Abruptio Placentae Nursing Care & Management

Abruptio placentae, or placental abruption, is an obstetric emergency: the placenta detaches from the uterine wall before delivery. It can cause major maternal hemorrhage and threaten the fetus fast. Early recognition, large-bore access, and tight monitoring are what protect both patients.

What is Abruptio Placentae?

Abruptio placentae (placental abruption) is the premature separation of a correctly implanted placenta late in pregnancy.

Pathophysiology

The placenta is implanted in the correct location. For an unknown reason it suddenly begins to separate, causing bleeding. This separation occurs late in pregnancy and accounts for 10% of perinatal deaths.

Risk Factors

• High parity. Multiple prior births raise the risk.
• Short umbilical cord. Can pull the placenta loose, especially with trauma.
• Advanced maternal age. Women over 35 years old are at higher risk.
• Direct trauma. Any abdominal trauma can separate the placenta.
• Chorioamnionitis. Infection of the fetal membranes and fluid that predisposes to premature separation.

Types

Graded by the degree of placental separation.

• Grade 0. No sign of separation; slight separation is diagnosed after birth.
• Grade 1. Minimal separation with vaginal bleeding, no change in fetal vital signs.
• Grade 2. Moderate separation with evident fetal distress; uterus hard and painful on palpation.
• Grade 3. Extreme separation; maternal shock and fetal death are imminent without intervention.

Signs and Symptoms

Catch these before the abruption progresses to a critical stage.

• Sharp, stabbing pain. Pain in the upper uterine fundus as separation begins.
• Heavy bleeding. Follows separation. External bleeding occurs when the placenta separates from the edges; internal bleeding occurs when it separates from the center and blood pools underneath.
• Tense, rigid uterus. The Couvelaire uterus: board-like and hard, often without visible bleeding.

Diagnostic Tests

• Hemoglobin level and fibrinogen level. Performed to rule out disseminated intravascular coagulation.

Medical Management

• Intravenous therapy. Once bleeding starts, the physician orders a large-gauge catheter to replace fluid losses.
• Oxygen inhalation. Delivered by face mask to prevent fetal anoxia.
• Fibrinogen determination. Repeated several times before birth to detect DIC.

Surgical Management

• Cesarean delivery. When birth is imminent, cesarean is the safest route.
• Hysterectomy. If the woman develops DIC, hysterectomy prevents exsanguination.

Nursing Management

Nursing Assessment

• Assess for signs of shock, especially with heavy bleeding.
• Determine whether the bleeding is external or internal.
• Monitor contractions if separation occurs during labor.
• Obtain baseline vital signs.
• Note when the bleeding began, the amount and kind, and any interventions done before admission.
• Assess the quality of pain.

Nursing Diagnosis

• Deficient fluid volume related to bleeding during premature placental separation.

Nursing Interventions

• Position the woman lateral, not supine, to avoid pressure on the vena cava.
• Monitor fetal heart sounds.
• Monitor maternal vital signs for baseline data.
• Avoid vaginal and abdominal examinations to prevent further injury to the placenta.

Evaluation

Maternal vital signs are within normal range, especially blood pressure. Urine output stays above 30mL/hr. Bleeding is absent or minimal. The uterus is no longer tense and rigid. Fetal heart sounds are within normal range.