Placenta previa is a significant obstetric complication arising when the placenta implants in the lower segment of the uterus, either partially or completely obstructing the cervical os. This aberrant placental positioning poses substantial risks of hemorrhage, particularly during the later stages of pregnancy and labor. For nurses and healthcare professionals, a thorough understanding of placenta previa and its associated nursing diagnoses is crucial for delivering optimal patient care and ensuring positive maternal and fetal outcomes. This article provides an in-depth exploration of nursing diagnoses relevant to placenta previa, empowering nurses to effectively manage and support patients facing this condition.
Understanding Placenta Previa: Risk Factors and Complications
The placenta, vital for fetal sustenance, typically implants in the upper uterine segment. In placenta previa, however, the placenta abnormally implants low in the uterus. Several factors elevate the risk of placenta previa, including:
- Advanced Maternal Age: Women over 35 years old are at increased risk.
- Multiparity: The risk rises with each subsequent pregnancy.
- Uterine Scarring: Prior cesarean deliveries, uterine surgeries, or dilatation and curettage (D&C) procedures can increase risk.
- Previous Placenta Previa: A history of placenta previa significantly increases the likelihood of recurrence.
- Cocaine Use and Smoking: These substances are associated with an elevated risk.
Placenta previa can lead to serious complications for both mother and baby:
- Hemorrhage: Painless vaginal bleeding, often in the second or third trimester, is the hallmark symptom. Bleeding can be severe and life-threatening.
- Preterm Labor and Delivery: Bleeding and uterine irritability can trigger preterm labor.
- Fetal Distress: Maternal hemorrhage can compromise fetal oxygen supply, leading to fetal distress.
- Intrauterine Growth Restriction (IUGR): Although less directly linked, placental issues can sometimes affect fetal growth.
- Emergency Cesarean Delivery: Often necessary to manage bleeding and deliver the baby safely.
- Maternal and Fetal Shock: Severe blood loss can result in shock for both mother and baby.
- Maternal or Fetal Death: In rare, severe cases, placenta previa can be fatal for either the mother or the fetus.
Nursing Process and Placenta Previa
Nurses are integral to the management of placenta previa. Their role encompasses vigilant monitoring, patient education, and prompt intervention to mitigate risks and optimize outcomes. The nursing process provides a structured framework for care:
- Assessment: Identifying risk factors, monitoring for bleeding, assessing vital signs, evaluating fetal well-being, and understanding the patient’s emotional state are crucial initial steps.
- Nursing Diagnosis: Based on assessment findings, nurses formulate relevant nursing diagnoses to guide care planning.
- Planning: Developing individualized care plans that prioritize patient safety, fetal well-being, and psychological support.
- Implementation: Executing planned interventions, including monitoring, medication administration, patient education, and emotional support.
- Evaluation: Continuously assessing the effectiveness of interventions and adjusting the care plan as needed.
Key Nursing Diagnoses for Placenta Previa
Several nursing diagnoses are pertinent to patients with placenta previa. These diagnoses address the physiological and psychological challenges associated with this condition. Here are some primary nursing diagnoses, expanded from the original article, with more detailed considerations for each:
1. Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output related to hemorrhage secondary to placenta previa, as evidenced by tachycardia, hypotension, pallor, and patient reports of fatigue and dizziness.
Related Factors:
- Hemorrhaging: Significant blood loss reduces circulating volume.
- Vaginal Bleeding: Overt blood loss further diminishes blood volume.
- Hypovolemia: Reduced blood volume leads to decreased preload and stroke volume.
- Anxiety and Stress: Can exacerbate cardiovascular strain.
As Evidenced By:
- Tachycardia: Heart rate increases to compensate for reduced cardiac output.
- Hypotension: Blood pressure decreases due to reduced blood volume.
- Pallor and Cyanosis: Reflects decreased tissue perfusion and oxygenation.
- Fatigue and Weakness: Result from reduced oxygen delivery to tissues.
- Dizziness and Lightheadedness: Due to decreased cerebral perfusion.
- Restlessness and Anxiety: Body’s response to physiological stress.
- ECG Changes (in severe cases): May indicate myocardial ischemia.
- Decreased Peripheral Pulses: Weak or thready pulses reflect reduced peripheral perfusion.
- Prolonged Capillary Refill: Indicates poor peripheral circulation.
- Oliguria (decreased urine output): Kidneys attempt to conserve fluid.
Expected Outcomes:
- Patient will maintain stable vital signs within acceptable limits for pregnancy.
- Patient will demonstrate adequate tissue perfusion, evidenced by warm and dry skin, strong peripheral pulses, and stable mental status.
- Patient will remain free from complications of decreased cardiac output, such as shock or organ dysfunction.
Nursing Assessments:
- Continuous Vital Sign Monitoring: Closely monitor blood pressure, heart rate, respiratory rate, and oxygen saturation. Note trends and report significant changes immediately.
- Assess for Signs of Hypovolemic Shock: Be vigilant for signs of shock, including rapid heart rate, low blood pressure, altered mental status (confusion, lethargy), cool, clammy skin, and decreased urine output.
- Evaluate Level of Consciousness: Changes in mental status can be an early indicator of decreased cerebral perfusion. Assess orientation, alertness, and responsiveness.
- Monitor Fetal Heart Rate (FHR): Continuous fetal monitoring is essential to assess fetal well-being and detect signs of fetal distress related to maternal hypovolemia.
- Assess Bleeding: Quantify vaginal bleeding – note the amount, color, and presence of clots. Use pads and weigh them to estimate blood loss accurately.
- Review Laboratory Values: Monitor hemoglobin and hematocrit levels to assess the extent of blood loss and the need for blood transfusion.
Nursing Interventions:
- Ensure Bed Rest: Promote bed rest to minimize activity and reduce the risk of further bleeding. Position the patient on her left side to enhance uteroplacental blood flow.
- Administer Intravenous Fluids: Initiate and maintain IV fluid administration as prescribed to restore and maintain intravascular volume. Crystalloids (e.g., Lactated Ringers, Normal Saline) are typically used initially.
- Prepare for Blood Transfusion: Type and crossmatch the patient’s blood and have blood products readily available in case of significant blood loss and need for transfusion. Administer blood transfusions as ordered.
- Administer Oxygen Therapy: Provide supplemental oxygen as needed to maintain adequate maternal and fetal oxygenation, especially if signs of fetal distress or maternal hypoxemia are present.
- Medication Administration: Administer tocolytic medications (e.g., magnesium sulfate) as prescribed to inhibit preterm labor if the pregnancy is preterm and delivery is not immediately necessary. Corticosteroids may also be administered to promote fetal lung maturity if preterm delivery is anticipated.
- Maintain Calm Environment: Reduce patient anxiety by providing a calm and reassuring environment. Explain procedures and treatments clearly and answer questions honestly. Anxiety can exacerbate physiological stress.
- Prepare for Potential Cesarean Delivery: Placenta previa often necessitates cesarean delivery. Prepare the patient physically and emotionally for this possibility. Ensure informed consent is obtained.
- Assist with Surgical Interventions: In cases of severe hemorrhage, be prepared to assist with surgical interventions such as uterine artery ligation, compression sutures, or hysterectomy if conservative measures fail to control bleeding.
- Strict Intake and Output Monitoring: Accurately monitor and record fluid intake and output to assess fluid balance and kidney function.
2. Deficient Fluid Volume
Nursing Diagnosis: Deficient Fluid Volume related to active blood loss secondary to placenta previa, as evidenced by decreased blood pressure, increased heart rate, and vaginal bleeding.
Related Factors:
- Bleeding: Vaginal bleeding is the primary cause of fluid volume deficit.
- Disrupted Placental Implantation: The underlying pathology leading to bleeding.
- Hypovolemia: Direct result of blood loss.
As Evidenced By:
- Hypotension: Systolic and diastolic blood pressure decreases.
- Tachycardia: Heart rate increases to compensate for decreased volume.
- Decreased Pulse Pressure: The difference between systolic and diastolic blood pressure narrows.
- Altered Mental Status: Confusion, restlessness, or lethargy due to decreased cerebral perfusion.
- Decreased Hemoglobin and Hematocrit: Reflects blood loss.
- Dry Mucous Membranes and Poor Skin Turgor: Signs of dehydration, though less specific to acute blood loss.
- Oliguria: Reduced urine output as the body attempts to conserve fluid.
- Weak Peripheral Pulses: Reduced volume leads to weaker pulses.
- Vaginal Bleeding: Overt sign of fluid loss.
Expected Outcomes:
- Patient will demonstrate adequate fluid volume, evidenced by stable vital signs, urine output of at least 30 mL/hour, and moist mucous membranes.
- Patient will maintain hemodynamic stability throughout hospitalization.
- Patient will adhere to activity restrictions to minimize the risk of further bleeding.
Nursing Assessments:
- Monitor Vital Signs Frequently: Pay close attention to blood pressure and heart rate trends. Hypotension and tachycardia are key indicators of fluid volume deficit.
- Assess for Signs of Dehydration: Evaluate mucous membranes for dryness, assess skin turgor (though less reliable in pregnant women), and monitor for thirst.
- Quantify Blood Loss: Accurately assess and document the amount of vaginal bleeding. Use objective measures like pad counts and weighing pads when possible.
- Monitor Urine Output: Insert a Foley catheter as ordered for accurate monitoring of urine output. Oliguria is an important sign of hypovolemia.
- Review Laboratory Values: Monitor hemoglobin, hematocrit, and electrolyte levels. Decreasing hemoglobin and hematocrit indicate blood loss.
- Assess Mental Status: Changes in mental status can indicate decreased cerebral perfusion due to hypovolemia.
Nursing Interventions:
- Administer IV Fluids: Initiate and maintain intravenous fluid therapy as prescribed. Isotonic crystalloids are the initial fluids of choice to expand intravascular volume.
- Prepare for Blood Product Administration: Have blood products readily available and administer transfusions as ordered to replace blood loss and improve oxygen-carrying capacity.
- Strict Intake and Output: Maintain meticulous records of fluid intake and output to guide fluid replacement therapy.
- Monitor Fetal Heart Rate: Continuous fetal monitoring is crucial to assess fetal well-being and detect signs of fetal distress secondary to maternal hypovolemia.
- Administer Medications as Ordered: Administer tocolytics and corticosteroids as prescribed, as discussed in the Decreased Cardiac Output section.
- Educate Patient on Activity Restrictions: Explain the importance of bed rest and activity limitations to minimize the risk of further placental disruption and bleeding.
- Provide Perineal Care: Provide frequent perineal care to maintain comfort and hygiene, especially with ongoing vaginal bleeding.
- Monitor for Complications of Fluid Replacement: Assess for signs of fluid overload, although less common in the context of hemorrhage, especially if blood products are also being administered.
3. Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility related to prescribed activity restrictions and bed rest for placenta previa management, as evidenced by imposed limitations on movement.
Related Factors:
- Activity Restrictions: Medical recommendations to limit activity to reduce bleeding risk.
- Bed Rest: May be prescribed to minimize placental disruption.
- Fear of Bleeding: Patient may be hesitant to move due to anxiety about triggering bleeding.
As Evidenced By:
- Medical Protocol Requiring Reduced Activity: Explicit orders for bed rest or limited activity.
- Patient Verbalization of Difficulty with Movement: Patient may express frustration or difficulty with restricted mobility.
- Decreased Muscle Strength (potential, with prolonged bed rest): Prolonged inactivity can lead to muscle weakness.
Expected Outcomes:
- Patient will verbalize understanding of and adherence to prescribed activity restrictions.
- Patient will maintain muscle strength and joint mobility to the extent possible within activity limitations.
- Patient will demonstrate strategies to prevent complications of immobility, such as pressure ulcers and constipation.
Nursing Assessments:
- Assess Baseline Activity Level: Determine the patient’s usual activity level to understand the impact of activity restrictions.
- Assess Understanding of Activity Restrictions: Evaluate the patient’s understanding of the rationale for activity limitations and the specific restrictions prescribed.
- Assess Physical Capabilities: Assess muscle strength, range of motion, and functional mobility within the context of prescribed restrictions.
- Identify Support System: Assess the availability of support at home for ADLs if activity restrictions are to continue after discharge.
- Assess for Psychosocial Impact of Immobility: Inquire about the patient’s feelings regarding activity restrictions and potential impact on daily life and emotional well-being.
Nursing Interventions:
- Educate on Rationale for Activity Restrictions: Thoroughly explain the reasons for reduced activity, emphasizing its role in minimizing placental stress and bleeding risk.
- Clarify Specific Activity Orders: Provide clear, written instructions regarding permitted activity levels. Address questions and clarify any ambiguities. Often, “pelvic rest” is prescribed, meaning nothing in the vagina, and limitations on strenuous activity. Strict bed rest is less common now but may still be indicated in some situations.
- Encourage Active Range of Motion (AROM) Exercises: Instruct and encourage the patient to perform AROM exercises within the limitations of bed rest or activity restrictions to maintain joint mobility and muscle tone. Focus on extremities.
- Promote Circulation: Teach leg exercises (ankle pumps, calf stretches) to improve circulation and prevent deep vein thrombosis (DVT), especially if bed rest is prolonged.
- Prevent Skin Breakdown: Implement pressure ulcer prevention strategies, including frequent repositioning (within activity limits), pressure-relieving devices (special mattresses or cushions), and skin assessment.
- Prevent Constipation: Encourage adequate fluid intake (within medical limitations), fiber-rich foods if tolerated, and stool softeners as prescribed to prevent constipation associated with decreased mobility.
- Address Psychosocial Needs: Recognize the emotional impact of activity restrictions and bed rest. Provide emotional support, encourage verbalization of feelings, and facilitate access to social work or counseling services if needed. Help the patient find diversional activities suitable for bed rest, such as reading, watching movies, or engaging in hobbies that can be done in bed.
- Ensure Safety: Maintain a safe environment, especially if the patient is getting out of bed for limited activities. Ensure the call bell is within reach, provide assistance with ambulation as needed, and keep the bed in a low position.
4. Risk for Bleeding
Nursing Diagnosis: Risk for Bleeding related to placenta previa and potential for placental disruption during pregnancy and labor.
Related Factors:
- Placenta Previa: Abnormal placental location predisposes to bleeding.
- Low-Lying Placenta: Even if not completely previa, a low-lying placenta increases bleeding risk.
- Uterine Contractions (Braxton Hicks or Labor): Can cause placental separation and bleeding.
- Sexual Intercourse/Vaginal Penetration: Can disrupt the placenta.
- Vaginal Examinations: Should be avoided unless absolutely necessary and placenta previa is ruled out or delivery is imminent.
- Strenuous Activity: Can increase risk.
As Evidenced By:
- (Risk Diagnosis – No “As Evidenced By” – Potential problem not yet present) Risk diagnoses are based on risk factors, not current signs and symptoms.
Expected Outcomes:
- Patient will remain free from episodes of significant bleeding throughout pregnancy and labor to the extent possible.
- Patient will demonstrate understanding of and adherence to precautions to minimize bleeding risks.
- Patient will deliver the infant without excessive blood loss.
Nursing Assessments:
- Monitor Vital Signs: Regularly assess vital signs, particularly blood pressure and heart rate, to detect early signs of bleeding (tachycardia, hypotension).
- Assess for Vaginal Bleeding: Continuously monitor for any vaginal bleeding – note amount, color, and characteristics.
- Review Ultrasound Reports: Confirm placental location and type of placenta previa (complete, partial, marginal, low-lying) from ultrasound reports.
- Assess Patient Understanding of Risk Factors: Evaluate the patient’s knowledge about activities that can increase bleeding risk.
- Monitor Coagulation Studies (if indicated): If there are concerns about bleeding diathesis or if bleeding is significant, monitor coagulation studies (PT, PTT, platelets).
Nursing Interventions:
- Educate on Bleeding Precautions: Provide thorough patient education regarding activities to avoid to minimize bleeding risk. This includes:
- Pelvic Rest: Strict avoidance of sexual intercourse, vaginal douching, tampons, and anything inserted into the vagina.
- Avoid Strenuous Activity and Heavy Lifting: Limit physical exertion and lifting more than 20 pounds.
- Report Any Vaginal Bleeding Immediately: Instruct the patient to promptly report any vaginal bleeding, no matter how minimal.
- Avoid Vaginal Examinations: Emphasize that vaginal examinations are contraindicated in the presence of placenta previa unless delivery is imminent and placenta previa has been confirmed and planned for.
- Prepare for Potential Blood Transfusion: Ensure the patient’s blood type and antibody screen are current, and type and crossmatch blood if indicated as a precaution for potential transfusion.
- Administer Blood Products as Ordered: Be prepared to administer blood transfusions if bleeding occurs and is significant.
- Monitor Fetal Heart Rate: Closely monitor fetal heart rate for signs of fetal distress, which can occur with maternal bleeding.
- Prepare for Cesarean Delivery: Anticipate the likelihood of cesarean delivery, especially for complete and partial placenta previa. Prepare the patient physically and emotionally for surgery. Educate about the surgical procedure, pre-operative and post-operative care.
- Administer Tocolytics and Corticosteroids (as indicated): As discussed previously, these medications may be used in preterm pregnancies.
- Ensure Ready Access to Emergency Care: For patients discharged home with placenta previa, ensure they understand the importance of immediate access to a hospital and emergency care if bleeding occurs. Provide clear instructions on when and how to seek emergency medical attention.
5. Situational Low Self-Esteem
Nursing Diagnosis: Situational Low Self-Esteem related to changes in health status and pregnancy complications associated with placenta previa, as evidenced by verbalizations of helplessness, guilt, and negative self-perception.
Related Factors:
- Change in Health Status: Diagnosis of placenta previa represents a deviation from a normal, healthy pregnancy.
- Situational Crisis: Pregnancy complications are inherently stressful and can be perceived as a crisis.
- Fear for Fetal Well-being: Concerns about the baby’s health and survival contribute to emotional distress.
- Perceived Loss of Control: Lack of control over the placental position and the need for medical interventions can lead to feelings of helplessness.
- Guilt (Unwarranted): Patients may mistakenly believe they caused the placenta previa or could have prevented it, leading to guilt.
As Evidenced By:
- Expresses Helplessness: Statements indicating a lack of control or inability to influence the situation.
- Self-Negating Verbalizations: Negative statements about self-worth or abilities.
- Underestimates Ability to Deal with Situation: Expresses doubt in coping mechanisms.
- Expresses Guilt or Shame: Verbalizes feelings of responsibility or blame for the condition.
- Withdrawal: Social withdrawal or decreased interaction.
- Anxiety and Depression: May exhibit signs of anxiety or depression related to the diagnosis.
- Negative Body Image: Concerns about body changes and the impact of pregnancy complications on self-perception.
Expected Outcomes:
- Patient will verbalize acceptance of the diagnosis and demonstrate a more positive outlook regarding her pregnancy.
- Patient will participate actively in her care and adhere to the treatment plan.
- Patient will express improved self-esteem and confidence in her ability to cope with the situation.
- Patient will utilize available support systems effectively.
Nursing Assessments:
- Assess Emotional State: Regularly assess the patient’s emotional status and mood. Inquire about feelings related to the diagnosis, pregnancy, and potential outcomes.
- Identify Support Systems: Determine the availability and quality of the patient’s social support network (partner, family, friends).
- Assess Coping Mechanisms: Evaluate the patient’s usual coping strategies and their effectiveness in dealing with the current situation.
- Screen for Depression and Anxiety: Use standardized screening tools or questionnaires to assess for symptoms of depression and anxiety.
- Assess Self-Perception: Explore the patient’s feelings about herself, her body, and her role as a mother in the context of placenta previa.
- Listen Actively and Empathetically: Provide a safe and supportive environment for the patient to express her feelings and concerns without judgment.
Nursing Interventions:
- Provide Emotional Support: Offer reassurance, empathy, and a non-judgmental listening ear. Acknowledge and validate the patient’s feelings and anxieties.
- Educate About Placenta Previa: Provide accurate and understandable information about placenta previa, its causes (often unknown or multifactorial), risk factors, and management. Emphasize that it is not the patient’s fault and that she did not cause it. Correct any misconceptions or misinformation.
- Focus on Controllable Factors: Help the patient identify aspects of the situation she can control, such as adherence to activity restrictions, reporting symptoms promptly, and participating in her care. Empower her to take an active role in managing her health.
- Promote Positive Self-Talk: Encourage the patient to engage in positive self-talk and challenge negative thoughts. Help her reframe negative perceptions into more balanced and realistic perspectives.
- Facilitate Support Systems: Encourage the patient to utilize her support network. Facilitate communication with her partner, family, or friends.
- Refer to Support Groups or Counseling: Connect the patient with support groups for women with high-risk pregnancies or pregnancy complications. Refer for professional counseling or therapy if needed, especially if symptoms of depression or anxiety are significant.
- Promote Realistic Expectations: Help the patient develop realistic expectations for her pregnancy and delivery. Prepare her for the possibility of cesarean delivery and potential complications, while also emphasizing the positive aspects and the goal of a healthy mother and baby.
- Involve Partner/Family: Include the patient’s partner or family in education and support efforts, as appropriate, to create a cohesive support system.
Conclusion
Effective nursing care for patients with placenta previa hinges on accurate nursing diagnoses and comprehensive, patient-centered care plans. By understanding the key nursing diagnoses – Decreased Cardiac Output, Deficient Fluid Volume, Impaired Physical Mobility, Risk for Bleeding, and Situational Low Self-Esteem – nurses can proactively address the physiological and psychological challenges posed by this condition. Vigilant assessment, timely interventions, thorough patient education, and compassionate emotional support are essential to optimize maternal and fetal outcomes and empower women facing placenta previa throughout their pregnancy journey. This detailed guide provides a robust framework for nurses to deliver exceptional care and make a significant positive impact on the lives of their patients.
References
- American College of Obstetricians and Gynecologists (ACOG). (2018). Placenta previa. Practice Bulletin No. 175. Obstetrics & Gynecology, 132(6), e271-e288.
- Anderson-Bagga FM, & Sze A. (2022). Placenta previa. In StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539818/
- Bakker, R. (2018). Placenta previa. Medscape. Updated: Jan 08, 2018. From: https://emedicine.medscape.com/article/262063-overview
- Ignatavicius, D. D., Workman, M. L., & Rebar, C. R. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care (9th ed.). Elsevier, Inc.
- Mayo Clinic. (2022). Placenta previa. Updated May 11, 2022. From: https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768
- WebMD. (2020). Placenta Previa. Reviewed by Arefa Cassoobhoy, MD, MPH. Updated July 28, 2020. From: https://www.webmd.com/baby/guide/what-is-placenta-previa
