MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
MCN 4
PLACENTA PREVIA
- implantation of the placenta in the lower uterine segment
CLASSIFICATION
 LOW- LYING
- The placenta encroaches the lower segment of the uterus but does infringe on the cervical os
 MARGINAL
- the placenta touches, but does not cover the top of the cervix
 PARTIAL
- The placenta partially covers the top of the cervix
 COMPLETE
- The placenta completely covers the top of the cervix
PREDISPOSING FACTOR
 Multiparity 80%
 Advanced maternal age (older than 35 yrs old in 33% cases)
 Multiple gestation
 Previous cesarean section
 Uterine incisions
 Prior placenta previa (12x greater)
ASSESMENT
 Painless, bright red vaginal bleeding after 7th month of pregnancy
 Soft, non-tender abdomen; relaxes between contractions
 FHR stable and within normal limits unless maternal shock is present
 Signs of infection may be present
DIAGNOSIS
Transabdominal ultrasound shows location of the placenta and confirms suspicious of placenta
previa
NURSING INTERVENTIONS
 No admission vaginal examination; if a vaginal examination is to be performed, double set-ups
(vaginal and cesarean) must be provided
 Take and record VS, assess bleeding, and maintain a perineal pad count. Weigh perineal pads
before and after use to estimate blood loss
 Assess for shock and administer oxygen as indicated
 Monitor FHR continuously
 Enforce strict bed rest to minimize risk to fetus (side-lying)
 Monitor Hgb and Hct; prepare for cesarean if bleeding persists
 Administer IV therapy and/or blood replacement
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
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CREATED BY: JERLYN R.
Prepare client for ambulation and discharge (may be within 48 hours of last bleeding episode)
Instruct client to return to hospital if bleeding recurs to avoid intercourse until after birth
Proper handwashing and toileting to prevent infection
ABRUPTIO PLACENTA
- premature separation of a normally implanted placenta after the 20 th week of pregnancy, typically with
severe hemorrhage
ETIOLOGY
- causes is unknown
 RISK FACTORS INCLUDE:
- Uterine anomalies
- Multiparity
- Preeclampsia
- Previous cesarean section
- Renal or vascular disease
- Trauma to the abdomen
- Previous third trimester bleeding
- Abnormally large placenta
- Short umbilical cord
TYPES OF ABRUPTIO PLACENTA
 CONCEALED (CENTRAL) HEMORRHAGE
- Placenta separates centrally
- large amount of blood accumulates under the placenta
 EXTERNAL (MARGINAL) HEMORRHAGE
- Placenta separates marginally
- blood flows under the membranes and through the cervix
ASSESSMENT
• Intense localized uterine pain, with or without vaginal bleeding
- Concealed if center of the placenta separates and margins are intact; darkred blood may/may not be evident with partially detached placenta at margins
• Uterus firm to boardlike, with severe continuous pain
• Uterine contractions
• Uterine outline possibly enlarged or changing shape
 FHR present or absent (hyperactivity then cessation of fetal movements
ASSOCIATED FINDINGS
Severe abruption placenta may produce such complication:
 Renal failure
 Disseminated intravascular coagulation
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
 Maternal and fetal death
 Hypofibrogenemia
THERAPEUTIC INTERVENTIONS
LABORATORY AND DIAGNOSTIC FINDINGS
-Ultrasound may be able to identify the extent of abruptio.
TREATMENT
• Replacement of blood loss
• WITH MODERATE OR SEVERE SEPARATION OR MATERNAL/FETAL DISTRESS: Emergency
cesarean birth
• WITH MILD SEPARATION WITHOUT FETAL DISTRESS AND IN THE PRESENCE OF SOME
CERVICAL EFFACEMENT AND DILATION: Induction of labor maybe attempted
NURSING INTERVENTIONS
• continue evaluate maternal and fetal physiologic status, particularly:
 Vital sign
 Bleeding
 Electronic fetal and maternal monitoring tracings
 Decreasing urine output
 Never perform vaginal or rectal exam or take any action that would stimulate uterine activity.
• If bleeding could not be stopped with bedrest emergency C-section Is indicated
• Maintain in bedrest in left lateral recumbent.
 Assess for shock.
 Assess abdominal pain, tonicity of abdomen, perineal pads if bleeding evident, Hgb & Hct levels
 Administer IV therapy and/or blood replacement.
 Observe for signs of DIC such as seepage
of blood from IV site or incisional
DIFFERENCE BETWEEN ABRUPTIO PLACENTA AND PLACENTA PREVIA
CHARACTERISTICS
ABRUPTIO PLACENTA
PLACENTA PREVIA
rd
ONSET
3 trimester
3rd trimester
th
(common 8 month)
BLEEDING
May be concealed, external dark
Mostly external, small to profuse
hemorrhage, or bloody amniotic fluid
in amount, bright red
PAIN & UTERINE
Usually present; irritable uterus,
Usually absent; soft uterus
TENDERNESS
progresses to board-like consistency
FHR
May be irregular or absent
Usually normal
PRESENTING PART
May or not be engaged
Usually engaged
SHOCK
Moderate to severe depending on the
Usually not present unless
extent of hemorrhage
bleeding is excessive
DELIVER
Immediate delivery, usually by C
Delivery maybe delayed
section
depending on size of fetus and
amount of bleeding
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
PREGNANCY INDUCED HYPERTENSION (PIH)
COMPLICATIONS
H- hemolysis
E- elevated
L- liver enzymes
L-low
P- platelet
Inc. response to normal conc of
endogenous vasopressin
Vasospasm
Shifting of fluid from
intravascular to
interstitial
Kidneys
Vascular effect
Decrease glomerular
filtration 25%
vasoconstriction
Increase serum conc.
Of uric acid
Decrease circulation
Edema
Decrease organ
perfusion
Decrease urine output
Increase BP
+ protein

If mother has PIH
Delay production of
phosphatidyl GLYCEROL
Intermediate component in the metabolism
of CHO & lipids
Decrease in surfactant
production
2 phospholipids
Increase in RDS
PROPERTY OF JEFEM <3
lecithin
sphingo
MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
PREGNANCY- INDUCED HYPERTENSION
-A disorder occurring during pregnancy characterized by a triad of symptoms: edema, hypertension,
and proteinuria occurring after the 20th to 24th week of gestation and disappearing 6 weeks after birth.
INCIDENCE
 Occurs primarily in primiparas below 17 years and above 35 years of age
 Multiparity
 Chronic hypertension
 Diabetes mellitus
 Severe nutritional deficiencies
 Multiple pregnancy
 Trophoblastic disease
COMMON TYPES OF PIН
GESTATIONAL HYPERTENSION
• Increased BP during pregnancy that resolves within 6 weeks after birth • No edema or proteinuria is present
MILD PREECLAMPSIA
 ELEVATED BP - A systolic increase of 30 mm Hg and diastolic increase of 15 mm Hg or above
baseline X 2 at least 6 hours apart or BP above 140/90
 WEIGHT GAIN - More than 1lb/wk in the third trimester
 EDEMA - Hands and in front of tibia (1+ or 2+)
 PROTEINURIA - Equal/> 1 gm/24 hr (1+ or 2+ on qualitative testing)
SEVERE PREECLAMPSIA
All Changes associated with mild preeclampsia, plus
 ELEVATED BP - Systolic equal/> 160 mm Hg or diastolic equal/> 110 mm Hg X 2 at least 6 hours apart
with client restricted to bedrest
 EDEMA - Generalized edema, puffiness of face (3+ or 4+)
 PROTEINURIA - Equal/> 5 g/24 hour (3+ or 4+ on qualitative testing)
 HYPERREFLEXIA - 4+, CLONUS
 OLIGURIA - Equal/< 400-500 ml
 OTHER
Severe headaches, dizziness, blurred vision, retinal arteriolar spasms, spots before eyes, nausea and vomiting,
epigastric pain, irritability, pulmonary edema, elevated liver enzymes, hemolysis
ECLAMPSIA
All changes associated with preeclampsia, plus tonic and clonic
convulsions (grand mal seizure), cerebral hemorrhage, liver rupture, and coma.
HELLP SYNDROME (HEMOLYSIS, ELEVATED LIVER ENZYMES, LOW PLATELET COUNT)
 Occurs with little warning and often with no previous signs of PIH
 RUQ pain occurs in 90% of women; proteinuria may occur
 Liver enzymes are elevated; platelets and RBCs are low
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
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CREATED BY: JERLYN R.
Blood smear reveals broken cells Schistocytes or burr cells)
Occurs after 28 gestation or 48-72 hours after birth
SIGNS OF WORSENING PREECLAMPSIA
Rapid rise in BP
 Rapid weight gain
 Generalized edema
 Increased proteinuria
 Epigastric pain, marked hyperreflexia, and severe headache, which usually precede convulsions in
eclampsia
 Visual disturbances
 Oliguria (<120 ml in 4 hours)
 Irritability
 Severe nausea and vomiting
SIGNS OF WORSENING PREECLAMPSIA
BLOOD CHEMISTRY
• Rise in Hct
• Elevated uric acid and BUN
• Elevated serum creatinine
• Decrease in RBCs, platelets
QUALITATIVE URINALYSIS
• Increase in albumin output (proteinuria)
• Decrease in urinary output (oliguria)
Question:
What is the most common aura associated with Eclamptic clients?
Answer:
epigastric pain
GUIDELINES FOR PREVENTION OF PΙΗ
 Sound nutrition counseling during pregnancy and lactation.
 Increase CHON to 60 g daily in the 2nd and 3rd trimesters. 200
 Infant aspirin and Motrin may be used daily.
 Caloric intake increased by 10% during pregnancy. Severe caloric restriction harmful during pregnancy
 Restriction of Na is harmful during pregnancy, can result in fld.and electrolyte imbalance. (reduced
circulatory vol.)
 Diuretics contraindicated during pregnancy. (Hypovolemia and depletes essential nutrients for mother and
child)
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
PIH TREATMENT
MILD PREECLAMPSIA
 Bedrest in the left lateral recumbent position.
 High-protein diet
 Ambulatory care: frequent visits to obstetrician.
 frequent rest periods with feet elevated
 Sedative to ensure rest and sleep
 Administer magnesium sulfate.
SEVERE PREECLAMPSIA
 Hospitalization and complete bedrest.
 Administration of electrolyte replacements, sedative antihypertensives such as diazepam or
Phenobarbital or an anticonvulsant such as Phenytoin
 Magnesium sulfate given IV by infusion pump or IM to prevent or limit seizures.
 Albumin concentrate to increase renal flow and correct the hypovolemia.
 Antihypertensives: Hydralazine HCI (Aprésoline) and Diazoxide (Hyperstat)
 Insert Foley catheter
 Labor induction or cesarean birth once symptoms are under control
ECLAMPSIA
 Hospitalization and complete bedrest
 Institute seizures precaution
-Minimize all stimuli.
-Darken room.
- Limit visitors.
- Pad bedsides and bedrails.
 Check V/S and lab. values frequently.
 Administer medications as ordered such as Magnesium sulfate, Diazepam, Phenobarbital or Phenytoin.
 Prepare for C-section when seizures stabilized.
 Continue observations 24-72 hours postpartum.
NURSING MANAGEMENT
 Monitor BP: every 15 minutes during critical phase; every 1-4 hours as condition improves.
 Insert foley catheter; measure and record output, protein level and specific gravity
 Maintain high-protein diet with normal salt intake.
 Assess for edema of face, arms, hands, legs, ankles and feet. Also assess for pulmonary edema.
 Weigh client daily.
 Assess deep tendon reflexes every 4 hours,
 Assess for placental separation, headache and visual disturbance, epigastric pain and altered level of
consciousness.
 Monitor FHR.
 Observe for signs of labor and bleeding.
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
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CREATED BY: JERLYN R.
Be prepared for an induced or emergency cesarean birth.
Institute seizure precautions. (Seizures may occur 72 hours after delivery
Address emotional and psychosocial needs.
MAGNESIUM SULFATE
MECHANISM OF ACTION
Prevents seizures and blocks neuromuscular transmission.
SIDE EFFFECTS:
FLUSHING, THIRST, ABSENCE OF DEEP TENDON REFLEXES, RESPIRATORY DEPRESSION, CARDIAC
ARRHYTHMIAS, CARDIAC ARREST. DECREASED URINARY OUTPUT
NURSING IMPLICATIONS
 Assess for magnesium toxicity.
 Assess for depressed patellar reflex.
 Assess deep respirations.
 Signs of paralysis
 Assess magnesium levels every 6 hours (Therapeutic range: 4-8 mg/dl)
 Antidote: Calcium gluconate
 Stop administration if signs of toxicity or if urinary output <30 cc/hr
Question:
What medication should be at the bedside of a patient of Mg SO4?
Answer:
calcium gluconate
DIAZEPAM (VALIUM)
MECHANISM OF ACTION
STOPS SEIZURE ACTIVITY
SIDE EFFECTS:
HYPOTENSION, DROWSINESS, LETHARGY, BLURRED VISION, RESPIRATORY DEPRESSION, NAUSEA,
VOMITING, URINARY RETENTION AND CONSTIPATION
NURSING IMPLICATIONS
• INFUSE DRUGS SLOWLY OVERTIME.
• ASSESS VITAL SIGNS.
• STRICT I&O.
• STRICT BEDREST.
• HAVE VALIUM AND CALCIUM GLUCONATE AT BEDSIDE
PROPERTY OF JEFEM <3
MCN 102 REVIEWER 4
CREATED BY: JERLYN R.
ANTIHYPERTENSIVES: HYDRALAZINE HCL (APRESOLINE) AND DIAZOXIDE (HYPERSTAT)
MECHANISM OF ACTION
RELAXES ARTERIAL SMOOTH MUSCLE TO REDUCE BP PERIPHERAL VASODILATOR USED FOR
SEVERE HYPERTENSION
SIDE EFFECTS:
HEADACHE, DIZZINESS, DROWSINESS, EPIGASTRIC PAIN HYPOTENSION, TACHYCARDIA, ANGINA,
HYPERGLYCEMIA AND SODIUM AND WATER RETENTION
NURSING IMPLICATIONS
 MONITOR VITAL SIGNS ESP. PR AND BP
 CHANGE POSITIONS SLOWLY AND AVOID SUDDEN POSITION CHANGES.
 LIE DOWN FOR A WHILE IF DIZZINESS PERSISTS.
 SMALL, FREQUENT FEEDINGS.
 REPORT IMMEDIATELY IF SEVERE CONSTIPATION PERSISTS, UNEXPLAINED FEVER. MALAISE
MUSCLE OR JOINT ACHES CHEST PAIN SKIN RASH, TINGLING AND NUMBNESS.
PROPERTY OF JEFEM <3