Placenta Previa Nursing Care Plans

Painless, bright red vaginal bleeding in the third trimester is placenta previa until you prove otherwise. The placenta has implanted in the lower uterine segment instead of the upper fundus, and as that segment thins and the cervix starts to dilate late in pregnancy (around week 30), the placenta cannot stretch to keep up. A portion loosens, vessels tear, and the patient bleeds. The bleed is painless because nothing is being torn out of muscle the way it is in an abruption.

Previa comes in four degrees: low-lying (implanted in the lower segment), marginal (the edge reaches the cervical os), partial (it covers part of the os), and total (it covers the os completely). Risk climbs with high parity, advanced maternal age, prior cesarean births, prior uterine curettage, and multiple gestation.

The two rules that govern everything you do: no vaginal exams until previa is ruled out, and have blood and a cesarean setup ready before you ever need them. A digital exam can dislodge the placenta and turn a stable patient into a hemorrhage in seconds.

Nursing Care Plans and Management

Care centers on close monitoring of maternal vitals, uterine activity, and vaginal bleeding, with bed rest to limit bleeding episodes and emotional support and teaching for a frightened patient and family.

Nursing Problem Priorities

1. Monitor maternal vital signs and uterine activity.
2. Assess and manage vaginal bleeding.
3. Maintain maternal and fetal perfusion and hemodynamic stability.
4. Prevent infection.
5. Support the patient and family, and teach warning signs.

Nursing Assessment

Assess for the following subjective and objective data:

• Painless vaginal bleeding, typically third trimester
• Bright red blood
• Soft, relaxed, nontender uterus on palpation
• Malpresentation, such as breech
• Decreased fetal movement or fetal distress
• Anemia signs: fatigue, weakness
• Shock signs in severe cases: lightheadedness, dizziness, tachycardia

Nursing Goals

Goals and expected outcomes may include:

• The patient maintains fluid volume at a functional level, shown by adequate urine output and stable vital signs.
• The patient shows no active bleeding and stays hemodynamically stable.
• The patient demonstrates behaviors that support circulation and adequate perfusion.
• The patient stays free of infection and can name steps to prevent it.

Nursing Interventions and Actions

1. Preventing Hemorrhage

Previa bleeding is an emergency. The open vessels of the uterine decidua put the patient at risk for hemorrhage, and the risk continues after birth: the lower segment where the placenta sat has fewer muscle fibers than the fundus, so it contracts weakly and does not clamp down on those vessels the way the upper uterus would.

Assess the color, odor, consistency, and amount of vaginal bleeding. Inspect the perineum and estimate the current rate of loss. Previa bleeding is usually abrupt, painless, bright red, and sudden. It can be provoked by intercourse, a vaginal exam, or labor, and sometimes there is no identifiable trigger.

Monitor vital signs. Get a baseline, then reassess blood pressure every 5 to 15 minutes, or run a continuous electronic cuff. Hypotension, tachycardia, and tachypnea signal hypovolemic shock.

Assess hourly intake and output. Track urine output as often as every hour. Adequate output tells you blood volume is still perfusing the kidneys.

Assess the abdomen for tenderness or rigidity; if present, measure girth at the umbilicus at a set interval. A tender or rigid uterus points away from previa toward rupture or abruption. Serial girth measurements tell you whether a concealed bleed is expanding.

Monitor fetal heart rate and uterine activity continuously with external monitors only. Do not place an internal fetal or uterine monitor; it can provoke hemorrhage. Fetal hypoxia develops when a large area of placenta separates and oxygen transfer drops.

Weigh perineal pads to estimate blood loss. Weigh before and after use and subtract. One gram of weight gain equals roughly 1 mL of blood.

Avoid vaginal examinations. A digital vaginal exam is absolutely contraindicated until previa is excluded, because it can provoke life-threatening hemorrhage. Keep instruments away from the cervix. If previa is suspected and ultrasound is unavailable, a provider may perform an exam only with a double setup ready for both vaginal and cesarean birth.

Position the patient on bed rest in a left side-lying position, hips elevated if ordered. Left lateral positioning takes pressure off the placenta and cervical os and improves placental perfusion.

Review ultrasound and laboratory results. See Laboratory and Diagnostic Procedures.

Perform an Apt or Kleihauer-Betke test as ordered. See Laboratory and Diagnostic Procedures.

Give supplemental oxygen as ordered by face mask or nasal cannula at 10 to 12 L/min. Keep oxygen equipment at the bedside in case fetal heart tones show distress (bradycardia, tachycardia, late or variable decelerations). Oxygen raises the saturation of the hemoglobin she has left.

Start IV fluids as ordered. Use a large-gauge catheter so the same line can carry blood. Run Ringer's lactate or normal saline rapidly if shock is present. Reduce the rate to 3 mL/min once the pulse slows to under 100 beats/min and systolic BP rises to 100 mm Hg or higher.

Administer tocolytics as prescribed. See Pharmacologic Management.

Administer blood and blood products as indicated. See Pharmacologic Management.

Prepare for vaginal or cesarean birth. Vaginal birth is safest for the infant when feasible. If the previa covers under 30% of the os on ultrasound, vaginal birth may be possible. If it covers over 30% and the fetus is mature, cesarean is usually safest for both.

2. Promoting Effective Cardiac Function and Tissue Perfusion

With large blood loss the heart pumps faster to compensate, but moves less blood with each beat. Watch for the body's compensation to fail.

Monitor vital signs, especially blood pressure. Baroreceptors sense a falling pressure and fire the sympathetic system to raise heart rate and constrict vessels. A rising pulse with a still-normal pressure is an early warning, not reassurance.

Monitor intake and output. Oliguria and increased thirst are signs of impending hemorrhagic shock. After a bleed the kidneys retain sodium and water and release renin, driving angiotensin II and aldosterone to defend volume.

Palpate peripheral pulses for rate, regularity, amplitude, and symmetry. Differences reflect how altered cardiac output is reaching the periphery.

Watch for changes in level of consciousness. Confusion, disorientation, and restlessness point to falling cerebral perfusion.

Keep the environment calm and quiet, and schedule uninterrupted rest. Reducing stress limits catecholamine release and myocardial workload, and rest prevents cardiovascular strain.

Teach relaxation and deep breathing. These give the patient a measure of control and release tension. Breathing techniques learned in prenatal classes work well here.

Elevate the legs or use left side-lying positioning for hypotension. Raising the legs or rolling a hypotensive pregnant patient onto her left side displaces the fetus off the inferior vena cava and improves circulation. Do not use Trendelenburg; it raises aspiration risk and does not improve cardiopulmonary performance.

Order blood typing and cross-matching and review labs. See Laboratory and Diagnostic Procedures.

Give high-flow supplemental oxygen as prescribed. Provide ventilatory support if needed, but avoid excessive positive-pressure ventilation, which is harmful in hypovolemic shock.

Start two large-bore IV lines and give isotonic crystalloid. A short, large-caliber catheter beats a long thin one. Use lactated Ringer's or normal saline, give a 1 to 2 liter bolus, and reassess the response.

Transfuse as ordered. If the patient is markedly hypotensive, start type O blood with crystalloid. Transfuse packed RBCs if she stays unstable after 2000 mL of crystalloid. Warm blood and fluids when possible. Draw a type and cross before transfusing. Large-volume transfusion leads to coagulopathy, so give FFP and platelets when clotting fails.

Weigh perineal pads and inspect for ongoing loss. A weakened clotting mechanism raises the risk of postpartum hemorrhage.

Assess general appearance and mental status. Pale, ashen, diaphoretic skin and a confused or agitated patient signal worsening shock. Pale conjunctivae suggest chronic anemia.

Assess the lower extremities for erythema, edema, and calf tenderness. Surgery, anesthesia, and decreased activity raise the risk of thrombus formation.

Auscultate bowel sounds. Reduced splanchnic blood flow can shut down peristalsis.

Turn the patient often and encourage coughing, deep breathing, and an incentive spirometer. These prevent secretion stasis and atelectasis. Leg lifts and toe wiggling improve venous return on bed rest.

Avoid high Fowler's, pressure under the knees, and crossing the legs. These pool blood in the pelvis and extremities and raise thrombus risk. A bed cradle can lift bedclothes off an affected leg.

Teach foot and leg exercises and ambulate as soon as able. Movement drives circulation and prevents stasis. After a cesarean, get her up as ordered.

Encourage adequate fluids, about 6 to 8 glasses a day. Staying hydrated improves circulation and lowers blood viscosity.

Use range-of-motion exercises and sequential compression devices on a schedule. Both stimulate lower-extremity circulation and cut the risk of venous stasis.

Give Rho(D) immune globulin (RhoGAM) as indicated. See Pharmacologic Management.

3. Preventing Infection

A patient with previa is more prone to infection after birth because vaginal organisms reach the placental site easily, and that site is a good growth medium.

Watch for signs and symptoms of infection. Take the temperature every 2 to 4 hours, more often if elevated. Sustained fetal tachycardia over 160 beats/min for 10 minutes or longer can also signal infection. The patient may look ill, hypotensive, diaphoretic, with cool, clammy skin.

Assess amniotic fluid for color, clarity, and odor. Cloudy, yellow, or foul fluid suggests infection. Green (meconium) staining suggests fetal compromise.

Use hand hygiene and aseptic technique for all care. Anything introduced into the birth canal during labor, birth, and the postpartum period should be sterile. Follow standard precautions.

Teach proper perineal care. Wipe front to back to avoid bringing E. coli forward from the rectum. Each patient keeps her own perineal supplies.

Tell the patient to avoid douching. Douching disrupts vaginal flora and predisposes to pelvic inflammatory disease, bacterial vaginosis, and ectopic pregnancy.

Obtain amniotic fluid for culture and diagnostics. Culture is the gold standard for intraamniotic infection. Faster results come from Gram stain, glucose level, white cell count, and leukocyte esterase.

Prepare the patient for amniocentesis. It is the only invasive procedure that confirms acute chorioamnionitis, and it carries a risk of rupturing intact membranes.

Administer antibiotics as prescribed. See Pharmacologic Management.

Have parents watch the infant for effects of antibiotic therapy. White plaques or thrush in the infant's mouth can develop when maternal antibiotic passes into breast milk and overgrows fungal organisms.

4. Medications and Pharmacologic Support

Drug therapy aims to stop or manage bleeding and stabilize mother and fetus.

Tocolytics (magnesium sulfate, terbutaline, or nifedipine). Consider tocolysis with minimal bleeding and extreme prematurity to buy time for antenatal corticosteroids. Evidence suggests tocolytics can prolong the pregnancy and improve birth weight without harming mother or fetus.

Rho(D) immune globulin (RhoGAM). Give to Rh-negative mothers with significant vaginal bleeding to prevent sensitization and Rh antibody formation.

Blood products (packed RBCs or fresh frozen plasma). With significant bleeding, rapid replacement is the priority. Activate the massive transfusion protocol to stabilize hemodynamics with a fast supply of products.

Antibiotics. IV antibiotics treat infection; common choices are ampicillin, gentamicin, and third-generation cephalosporins such as cefixime. Stress finishing the full course if therapy continues at home.

5. Diagnostic and Laboratory Procedures

Ultrasound. Routine first- and second-trimester sonography identifies previa early. Repeat a followup sonogram at 28 to 32 weeks to look for persistent previa. Use transvaginal ultrasound to confirm placental location.

CBC and coagulation profile. Hemoglobin, hematocrit, PT, PTT, fibrinogen, platelet count, type and cross, and antibody screen establish baselines, detect a clotting disorder, and ready blood for replacement.

Kleihauer-Betke test. When fetal-maternal transfusion is a concern, this detects whether blood is fetal or maternal in origin and guides RhoGAM dosing in Rh-negative mothers.

Blood typing and cross-matching. Typing flags incompatibilities; cross-matching tests donor and recipient compatibility to minimize transfusion reactions.

ABGs, liver and kidney function tests, and serum electrolytes. Poor perfusion can infarct organ tissue and release intracellular enzymes. Watch sodium for shifts driven by vasopressin and aldosterone. Hemoglobin, hematocrit, and coagulation studies track circulating volume and the effect of your interventions.