U Assessment

HISTORY. Although many women who develop placenta previa have an unremarkable obstetric or gynecologic history, some have had previous uterine surgeries or infections. The

734 Placenta Previa prenatal course of the current pregnancy is often uneventful until the patient experiences a bout of bright red, painless bleeding. Question the patient as to the onset and amount of bleeding first noticed. The initial bleeding in placenta previa is often scant because few uterine sinuses are exposed.

PHYSICAL EXAMINATION. The classic sign of placenta previa is painless, bright red bleeding; assess the amount and character of blood loss. Most often this bleeding occurs between 28 and 34 weeks when the lower uterine segment thins and the low implantation site is disrupted. With a marginal or low-lying placenta previa, the bleeding may not start until the patient is in labor. Assess the uterus for contractions; unless the patient is in labor, the uterus is relaxed and nontender. A vaginal examination should not be performed because even the gentlest examination can cause immediate hemorrhage.

Check the vital signs; note any symptoms of hypovolemic shock (restlessness; agitation; increased pulse; delayed capillary blanching; increased respirations; pallor; cool, clammy skin; hypotension; and oliguria). Monitor the baseline fetal heart rate and the presence or absence of accelerations, decelerations, and variability in the electronic fetal monitoring (EFM).

Ask the patient if she feels the fetus move. Assess the fetal position and presentation by using Leopold's maneuvers. Monitor the patient's contraction status, and palpate the fundus to determine the intensity of contractions. View the fetal monitor strip to assess the frequency and duration of the contractions; more often, the uterus is soft and nontender, unless the patient is in labor. Throughout the patient's hospitalization, continue to monitor for signs of hypovolemic shock and the amount and character of bleeding. Maintain continuous EFM until bleeding ceases; then, if hospital policy permits, monitor the fetus for 30 minutes every 4 hours.

PSYCHOSOCIAL. The heavy, bright red bleeding that often accompanies placenta previa is anxiety producing for the mother and significant others. The patient is concerned not only for herself but also for the well-being of the infant. Determine the patient's support system because many of these patients have been on complete bedrest for an extended period of time. Assess the effect of prolonged bedrest on the patient's job, childcare, interpersonal, financial, and social responsibilities.

Diagnostic Highlights

General Comments: Vaginal exams are contralndlcated for a pregnant patient who Is bleeding until a previa Is ruled out by ultrasound visualization.

Test

Normal Result

Abnormality with Condition

Explanation

Transvaginal ultrasound (preferred); also done is a transabdominal ultrasound

Placental implantation visualized in fundus of uterus

Placental implantation visualized in lower uterine segment

Visualization of placenta determines location and can rule out other causes of bleeding (e.g., abruption, cervical lesion, excessive show)

Red blood cell (RBC) count

4-5.4 mL/mm3

Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

Hemoglobin (Hgb)

12-16 g/dL

Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

Hematocrit (Hct)

37%-47%

Decreases several hours after significant blood loss has occurred

Active bleeding causes decrease

Other Tests: Blood type and crossmatch; coagulation studies If bleeding Is excessive

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