HISTORY. Obtain an obstetric history. Determine the date of the last menstrual period to calculate the estimated day of delivery and gestational age of the infant. Inquire about alcohol, tobacco, and drug usage, and any trauma or abuse situations during pregnancy. Ask the patient to describe the onset of bleeding (the circumstances, amount, and presence of pain). When obtaining a history from a patient with an abruption, recognize that it is possible for her to be disoriented from blood loss and/or cocaine or other drug usage. Generally, patients have one of the risk factors, but sometimes no clear precursor is identifiable.

PHYSICAL EXAMINATION. Assess the amount and character of vaginal bleeding; blood is often dark red in color, and the amount may vary, depending on the location of abruption. Palpate the uterus; patients complain of uterine tenderness and abdominal/back pain. The fundus is woodlike, and poor resting tone can be noted. With a mild placental separation, contractions are usually of normal frequency, intensity, and duration. If the abruption is more severe, strong, erratic contractions occur. Assess for signs of concealed hemorrhage: slight or absent vaginal bleeding; an increase in fundal height; a rigid, boardlike abdomen; poor resting tone; constant abdominal pain; and late decelerations or decreased variability of the fetal heart rate. A vaginal exam should not be done until an ultrasound is performed to rule out placenta previa.

Using electronic fetal monitoring, determine the baseline fetal heart rate and presence or absence of accelerations, decelerations, and variability. At times, persistent uterine hypertonus is noted with an elevated baseline resting tone of 20 to 25 mm Hg. Ask the patient if she feels the fetal movement. Fetal position and presentation can be assessed by Leopold's maneuvers. Assess the contraction status, and view the fetal monitor strip to note the frequency and duration of contractions. Throughout labor, monitor the patient's bleeding, vital signs, color, urine output, level of consciousness, uterine resting tone and contractions, and cervical dilation. If placenta previa has been ruled out, perform sterile vaginal exams to determine the progress of labor. Assess the patient's abdominal girth hourly by placing a tape measure at the level of the umbilicus. Maintain continuous fetal monitoring.

PSYCHOSOCIAL. Assess the patient's understanding of the situation and also the significant other's degree of anxiety, coping ability, and willingness to support the patient.

Diagnostic Highlights

General Comments: Abruptio placentae is diagnosed based on the clinical symptoms, and the diagnosis is confirmed after delivery by examining the placenta.

Abnormality with

Test Normal Result Condition Explanation

Pelvic ultrasound Placenta is visualized in None; ultrasound is used If the placenta is in the lower the fundus of the uterus to rule out a previa uterine segment, a previa

(not an abruption) exists

Other Tests: Complete blood count (CBC); coagulation studies; type and crossmatch; nonstress test and biophysical profile are done to assess fetal well-being

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