1
Running Head: OB CASE STUDY
Cardiac Case Study
Molly Boyle, Justine Chamberlain, Mollye Evans, Adria Grubb, Kelsey Lawrence, Christa
McMurray, Victoria Morris, Ashley Wolcott
Northwest University
Author Note
Kelsey Lawrence, Buntain School of Nursing, Northwest University.
Correspondence concerning this article should be addressed to Kelsey Lawrence, Buntain
School of Nursing Northwest University, 5520 108th Ave NE, Kirkland WA 98033.
E-Mail: kelsey.lawrence12@northwestu.edu
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OB CASE STUDY
Cover Sheet
Kelsey Mattisen Grant: Editor/Intro
Christa McMurray: Meds
Molly Boyle & Justine Chamberlain : Pathos
Victoria Morris : Labs
Ashley Wolcott : Assessment
Adria Grubb & Mollye Evans : Care plan/ Diagnosis
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OB CASE STUDY
Introduction
At seven months pregnant, Mary presents to the emergency department with signs of
placenta previa: painless bright red bleeding and slightly unstable vital signs. The bleeding began
earlier that morning and has not stopped since according to Mary. After finding a bright red spot
on the back of Mary’s jeans, the emergency room nurse calls the labor and delivery unit and has
Mary transported there. Mary’s prenatal care has been managed by a mid-wife consistently.
Other than one instance of red spotting two weeks ago following intercourse and presentation of
a low lying posterior placenta, Mary’s pregnancy has been uneventful thus far. Psychosocially,
Mary has a history of a suicide attempt made a seventeen years and has been sexually active
since age fifteen. However, now she is graduating law school and is in a married, monogamous
relationship. The following describes the care that a labor and delivery nurse should anticipate
and provide to the above patient.
Pathophysiology
Placenta Previa
Mary’s presenting symptoms are consistent with a diagnosis of placenta previa. Placenta previa
is when the placenta is implanted in the lower segment either near or over the internal cervical
os. There are three different classifications of placenta previa dependent on the degree in which
the internal cervical os is covered by the placenta. These include: low-lying placenta, placenta
previa, and marginal placenta. In Mary’s case the ultrasound revealed that her placenta was
considered low-lying, when the placenta is implanted in the lower uterine segment but does not
reach the os. Throughout gestation, the placement of the implanted placenta will tend to move
further away from the cervical os, which is why placenta previa can only be diagnosed in the
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OB CASE STUDY
second trimester. Because Mary is now 7 months pregnant, her diagnosis can be confirmed.
Placenta previa is hallmarked by the presenting sign of painless uterine bleeding, which is
exactly what Mary was experiencing in this case. This occurs due to gradual disruption of
placental attachment and that the uterus is not able to contract adequately to stop blood flow. If
blood loss is persistent, changes in vital signs may be seen including tachycardia, tachypnea, and
an initial increase in blood pressure. Each of these changes is consistent with Mary’s presenting
vital signs: BP 136/86, P 118, and RR 24. A woman with placenta previa is at extreme risk for
hemorrhaging and subsequent hypovolemic shock. This in turn puts not only the mother at risk,
but the fetus is at risk for injury and fetal distress due to loss of blood and impaired placental
perfusion. (Perry, 2010, p. 361-364).
Hypovolemic Shock
Hypovolemic shock is a state in which the body is experiencing acute fluid loss. In this
case, it is blood loss from Mary’s condition of placenta previa. When acute hemorrhage occurs
the inadequate fluid volume within the vascular system results in an inability for the vascular
system to provide adequate perfusion to vital organs and peripheral tissues. The body attempts to
compensate for this fluid loss through the alteration or activation of four main body system
functions: The Hematologic system responds by activating the coagulation cascade to promote
clotting to help stop the bleeding. In addition the renal system activates the Renin-angiotensinaldosterone system which promotes vasoconstriction and sodium and water retention in an
attempt to maintain adequate intravascular volume. The endocrine system stimulate an increase
of ADH to retain water as well. In addition, the cardiovascular system increases heart rate and
myocardial contractility to maintain an adequate cardiac output to meet the metabolic needs of
the body. The cardiovascular system also works to constrict blood vessels to shunt blood away
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OB CASE STUDY
from the source of bleeding and to shunt blood towards vital organs (Lewis, 2010). This works to
sustain the mother’s vital body systems needed to survive. However, during pregnancy the uterus
containing the fetus is not considered a vital organ. The lack of blood flow to the uterus results in
poor fetal oxygenation causing fetal distress. For this reason such an emergency usually results
in a preterm labor in order to save the mom and the baby.
Assessment
Mary, a 25 year old female in her third trimester, seven months pregnant, presents to the
ED after her husband brought her in. Two days following her last visit with the midwife, Mary
woke up to use the restroom at 0615 and started bleeding. She describes the bleeding as bright
red in color but painless. Mary reports that the bleeding hasn’t stopped since she awoke to use
the restroom. It would be important to clarify when this bleeding started, and if Mary has an
estimate of how much blood has been lost. This could be self-reported in how many pads she has
saturated.
Some important labs to test that would give better indications of the extent of bleeding
would be hemoglobin and hematocrit labs. Mary currently has a large red stain on the back of her
pants. Her vital signs are obtained and are as follows: blood pressure is 136/86, pulse is 118, and
respirations are 24 per minute, and temperature is 36.8 degrees Celsius. It would be important to
obtain what her baseline vital signs usually are, before her bleeding and admission to the
hospital. These could be obtained through self-report or from medical records of her visits to her
midwife. Mary’s oxygen saturation, pain level, capillary refill and weight were not reported, and
these would be essential information to obtain. Perfusion, which can be measured by the
capillary refill, is particularly important because the placenta needs to be perfused to provide
oxygen and nutrients to the fetus; this is also why oxygen saturation is vital information to
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OB CASE STUDY
obtain. Weight should be checked because this can show blood loss and in pregnancy a healthy
weight gain is expected. Pain should always be assessed. There is also no indication in the
information provided that Mary was checked for effacement, dilation, or presence of
contractions. These assessments show if labor has begun which can put stress on the fetus, and
would raise concern because Mary is not yet full term.
There was also no assessment material provided on the fetus. It would be expected that
electronic fetal monitoring would be started in the emergency room. This is the only way to
know how the fetus is doing, such as stress the fetus is experiencing or if the fetus is still viable.
The last piece of information that should be obtained from Mary is a list of current
medications, illicit drugs, herbs or supplements that she may have taken during her pregnancy, or
that she is still taking. This information is essential because it can tell about changes to blood
chemistry, damage that could be possible to both mother and fetus through drug use, and can
alert staff to any medications that may pose a threat to her current condition and any procedures
that may be performed.
Mary was placed in a wheelchair and sent to the labor and delivery floor. Upon further
investigation more information was obtained. Mary has been visiting a midwife for her prenatal
care which began at 10 weeks gestation and she has been consistent with care. It would be
important to obtain all information from the midwife such as; ultrasounds, vitals, calculated
delivery date, previous medication list and all labs and blood work done during her pregnancy.
The information from the midwife will also give a more detailed explanation of how this
pregnancy has progressed with each visit, including fundal height, ultrasounds, and reported kick
counts. Upon taking history of her pregnancy it is noted that Mary’s 20 week ultrasound showed
an active intrauterine pregnancy. The ultrasound showed all growth parameters were met, but
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OB CASE STUDY
that she had a low lying posterior placenta. Two weeks ago Mary had an episode of reddish
spotting, but did not report it because it was postcoitus, and she did not think there was a
significant cause. Mary did not report the amount of spotting, the length of time that the spotting
occurred, or if this was an isolated incidence. This would be vital information to obtain from her.
Mary did not report any other problems or concern throughout the pregnancy. She states
that, “both she and her husband work because while in college money is not plentiful.” She states
that “her job is not strenuous and she primarily works on researching law history.” Mary makes
up for her job being non-labor intensive by being active during her pregnancy. She describes
herself as an “exercise junkie”, power walking every afternoon to de-stress and to stay in shape.
The length or intensity of these walks was not reported, so further assessment is needed. Next, a
personal history of Mary is obtained. Menarche started at age 12, noting irregular periods with
moderate dysmenorrhea. She became sexually active at age 15, while now married and in a
monogamous relationship there is no mention of previous partners. Because she has been
sexually active since age 15, it would be important to obtain if Mary has had any previous
pregnancies, and the outcomes of those pregnancies. Mary had a rupture of an ovarian cyst in
which her right ovary was removed at age 16. Mary has a history of genital herpes and her first
outbreak was reported at age 18. She has not had any lesions since this time. Mary is hoping the
baby will not come until she has graduated from college. She is hoping that the birth will be
natural and un-medicated. With all the indicators of stress and a history of depression with a
suicide attempt it would be important to assess Mary for depression.
Labs/Diagnostics
Mary has just been admitted to the hospital and taken to the labor and delivery unit to be
cared for. No labs or diagnostic procedures have been done at this time. In order to determine the
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OB CASE STUDY
intravascular stability of the mother, hemoglobin and hematocrit levels will be drawn
immediately, as well as a type and cross. Mary has lost large quantities of blood, and it is
beginning to show in her vital signs. Her blood pressure and heart rate are rising, in attempts to
compensate for decreased intravascular volume. Depending on her lab values, she may need an
emergent O negative blood transfusion before the type and cross can be completed. This is
especially true if the placenta has separated beyond fetal viability, because an emergent Csection will be needed to try and save the baby, as well as remove the rest of the placenta and
stop the uterine bleeding. To determine the extent of separation, an ultrasound will be performed.
Coagulation studies will also be drawn to evaluate Mary’s risk for developing DIC due to
exhaustion of her body’s clotting factors. Regarding the unborn fetus, fetal heart monitoring will
be initiated immediately, and a non-stress test will be performed; increased fetal stress due to
decreased blood flow will further support the necessity of a C-section.
Lab/Diagnostic
Test
Abdominal
Ultrasound
Non-Stress
Test
Normal/Expected
Result
Normal imaging
would show no
placental
separation, and
normal
reproductive
anatomy for a
pregnancy of 7
months.
Patient’s Result
The patient’s results
are unknown at this
time.
Indication
Due to the extent of the ongoing
bleeding, and the likely hood of
Placenta Previa, an ultrasound is
needed to determine the
(Expected results for location/position of the placenta,
Mary are abnormal
and the extent of placental
due to continuous
separation. If only mild separation
bleeding)
has occurred, Mary may be placed
on strict bed-rest for the duration
of her pregnancy. However, if the
placenta has separated beyond
what can support the fetus, an
emergent C-section will likely be
needed.
A non-stress test
The patient’s results Due to the likelihood of placenta
that shows
are unknown at this
previa, the status of the fetus is
reactivity is
time.
unknown and at risk. This text
considered normal,
will allow medical staff to
because the fetus
(If the placenta is
determine if the fetus is receiving
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OB CASE STUDY
is receiving
enough oxygen for
movement and
activity.
Hematocrit &
Hemoglobin
Hct: 40-50%
Hgb: 13.5-18.0
g/dL.
still adequately
delivering blood and
oxygen to the fetus,
the result should be
reactive. However, if
the placenta has
separated too much,
the fetus will be
non-reactive as it
tries to conserve
oxygen)
The patient’s results
are unknown at this
time.
(Due to bleeding,
Mary’s lab values
will likely be lower
than normal.)
Type & Cross
O–
O+
A–
A+
B–
B+
AB –
AB +
The patient’s blood
type is unknown at
this time. Thus, until
a type and cross is
complete, Mary will
receive O – blood if
needed.
Fetal Heart
Rate
Monitoring
120-160 BPM
The patient’s results
are unknown at this
time.
Coagulation
Study
PT = 10-12 sec.
PTT= 30-45 sec.
INR= 1-2
(Fetal heart rate will
likely be on the
higher end, if not
abnormally high,
due to fetal distress
from placental
separation.)
The patient’s results
are unknown at this
time.
enough oxygen. If the test is nonreactive and the fetus is not
moving, but still has a heartbeat,
further testing will be necessary
to determine the level of fetal
distress.
On the time of admission, Mary
has lost a continuous but
unknown amount of blood, and
her hematocrit level needs to be
checked to determine the risk to
mom and baby, and the severity
of blood loss, and to determine
the necessity of a blood
transfusion.
Due to the extent of the ongoing
bleeding, Mary may need a blood
transfusion. The hospital will
likely draw blood in order to do
cross-matching, so there will be
compatible blood on site and
ready for Mary if she loses too
much blood. However, if there is
not enough time to perform the
type and cross, they may have to
give her blood type O negative, if
it becomes emergent.
At this time, the condition of the 7
month old fetus is unknown. A
fetal heart monitor will be used to
closely observe the fetus for signs
of fetal distress. Depending on the
extent of placental separation and
fetal distress, an emergent Csection may be necessary to save
mom, and attempt to save baby as
well.
Due to the unknown extent of
Mary’s bleeding, coagulation
blood labs will be drawn to
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OB CASE STUDY
evaluate for clotting ability. Mary
is at risk for DIC because her
body has been using up its
clotting factors.
Medications
MEDICATION
ORDER
DRUG/DOSE/ROUTE
DRUG CLASS
THERAPUETIC/
PHARMACOLOGIC
Iron
2-3mg/kg daily;
divided into three
doses; PO
T: Iron Supplement
TIME
DUE
TID
INDICATION
FOR THIS
PATIENT
ACTION &
EXPECTED
THERAPEUTIC
EFFECT
Prevention of iron
deficiency related
to bleeding
Action:
Supplements iron
supplies in the
body
COMMON &
SERIOUS SIDE
EFFECTS
Common:
constipation,
dark stools,
nausea
Serious: immune
hypersensitivity
reaction
Therapeutic Effect:
Prevention of
anemia
Dexamethasone
6mg IM; Q12 hours
for four doses
Q12;
four doses
Acceleration of
fetal lung
development
Common: body
fluid retention
(mother),
hypertension
NURS
INTERVEN
RELEVANT
(INCLU
DRUG
ONSET,PE
INTERACTIONS
DURATI
APPLICA
Zinc, tetracycline, -take with a
levothyroxine,
reduce naus
doxycycline
-take with
something
vitamin C (
orange juic
increase ab
-do not take
2 hours of o
medication
-monitor
hemoglobin
hematocrit,
RBCs
Rotavirus
-monitor liv
vaccine,
function
hydrocodone,
-take with m
aspirin, licorice,
-monitor vi
every four h
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OB CASE STUDY
Dexamethasone
6mg IM; Q12 hours
for four doses
Q12;
four doses
T: lipid-lowering
agents
Acceleration of
fetal lung
development
Action: causes the
fetus’ lungs to
produce surfactant,
which lubricates
the lining of the
alveoli, allowing
them to move
smoothly without
sticking together
during breathing
P: hmg Coa reductase
inhibitors
(mother)
warfarin
daily
-daily weig
Beta-blockers,
-SUBQ: ad
in lateral de
area
-monitor B
Serious:
Cardiomyopathy,
hyperglycemia,
pancreatitis,
osteoporosis,
conjunctival
hemorrhage,
glaucoma
Therapeutic Effect:
the infant is able to
breath better on
their own with less
respiratory
treatment
Terbutaline
250mcg once, may
repeat in 20 minutes;
IV or SUBQ
Once, then
may
repeat in
20min
Tocolysis
Common:
palpitations,
tachyarrhythmia,
headache,
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OB CASE STUDY
Terbutaline
250mcg once, may
repeat in 20 minutes;
IV or SUBQ
Once, then
may
repeat in
20min
T: sympathomimetic,
bronchodilator
Tocolysis
Action: beta 2
adrenergic agonist
with
bronchodilating
and smooth muscle
relaxing effects.
Elevates
intracellular level
of cAMP which
inhibits release of
inflammatory
mediators
P: Beta-2 Adrenergic
Agonist
seizure, tremor,
anxiety
Beta-blockers,
HR
Only compatible
with normal
saline
-Administe
-Verify pat
identity, blo
type, and u
blood befor
administrat
-Administe
4 hours afte
removal fro
blood bank
-Obtain vita
after first 1
then every
minutes
-monitor fo
of infusion
Serious: cardiac
dysrhythmia,
paradoxical
bronchospasm,
pulmonary
edema
Therapeutic Effect:
lower LDL.
Reduced risk of
MI. Slowing of
atherosclerosis.
Packed Red Blood
Cells
T: Blood Product
2 bags
Replacement of
blood volume
Action: Replaces
blood volume in
the intravascular
space
Therapeutic Effect:
Adequate blood
volume,
hematocrit, and
hemoglobin
Common: Fever,
itching
Serious:
Transfusion
Reaction
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0.9 Normal Saline
1000ml infusion,
100ml/hr IV
Continuous Increase in
infusion
intravascular fluid
volume,
maintenance of
electrolyte balance
T: IV fluid
Common: none
Serious:
hypervolemia
Interacts with
lithium
Action: increases
intravascular fluid
volume and
provides
electrolytes
Therapeutic Effect:
maintenance of
adequate blood
pressure
Diagnosis
Medical diagnoses: Placenta Previa and Shock
Priority #2: Decreased cardiac output r/t excessive blood loss secondary to placenta previa as
evidenced by patient’s rising pulse of 118 bpm.
Priority #1: Deficient fluid volume r/t excessive blood loss secondary to placenta previa as
evidenced by patient’s rapid, shallow breathing.
Priority #3: Ineffective peripheral tissue perfusion r/t hypovolemia and shunting of blood to
central circulation as evidenced by decreased fetal movement.
Priority #4: Anxiety/fear r/t maternal condition and pregnancy outcome as evidenced by increase
wariness with regards to her pregnancy.
Priority #5: Anticipatory grieving r/t actual/perceived threat to self, pregnancy, or infant as
evidenced by self-blame comments.
-Administe
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OB CASE STUDY
Plan, Implementation/Intervention, Evaluation
Nursing
Diagnosis
Goal/Outcome
Nursing Interventions
Evaluation
Priority #1:
Decreased
cardiac output
r/t excessive
blood loss
secondary to
placenta previa
as evidenced
by patient’s
pulse of 118 at
rest.
Goal:
Patient will exhibit signs of
restoration of cardiac output.
1. Assess patient’s uterus for tenderness and
tone. Take not of bleeding rate, amount, color,
degree of bleeding, CBC values, and coagulation
profile to determine severity of situation. Do not
perform vaginal examination as it may stimulate
further bleeding.
Outcome Criteria:
Patient’s apical pulse will be
regular and between 60-100
bpm within 24 hrs following
admit.
2. Establish baseline data for cardiac output (VS;
heart and breath sounds; skin color, tone, and
turgor; capillary refill; LOC; UOP; pulse
oximetry) to use as a basis for evaluating
effectiveness of treatment.
We expect
that the
patient will
exhibit signs
of increased
blood
volume and
restoration of
cardiac
output (i.e.,
normal pulse
and blood
pressure;
normal heart
and breath
sounds;
normal skin
color, tone,
and turgor;
normal
capillary
refill) within
24 hours of
her admit
date.
3. Initiate IV therapy or blood transfusions and
medications per physician order to restore blood
volume and prevent organ compromise to both
the mother and fetus.
(Perry,
Hockenberry,
Lowdermilk, &
Wilson, 2010,
p.363-364)
4. Place woman on bed rest to minimize oxygen
demands.
5. Monitor VS, intake and output, hemodynamic
status, and lab values to evaluate treatment
response.
Priority #2:
Deficient fluid
volume r/t
excessive
blood loss
secondary to
Goal:
Patient will exhibit signs of
increased blood volume.
1. Assess patient’s uterus for tenderness and
tone. Take not of bleeding rate, amount, color,
degree of bleeding, CBC values, and coagulation
profile to determine severity of situation. Do not
perform vaginal examination as it may stimulate
further bleeding.
We expect
that the
patient will
exhibit signs
of increased
blood
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OB CASE STUDY
placenta previa
as evidenced
by patient’s
thready pulses.
(Perry,
Hockenberry,
Lowdermilk, &
Wilson, 2010,
p.363-364)
Outcome Criteria:
Patient will exhibit normal
pulses (i.e., not absent or
thready) within 24 hrs from
admit.
1. Assess patient’s uterus for tenderness and
tone. Take not of bleeding rate, amount, color,
degree of bleeding, CBC values, and coagulation
profile to determine severity of situation. Do not
perform vaginal examination as it may stimulate
further bleeding.
2. Establish baseline data for cardiac output (VS;
heart and breath sounds; skin color, tone, and
turgor; capillary refill; LOC; UOP; pulse
oximetry) to use as a basis for evaluating
effectiveness of treatment.
3. Initiate IV therapy or blood transfusions and
medications per physician order to restore blood
volume and prevent organ compromise to both
the mother and fetus.
4. Monitor serum and urine osmolality, serum
sodium, BUN/creatinine ration, and hematocrit
for elevations. These are elevated with decreased
intravascular volume.
volume and
restoration of
cardiac
output (i.e.,
normal pulse
and blood
pressure;
normal heart
and breath
sounds;
normal skin
color, tone,
and turgor;
normal
capillary
refill) within
24 hours of
her admit
date.
5. Monitor pulse, respiration, and BP of patient q
15 minutes to 1 hr (if unstable) and q 4 hrs (if
stable) to follow patient’s status based off
trending data.
Priority #3:
Ineffective
peripheral
tissue
perfusion
(placenta) r/t
hypovolemia
and shunting of
blood to
central
Goal:
Patient will exhibit signs of
ongoing fetal well-being.
Outcome Criteria:
Patient will regain and
maintain adequate fetal
movement by the end of shift
on 4/21.
1. Monitor VS (BP, pulse, RR, temperature,
SpO2) for changes in patient status indicating
decline, requiring further intervention.
2. Monitor fetus continually for signs of
tachycardia, decreased movement, and loss of
reactivity on NST to identify and treat changes in
fetal status early.
3. Have patient in side-lying position to prevent
compression of aorta and vena cava.
We expect
that the
patient will
regain and
maintain
adequate
fetal
movement
before the
end of the
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OB CASE STUDY
circulation as
evidenced by
decreased fetal
movement.
Goal:
Patient will exhibit signs of
ongoing fetal well-being.
Outcome Criteria:
(Perry,
Patient will regain and
Hockenberry,
maintain adequate fetal
Lowdermilk, & movement by the end of shift
on 4/21.
Wilson, 2010,
p.363-364)
1. Monitor VS (BP, pulse, RR, temperature,
SpO2) for changes in patient status indicating
decline, requiring further intervention.
shift on 4/21.
2. Monitor fetus continually for signs of
tachycardia, decreased movement, and loss of
reactivity on NST to identify and treat changes in
fetal status early.
3. Have patient in side-lying position to prevent
compression of aorta and vena cava.
4. Obtain BPP per physician order to assess for
signs of chronic asphyxia.
5. Place patient on bed rest to decrease oxygen
demands.
Priority #4:
Anxiety/fear r/t
maternal
condition and
pregnancy
outcome as
evidenced by
increase
wariness with
regards to her
pregnancy.
(Perry,
Hockenberry,
Lowdermilk, &
Wilson, 2010,
p.363-364)
Goal:
Patient will have decreased
anxiety/fear.
Outcome Criteria:
Patient will verbalize two
techniques to control anxiety
by 4/21.
1. Assess patient’s uterus for tenderness and
tone. Take not of bleeding rate, amount, color,
degree of bleeding, CBC values, and coagulation
profile to determine severity of situation. Do not
perform vaginal examination as it may stimulate
further bleeding.
2. Establish baseline data for cardiac output (VS;
heart and breath sounds; skin color, tone, and
turgor; capillary refill; LOC; UOP; pulse
oximetry) to use as a basis for evaluating
effectiveness of treatment.
3. Initiate IV therapy or blood transfusions and
medications per physician order to restore blood
volume and prevent organ compromise to both
the mother and fetus.
4. Place woman on bed rest to minimize oxygen
demands.
5. Monitor VS, intake and output, hemodynamic
status, and lab values to evaluate treatment
response.
We expect
that the
patient will
verbalize that
music and
aromatherap
y help her
have
decreased
anxiety/fear
before the
end of the
shift on 4/21.
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OB CASE STUDY
Priority #5:
Anticipatory
grieving r/t
actual/perceive
d threat to self,
pregnancy, or
infant as
evidenced by
self-blame
comments.
Goal:
Patient will identify the
meaning of the loss to her and
her family.
Outcome Criteria:
Patient will verbalize two
things that contribute to her
feelings of loss by the end of
shift on 4/21.
(Perry,
Hockenberry,
Lowdermilk, &
Wilson, 2010,
p.363-364)
1. Concentrate on improving communication and
providing an environment in which the patient’s
husband care for his wife as much as possible.
We expect
that the
patient will
identify the
2. Focus on enhancing the individual coping
decline in her
skills of the patient to alleviate life problems and condition and
distressing symptoms.
the potential
3. Assess the influence of cultural beliefs, norms, harm to her
unborn child
and values on the patient’s grief.
as
4. Teach the patient to recognize grief responses. contributing
Recognition of these patterns allows the patient to to her
feelings of
manage their response more effectively and may
loss by the
prevent adverse outcomes to their physical and
end of the
mental health.
shift on 4/21.
5. Actively listen as the patient for her own
perceived loss. Normalize the patient’s
expressions of grief for herself. Demonstrate a
caring and hopeful approach.
Evidenced Based Practice Summary
Ensuring that care is based on the most current research is critical, especially when you
not only have one life, but two in your hands as a labor and delivery nurse. The following
describes five areas in labor and delivery nursing that are currently being researched through
evidence-based studies: bedrest, management of placenta previa, cervical length predicts
placental adherence and massive hemorrhage in placenta previa, hospitalization with placenta
previa, and clinical features, diagnosis, and course of placenta previa.
Bedrest is commonly used in situations where a high-risk pregnancy is suspected. In
healthcare, nurses aim to meet the needs of patients from a holistic perspective; this is why it is
important to gage the impact that complications have on a patient’s mental health. In a
comparative study performed by Dunn, Handley, and Shelton, women on bedrest, due to high
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OB CASE STUDY
risk pregnancies, had higher levels of anxiety and depression than those who were not on bedrest
(2007, p.1243). These women also had the lowest level of spiritual well-being. This study’s
findings suggest that high risk pregnancies are more likely to be associated with significant
emotional and social impacts to the patient as well as negative implications to the fetus, such as
delivering preterm (Dunn, Handley, & Shelton, 2007, p.1237). Maternal antepartum depression,
anxiety, and stress not only impact the pregnancy and fetal development; they also affect the
delivery and may carry into the postpartum period. This is why it is important to be aware of
meeting these patient’s psychological needs as well as their immediate physical needs.
Management of placenta previa in a patient who is actively bleeding is potentially an
obstetrical emergency that may require a C-section. In these cases, maternal and fetal monitoring
are extremely important. Goals of treatment include determining whether a C-section is required
and achieving/maintaining maternal hemodynamic stability (Lockwood & Russo-Stieglitz,
2014). The patient should be put on bedrest to prevent further trauma. Bleeding could be an
indication of the placenta separating from the uterine wall; with this we are concerned of fetal
hypoxia. If fetal stability is determined, cesarean delivery may not be required; however, special
care would be required to prevent reoccurrence. Labs help determine maternal hemodynamic
stability; complete blood count, type and screen, fibrinogen level, activated partial
thromboplastin time, and prothrombin time are a few of the labs that would be run (Lockwood &
Russo-Stieglitz, 2014). One or two large bore IV lines are usually inserted for therapies such as
crystalloid and blood product infusions. If massive blood loss is suspected, blood products may
need to be transfused to help maintain hemodynamic stability; however, this presents its own
risks if the patient rejects the transfusion. These are a few appropriate interventions in the
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management of placenta previa with active bleeding; however, each case is individual and
further complications require further intervention.
The quantitative study, cervical length predicts placental adherence and massive
hemorrhage in placenta previa, looks into the clinical significance in the association between
decreased cervical length and preterm labor. Some studies have reported an association between
decreased cervical length and antepartum/postpartum hemorrhage. For this study, 80 candidates
were used; they were diagnosed with placenta previa before 34 weeks, and there were no other
complications related to the pregnancy such as ruptured membranes, fetal growth restriction,
fetal anomalies, medical disorders that complicated the pregnancy, or evidence of
polyhydramnios. They did discover that women with placenta previa and a cervical length of
30mm or less were more likely to deliver earlier and were at a higher risk for emergent preterm
cesarean section than those with longer cervices. While this does not directly change how nurses
will care for women with placenta previa, the study believes that assessing/measuring the
cervical length should be included in a general assessment for pregnant women-especially if they
have placenta previa. This can better help the nurse anticipate and trend data to provide the most
efficient care.
Another study is: Waiting for something to happen: Hospitalization with placenta previa. This
qualitative study looks into the experience of women with placenta previa. For this study, 10
women who were admitted onto an antepartum unit at 28-33 weeks gestation for bedrest due to
being diagnosed with placenta previa. They all agreed to be interviewed while hospitalized and
4-6 weeks after returning home. The results showed that most of the women were shocked by the
diagnosis; most of them were diagnosed during a routine ultrasound in the second trimester and
were not experiencing painless bleeding. The reality of being hospitalized for the next few weeks
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was upsetting, but they discovered that the days went by more easily if they visited and invested
in supporting each other. Overall, this study supported what other studies have found: patients
experience boredom, anxiety about family, imprisonment, and worries about physical changes.
The take away that the study suggested was to help the women make the hospital (especially
their room) feel more like home. This could be done through decorating their room and
maintaining a routine as similar to home as possible. Mutual support was found to be helpful for
the women as well. This is important for nurses to know to better accommodate their patients; to
make them feel more comfortable and relaxed will help them have a better hospital experience.
Clinical features, diagnosis, and course of placenta previa is an article that shares the
most up to date information concerning placenta previa in how it presents itself, is diagnosed and
the course of the complication. The first useful piece of information to note is that any painless
bleeding after 20 weeks gestation should make the nurse suspect placenta previa; no digital
examination of the vagina should be done until the placental location is determined. Major risk
factors for placenta previa is previous history of having the complication, history of C-section,
and multiple gestations. These are good things for the nurse to know so s/he can know what to
assess for and what precautions to take if placenta previa is suspected.
Conclusion
Overall, there are many subject being researched within obstetrics as a whole, with
several involving the complication of placenta previa. Mary’s case is a scary one for any patient,
and as future nurses we want to look at holistic, safe, and best-practice care. It is those
components that can change a patient’s life.
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References
McCance, K.L. and Huether, S.E. (2009) Pathophysiology: The Basis of Disease in Adults and
Children (6th Ed.). St.Louis: Mosby.
Dunn, L., Handley, M., & Shelton, M. (2007). Spiritual well-being, anxiety, and depression in
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doi:10.1080/01612840701651504
Fukushima, K., Fujiwara, A., Anami, A., Fujita, Y., Yumoto, Y., Sakai, A., . . . Wake, N. (2012).
Cervical Length Predicts Placental Adherence and Massive Hemorrhage in Placenta
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Katz, A. (2001). Waiting for Something to Happen: Hospitalization with Placenta Previa. Birth,
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Lockwood, C. J., & Russo-Stieglitz, K. (2014, March). Clincal Features, Diagnosis, and Course
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Lockwood, C., & Russo-Stieglitz, K. (2014). Management of Placenta Previa. Waltham, MA:
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