitoring, such as using a fetal monitor and regularly checking the mother’s

vital signs (for example, blood pressure).

• Blood transfusion for the mother.

• Medications:

- Tocolytic agent

- Corticosteroids

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- Iron and Folate

• Notify Labor and Delivery that patient is being transported to the Delivery Room

Nursing Implications: Since the patient and fetus has an increased risk for severe

complications the management consists of pharmacological approach to lessen the risk

for complications of the patient. Tocolytic agents are given to decrease uterine irritability.

Corticosteroids are administered to enhance fetal pulmonary maturity if the risk of pre-

term birth is imminent. Iron and Folate are part of the medication as a safety margin in

the event of bleeding. Blood transfusion is also for the event of the occurrence of

hemorrhage. Vaginal examinations are avoided to prevent the exacerbation of the

condition.

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Discharge Plan

Objectives

 To promote positive coping.

 To prevent further complications.

 MEDICATIONS

Instructed patient and/or significant others to timely follow the ordered

prescription and to strictly monitor the right time, dose, frequency and route in giving

the medications.

Name of Breakfast Lunch Super At bedtime No. of

drugs days
Before After Before After Before After
Ferrous

Sulfate
60– 100 mg 9 am 9 pm

elemental

iron 2x/day
Continuing management plan/ referrals to other facilities (RHU/ Clinics)

 EXERCISE/ACTIVITY

Type of activity allowed:

• Low-intensity exercise

• Bed rest

Type of activity avoided:

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• Avoiding any activity that triggers uterine contractions or irritates the cervix, such as

sexual intercourse or orgasms.

• Avoiding moderate and strenuous exercise, heavy lifting (eg, more than approximately

20 pounds), or standing for prolonged periods of time (eg, >4 hours).

 TREATMENT

• Instruct the patient to on bedrest until your baby is born.

• Encourage the patient to follow up with obstetrician to return for repeat ultrasounds.

 ENVIRONMENT

• Encourage patient to maintain the cleanliness of the room.

 HEALTH TEACHING

• Encourage patient to do not do any heavy activity.

• Tell patient to immediately need to call the doctor or nurse call line right away, its start

bleeding.

• Instruct patient to do not put anything, such as tampons or douches, into the vagina. Use

pads if there are bleeding, and call your doctor or nurse call line.

• Encourage patient to be sure to make and go to all follow up care appointments.

 DIET

• Advised patient to take energy and iron rich food like green leaf vegetables.

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• Advised patient to avoid unsaturated fats like ghee and butter.

 SPIRITUAL AND PSYCHOLOGICAL NEEDS

• Encourage family support and patient is given a parental counseling to prevent stress

and helping them to create a positive first bond with their babies.

NURSING MANAGEMENT

ACTUAL IDEAL

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 Monitor Vital Signs  Monitor Vital Signs

 BP, Respiratory rate, Pulse rate,  BP, Respiratory rate, Pulse rate,

Temperature, Level of Activity Temperature, Level of Activity

 Promoted Adequate Fluid Intake  Promote Adequate Fluid Intake

 Encouraged significant other to  Encourage mother to increase

increase breastfeeding breastfeeding activity

 IV fluids regulated  IV fluids regulation

 Monitored the output stool and  Monitoring of the output stool and urine

urine through weighing

 Promoted bed rest  Encourage bed rest and safety

 Educated the significant other to  Encourage Mother’s patient to avoid baby

let the patient rest from from any activity

diversional activities such as  Eliminate Noise and Distractions

smartphones during nap time  Prevent from excessive Clothing or Bed

 Instructed and helped SO in Linens

changing patient’s loose  Elevated position

clothing  Air ventilation

 Provided pillows on both sides  Breastfeeding

of the patient and elevated the  Introduced Light Food

bed  Monitor Patient Well-being

 Provided air ventilation  Limiting of visitors

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 improvements from the disease  Promote Adequate Nutrition

 Educated SO the importance of  Importance of breastfeeding

complete bed rest  Management of the disease

 Raised the side rails  Environmental Sanitation

 Proper Hygiene

 Provided health education on  Risk Factors for infection

Adequate Nutrition  Effects of polluted air

 Benefits of breastfeeding  Provide information about the disease process,

 Importance of good sanitation prognosis, and treatment to the SO

and cleanliness in the  Promote safety and comfort

 Explained a brief definition of the

disease

 Provided safety and comfort

MEDICAL MANAGEMENT

ACTUAL IDEAL
 Medications:  Medications:

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  Magensium Sulfate  Dexamethasone acetate

 Terbutaline  Magensium Sulfate

 Ferrous Sulfate  Terbutaline

 Ferrous Sulfate

 Monitor any unusualties:  Monitor any unusualities:

 Ultrasound  Ultrasound

 Monitoring for invasive  Monitoring for invasive

placentations placentations

 Preparing for surgical  Preparing for surgical

interventions interventions

 Controlling blood loss  Controlling blood loss

 B-lynch or parallel vertical  B-lynch or parallel vertical

compression sutures compression sutures

 Uterine artery ligation  Uterine artery ligation

(O’Leary Stitch) (O’Leary Stitch)

 Hypogastric Artery  Hypogastric Artery

Ligation Ligation

 Hysterectomy  Hysterectomy

REFERENCES

Bakker, R. et al. (2018). Medscape. Placenta Previa. Retrieved from URL

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Mayo Clinic. (2018). MayoClinic.com. Placenta Previa. Retrieved from URL
https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-
causes/syc-20352768
Feosol. (2018). Feosol.com. Iron Absorption. Retrieved From URL
https://www.feosol.com/about-iron/iron-absorption/
Kahty. (2010). Scribd.com. Placenta Previa Pathophysiology. Retrieved from URL
https://www.scribd.com/doc/27928980/Placenta-Previa-Pathophysiology

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