Which of the following would the nurse assess a client experiencing Abruptio placenta?

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Answer:

A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa

Placental abruption (also known as abruptio placenta or the premature separation of the placenta) occurs when the placenta appears to have been implanted correctly but begins to separate suddenly, which results in bleeding. It may be partial or total; it may be marginal (separating at the edges) or central (separating in the middle). The separation generally occurs late in pregnancy, even as late as during the first or second stage of labor. 

The primary cause of placental abruption is unknown, but certain predisposing factors are high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, hypertension of pregnancy, direct trauma, vasoconstriction from cocaine or cigarette use, and thrombophilic conditions that lead to thrombosis formation. It can also be caused by maternal folate deficiency and chorioamnionitis or the infection of the fetal membranes and fluid.

Bleeding accompanied by abdominal or low back pain is typical of a placental abruption. Most or all of the bleeding may be concealed behind the placenta. Obvious dark red vaginal bleeding occurs when blood leaks past the edge of the placenta. The client’s uterus is tender and unusually firm or boardlike. Frequent, cramp-like uterine contractions often occur.

The treatment of choice, immediate cesarean birth, is performed because of the risk for maternal shock, clotting disorders, and fetal death. Blood and clotting factor replacement may be needed because of DIC.

Nurses play a vital role in preventing complications for clients with placental abruption. Accurate assessment and prompt intervention will promote the safe delivery of the newborn.

Here are four nursing care plans and nursing diagnoses for clients diagnosed with placental abruption.

Ineffective Peripheral Tissue Perfusion

Placental abruption occurs when the maternal vessels tear away from the placenta, and bleeding occurs between the uterine lining and the maternal side of the placenta. As the blood accumulates, it pushes the uterine wall and placenta apart. The placenta is the fetus’s source of oxygen and nutrients and the way the fetus excretes waste products. Diffusion to and from the maternal circulatory system is essential to maintaining these life-sustaining functions of the placenta. When accumulating blood causes separation of the placenta from the maternal vascular network, these vital functions of the placenta are interrupted (Rowe, 2022).

Nursing Diagnosis

• Ineffective Peripheral Tissue Perfusion

• Excessive blood loss
• Vasoconstriction
• Thrombophilic conditions

Possibly evidenced by 

• Loss of blood
• Variable fetal heart rate pattern
• Hypotension
• Tachycardia 
• Severe abdominal pain and rigidity
• Pallor
• Changes in LOC
• Decrease urine output
• Edema
• Delay in wound healing
• Positive Homan’s sign
• Hypothermia

Desired Outcomes

• The client will demonstrate vital signs within normal limits, a normal capillary refill, and warm, dry skin.
• The client will maintain strong and palpable peripheral pulses and adequate urine output.
• The client will verbalize the absence of abdominal pain.
• The client will display and maintain an average level of consciousness.

Nursing Assessment and Rationales

1. Assess the client’s vital signs, oxygen saturation, and skin color.
As with any hypovolemic condition, blood pressure drops as the pulse increases. With placental abruption, a relatively stable client may rapidly progress to a state of hypovolemic shock if the origin of the hemorrhage is not identified immediately (Deering & Smith, 2018). Low oxygen saturation levels and cyanosis of the skin or lips can indicate hypovolemia.

2. Monitor for restlessness, anxiety, hunger, and changes in level of consciousness (LOC).
These conditions may indicate decreased cerebral perfusion. Changes in the client’s level of consciousness may reflect diminished perfusion to the central nervous system. As the client’s condition leads to hypovolemic shock, the client’s level of consciousness progresses from an alert to an obtunded state (Deering & Smith, 2018).

3. Monitor the intake and output accurately.
An external or internal hemorrhage may cause dehydration. Decreased renal perfusion and renal failure may occur because of vasoconstriction, thereby decreasing urine output.

4. Monitor fetal heart sounds and rates continuously.
Signs of possible fetal jeopardy include prolonged fetal bradycardia, repetitive, late decelerations, and decrease short-term variability. The absence of fetal heart sounds may occur when the abruption progresses to the point of fetal death (Deering & Smith, 2018).

5. Assess uterine contractions and palpate the uterus.
Contractions and uterine hypertonus are part of the classic triad observed with placental abruption. Uterine activity is a sensitive marker of the placental abruption and, in the absence of vaginal bleeding, should suggest the possibility of an abruption, especially after some form of trauma or in a client with multiple risk factors. The client’s fundal height may increase rapidly because of an expanding intrauterine hematoma (Deering & Smith, 2018). The uterus is often firm and may be rigid and tender. If a substantial volume of blood has extravasated into the myometrium, it can become “woody hard,” with fetal parts no longer palpable (Ananth & Kinzler, 2022). If blood infiltrates the uterine musculature, Couvelaire uterus or uteroplacental apoplexy, forming a hard, boardlike uterus occurs. 

6. Assess the level and characteristics of abdominal pain.
The severity of abdominal pain is a useful marker of the severity of the abruption and, in turn, maternal and fetal/newborn risk of morbidity and mortality (Ananth & Kinzler, 2022). The bleeding may be accompanied by abdominal or low back pain or a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. If labor begins with the separation, each contraction will be accompanied by pain over and above the pain of the contraction.

7. Assess skin color, moisture, turgor, and capillary refill.
The changes in these parameters may reflect diminished circulation and hypoxia. Capillary refill time is a useful and rapid metric in determining the intravascular volume status of the client. Markers of reduced perfusion include delayed capillary refill time, dry mucous membranes, poor skin turgor, and absence of diaphoresis (McGuire et al., 2022).

8. Assess the extent of bleeding.
Obvious dark red vaginal bleeding occurs when blood leaks past the edge of the placenta. Vaginal bleeding is present in 80% of clients diagnosed with placental abruption. However, remember that 20% of abruptions are associated with a concealed hemorrhage, and the absence of vaginal bleeding does not exclude a diagnosis of placental abruption. The bleeding may be profuse and come in “waves” as the client’s uterus contracts. A fluid color of port wine may be observed when the membranes rupture in association with the hemorrhage (Deering & Smith, 2018).

9. Assess the client’s lower extremities for skin characteristics and peripheral pulses.
Reduced peripheral circulation often leads to skin and underlying tissue changes and delayed healing. Vasoconstriction or extreme blood loss may lead to partial or complete obliteration of a vessel with diminished perfusion to surrounding tissues.

10. Obtain specimens for laboratory and diagnostic testing.
Laboratory findings correlate with the degree of placental separation. The fibrinogen level is the test that correlates best with the severity of bleeding, presence of overt DIC., and the need for transfusion of multiple blood products.

Nursing Interventions and Rationales

1. Position the client in a lateral or left side-lying position.
Place the client in a lateral, not supine, position to prevent pressure on the vena cava and additional interference with fetal circulation. Fetal prognosis depends on the extent of the placental separation and the degree of fetal hypoxia; therefore, the delivery of oxygen to the fetus is essential.

2. Avoid performing a vaginal examination or any procedures that may disturb the injured placenta.
Do not perform a digital examination on a pregnant client with vaginal bleeding without first ascertaining the location of the placenta. Before a pelvic examination can be safely performed, an ultrasonographic examination should be performed to exclude placenta previa. If placenta previa is present, a pelvic examination, either with a speculum or with a bimanual examination, may initiate profuse bleeding (Deering & Smith, 2018).

3. Educate the client and significant others about prompt recognition and report of signs and symptoms of thrombosis or DIC.
Disseminated intravascular coagulation (DIC) is an acquired disorder of blood clotting in which the fibrinogen level falls below effective limits. Early symptoms include easy bruising or bleeding from an intravenous site. The client may also bleed from her mouth, nose, and incisions. Prompt recognition and reporting to the healthcare provider may prevent the worsening of the condition and future complications.

4. Administer oxygen by mask.
Administer continuous high-flow supplemental oxygen to the mother. Maternal oxygen administration can be used to attempt to lessen fetal distress and avoid fetal anoxia by increasing the available oxygen from the mother.

5. Administer intravenous fluids as indicated.
Obtain intravenous access using two large-bore needles and institute crystalloid fluid resuscitation. If needed, perform aggressive fluid resuscitation to maintain adequate perfusion (Gaufberg & Lo, 2021).

6. Administer blood and blood products as ordered.
Blood and clotting factor replacement may be needed because of DIC. Intravenous administration of fibrinogen or cryoprecipitate (which contains fibrinogen) can be used to elevate the client’s fibrinogen level prior to and concurrently with surgery.

Recommended nursing diagnosis and nursing care plan books and resources.

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