Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus. It is the most common cause of painless bleeding in the third trimester of pregnancy. It occurs in four degrees: low-lying placenta, which is implantation in the lower rather than in the upper portion of the uterus; marginal implantation, in which the placenta edge approaches that of the cervical os; partial placenta previa, which is implantation that occludes a portion of the cervical os; and total placenta previa, in which the implantation totally obstructs the cervical os.
Increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestations, and perhaps a male fetus are all associated with placenta previa.
"Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa."
Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa. The bleeding in placenta previa doesn’t usually begin, however, until the lower uterine segment starts to differentiate from the upper segment late in pregnancy (week 30) and the cervix begins to dilate. At this point, because the placenta is unable to stretch to accommodate the different shapes of the lower uterine segment or the cervix, a small portion loosens, and damaged blood vessels begin to bleed.
Nursing Care Plans
Nursing care management and treatment of placenta previa is designed to assess, control, and restore blood loss and to deliver a viable infant. Immediate therapy includes starting an IV line using a large bore catheter.
Here are four (4) placenta previa nursing care plans and nursing diagnoses:
Risk for Deficient Fluid Volume
The bleeding of placenta previa, like that of ectopic pregnancy, creates an emergency situation as the open vessels of the uterine decidua place the client at risk for hemorrhage. Postpartum hemorrhage may occur because the lower uterine segment, where the placenta was attached, has fewer muscle fibers than the upper uterus. The resulting weak contraction of the lower uterus does not compress the open blood vessels at the placental site as effectively as would the upper segment of the uterus.
- Risk for Deficient Fluid Volume
- Excessive vaginal bleeding
- Damaged uterine blood vessels
Possibly evidenced by
- (Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
- The client will maintain fluid volume at a functional level, possibly evidenced by adequate urinary output and stable vital signs.
- The client will display homeostasis as evidenced by the absence of bleeding.
Nursing Assessment and Rationales
1. Assess color, odor, consistency, and amount of vaginal bleeding.
Inspect the perineum for bleeding and estimate the present rate of blood loss. The bleeding with placenta previa is usually abrupt, painless, bright red, and sudden. The bleeding may be provoked by intercourse, vaginal examinations, or labor, and at times there may be no identifiable cause (Anderson-Bagga & Sze, 2019).
2. Monitor the client’s vital signs.
Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff. Signs of hypovolemic shock include hypotension, tachycardia, and tachypnea.
3. Assess hourly intake and output.
Monitor urine output frequently, as often as every hour, as an indicator that the client’s blood volume is remaining adequate to perfuse her kidneys.
4. Assess abdomen for tenderness or rigidity- if present, measure abdomen at the umbilicus (specify time interval).
A thorough abdominal examination to identify uterine tenderness can be useful in differentiating other causative factors for vaginal bleeding, including uterine rupture and placental abruption. Measure the abdominal girth to determine if the bleeding is progressing (Bakker & Smith, 2018).
5. Monitor the fetal heart rate and uterine contractions continuously.
Attach external monitoring equipment to record fetal heart sounds and uterine contractions; however, avoid the use of an internal monitor for either fetal or uterine assessment to prevent hemorrhage. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.
Nursing Interventions and Rationales
1. Weigh perineal pads to estimate blood loss.
Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss.
2. Avoid vaginal examinations.
Because of the risk of provoking life-threatening hemorrhage, a digital examination of the vagina is absolutely contraindicated until placenta previa is excluded. Instruments should not be placed near the cervix because uncontrolled bleeding can result (Bakker & Smith, 2018). If placenta previa is suspected and ultrasound is unavailable, the provider may perform a vaginal examination with preparations for both vaginal and cesarean births (a double set-up) in place.
3. Position the client supine with hips elevated if ordered or in a left side-lying position.
To ensure an adequate blood supply to the client and fetus, place the client immediately on bed rest in a left side-lying position. The left side-lying position decreases pressure on the placenta and cervical os and improves placental perfusion.
4. Review ultrasound and laboratory results.
Routine sonography in the first and second trimesters of pregnancy provides early identification of placenta previa. A follow-up sonogram is recommended at 28 to 32 weeks of gestation to look for persistent placenta previa (Bakker & Smith, 2018). If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen is assessed to establish baselines, detect a possible clotting disorder, and ready blood for replacement if necessary.
5. Perform an Apt or Kleihauer-Betke test.
If there is concern about fetal-maternal transfusion, a Kleihauer-Betke test can be performed. These are test strip procedures that can be used to detect whether the blood is fetal or maternal in origin.
6. Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min.
Have oxygen equipment available in case the fetal heart sounds indicate fetal distress, such as bradycardia or tachycardia, late deceleration, or variable decelerations during the exam. Oxygen supplementation increases available oxygen to saturate decreased hemoglobin.
7. Initiate IV fluids as ordered (specify fluid type and rate).
Administer intravenous fluid as prescribed, preferably with a large-gauge catheter to allow for blood replacement through the same line. Attach Ringer’s lactate or normal saline at a rapid rate if a shock is present. Reduce the infusion rate to 3 ml/min when the pulse slows down to less than 100 beats/min and systolic BP increases to 100 mm Hg or higher (World Health Organization, 2015).
8. Administer tocolytic agents as prescribed.
Tocolysis may be considered in cases of minimal bleeding and extreme prematurity in order to administer antenatal corticosteroids. One study appeared to suggest that the use of tocolytics increases the pregnancy duration and the baby’s birth weight without causing adverse effects on the mother and the fetus (Bakker & Smith, 2018).
9. Administer blood and blood products as indicated.
In instances where significant bleeding ensues, rapid replacement of blood products is a priority. Activation of the Massive Transfusion Protocol is warranted, allowing for stabilization of the client’s hemodynamic status by way of a rapid supply of blood products (Bakker & Smith, 2018).
10. Prepare for a vaginal or cesarean birth.
Vaginal birth is always safest for the infant. If the previa is under 30% by abdominal or transvaginal ultrasound, it may be possible for the fetus to be born past it. If over 30% and the fetus is mature, the safest birth method for both mother and baby is often cesarean birth.
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her baby:
- Abortion (Termination of Pregnancy) | 8 Care Plans
- Cervical Insufficiency (Premature Dilation of the Cervix) | 4 Care Plans
- Cesarean Birth | 11 Care Plans
- Cleft Palate and Cleft Lip | 7 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans
- Hyperbilirubinemia (Jaundice) | 4 Care Plans
- Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor | 45 Care Plans
- Neonatal Sepsis | 8 Care Plans
- Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans
- Placental Abruption | 4 Care Plans
- Placenta Previa | 4 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 5 Care Plans
- Prenatal Hemorrhage (Bleeding in Pregnancy) | 9 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans
- Prenatal Infection | 5 Care Plans
- Preterm Labor | 7 Care Plans
- Puerperal & Postpartum Infections | 5 Care Plans
- Substance Abuse in Pregnancy | 9 Care Plans
References and Sources
- Anderson-Bagga, F., & Sze, A. (2019, April). Home. YouTube. Retrieved September 13, 2022.
- Bakker, R., & Smith, C. V. (2018, January 8). Placenta Previa: Practice Essentials, Pathophysiology, Etiology. Medscape Reference. Retrieved September 13, 2022.
- Balayla, J., Desilets, J., & Shrem, G. (2019, July 13). Placenta previa and the risk of intrauterine growth restriction (IUGR): a systematic review and meta-analysis. Journal of Perinatal Medicine, 47(6), 577-584.
- Bany, F. M., & Rosenkrantz, T. (2018, May 8). Chorioamnionitis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved September 14, 2022.
- Hassan, S. S. (2010). The frequency and clinical significance of intra-amniotic infection and/or inflammation in women with placenta previa and vaginal bleeding: an unexpected observation. PubMed. Retrieved September 14, 2022.
- Klabunde, R. E. (2021). Cardiovascular Physiology Concepts (R. E. Klabunde, Ed.). Lippincott Williams & Wilkins.
- Kolecki, P., & Brenner, B. E. (2022, September 1). Hypovolemic Shock Treatment & Management: Prehospital Care, Emergency Department Care. Medscape Reference. Retrieved September 13, 2022.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Udeani, J., & Geibel, J. (2018, September 12). Hemorrhagic Shock: Background, Pathophysiology, Epidemiology. Medscape Reference. Retrieved September 14, 2022.
- World Health Organization. (2015). Emergency Treatments for the Woman – Pregnancy, Childbirth, Postpartum and Newborn Care. NCBI. Retrieved September 13, 2022.