Now let's talk about an abruptio placenta.
So an abruptio placenta occurs when
there's separation of the placenta
from the uterine wall prior to delivery.
So hopefully we have a baby that comes out and
then a little bit later the placenta comes out.
Because remember, the placenta is the lungs and,
and it's our filter, and it's everything else.
So if it comes out first and the baby's
sort of hanging out with no oxygen,
so we need to make sure that the
baby comes out, and then placenta.
With an abruption, it's the opposite.
This affects about one in 100 pregnancies.
And when we think about risk factors,
anything that's going to cause
premature separation of the placenta
may be related to hypertension,
and this could be chronic,
or it could be preeclampsia.
Any type of abdominal trauma, so someone
who's involved in a motor vehicle accident,
someone who falls or anything else.
Why cocaine specifically?
Because it's a rapid vasoconstrictor and the
placenta, if nothing else, it has lots of vessels.
So anything that's going to cause a
rapid vasoconstriction of the placenta
will cause it to separate from the uterine wall.
A history of an abruption in a previous pregnancy,
Again, smoking, premature rupture of the membranes,
they may all be connected to something else,
and multiple gestation.
And this has to do with overdistending the uterus.
So anything that would cause the uterus to
be overdistended, like having lots of babies,
or having polyhydramnios, which is lots of
fluid, would also cause abruptio placenta.
And one final risk factor I want to talk
about could be something that we cause.
If a client is being induced or
augmented in their labor with oxytocin,
we're giving the medication
to stimulate contractions.
If those contractions get too close
together, and we overstimulate the uterus,
it can cause the placenta to
separate from the uterine wall.
So that could be a reason that we cause.
Thinking about the assessment, so remember, with
placenta previa, the uterus is soft and it's painless,
and abruptio placenta is exactly the opposite.
The pain is sharp, it's sudden, and it feels
like stabbing pain right in the abdomen.
So it is very, very painful.
So abruptio is painful, placenta previa is not.
We also may notice hypertonic or
tachysystole on our fetal heart rate monitor,
so the contractions are coming too close together.
We may notice fetal distress.
So again, we may see late decelerations
from poor perfusion through the placenta,
or we may just see plain old bradycardia.
If the placenta completely separates from the
uterine wall, the baby won't be getting any oxygen,
and then you'll see the heart rate just begin
to plummet and it will not return to baseline.
If the bleeding is profound, then we may
notice that the client exhibit signs of shock
so that will be from blood loss.
We may see changes in the hemoglobin and
hematocrit, and we may see issues with clotting.
So if the bleeding goes on for a prolonged
period of time, we may get to the point where
disseminated intravascular coagulopathy happens
and so then we have a client who is bleeding out.
So we may see petechiae, we may see bleeding
from the IV site and all kinds of things.
So what do we do about an abruptio placenta?
Well, first we're going to do an ultrasound,
and the ultrasound is going to let us know
what the integrity of the placenta is.
So is the placenta totally adhered to
the uterine wall like it should be?
Or do we notice blood collecting
either in the center of the placenta,
or the top or bottom or sides.
So we're looking for blood collection that would let
us know that there's been a premature separation.
We may also do a biophysical profile to
check on the well being of the fetus.
So remember, this is also an ultrasound and
we're looking at tone and respiratory reflex
and we're looking for movement of the fetus,
amniotic fluid, and then also a non-stress test
to make sure that we have good fetal well being.
In the case of a complete abruption, this
is not going to allow for a vaginal birth.
We will do a Caesarean birth so
that we can get the baby out.
Remember, if that placenta separates
from the uterine wall, we have separated
their ability to breathe so
we've got to get them out.
So a complete abruption is an absolute emergency
and we have a very few minutes to make sure that
that baby is going to be delivered alive.
In terms of assessment for the nurse,
One of our biggest things that we're
going to do is to feel the uterus.
Our best diagnostic tool is our hands.
And so remember, for a placenta
previa, the uterus is soft.
In this particular case, the
uterus is going to feel rock hard
because there's blood building up behind
that placenta and it's going to create
pressure inside the uterine cavity.
So a rock hard, painful uterus
is going to be what we notice.
When we look on the fetal monitor, we may
find that we're having late decelerations,
we may find that the resting tone
on the toco has started to elevate,
or we may notice that contractions
are coming a lot closer together,
and there's no rest in between.
That lets us know what the uterus is doing.
We also are going to monitor the
hemodynamic status of the birthing person.
So are we noticing changes in
their hemoglobin and hematocrit?
That might be a sign that we're going into shock.
We're going to administer IV
fluids and maybe blood products
depending on what the amount of blood loss is.
We're going to monitor urinary output.
Again, if we're getting into a
situation where shock is developing,
this may be a place that we begin to notice that,
and we're going to provide emotional support.
This is scary stuff.
So clients can actually die from the
bleeding, they may lose the baby,
and there are going to be lots of
people coming in and out of the room
so we need to be in constant communication
with that person and their family
to let them know what's going
on, what do we need to do next.
We need to prepare for the birth.
So if we are able to deliver vaginally because
it's a partial separation or delivery is imminent,
we need to be thinking about
what could happen postpartum.
So being prepared, making sure that we have
a CBC and this patient is typed and crossed.
If we're going to the emergency
room for a crash Caesarean,
that we're ready also for that.