Abruptio Placenta – Late Pregnancy Bleeding (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Now let's talk about an abruptio placenta.

    00:04 So an abruptio placenta occurs when there's separation of the placenta from the uterine wall prior to delivery.

    00:12 So hopefully we have a baby that comes out and then a little bit later the placenta comes out.

    00:18 Because remember, the placenta is the lungs and, and it's our filter, and it's everything else.

    00:23 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.

    00:32 With an abruption, it's the opposite.

    00:35 This affects about one in 100 pregnancies.

    00:38 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.

    00:50 Any type of abdominal trauma, so someone who's involved in a motor vehicle accident, someone who falls or anything else.

    00:58 Cocaine use.

    00:59 Why cocaine specifically? Because it's a rapid vasoconstrictor and the placenta, if nothing else, it has lots of vessels.

    01:06 So anything that's going to cause a rapid vasoconstriction of the placenta will cause it to separate from the uterine wall.

    01:14 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.

    01:25 And this has to do with overdistending the uterus.

    01:27 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.

    01:40 And one final risk factor I want to talk about could be something that we cause.

    01:44 If a client is being induced or augmented in their labor with oxytocin, we're giving the medication to stimulate contractions.

    01:53 If those contractions get too close together, and we overstimulate the uterus, it can cause the placenta to separate from the uterine wall.

    02:01 So that could be a reason that we cause.

    02:06 Thinking about the assessment, so remember, with placenta previa, the uterus is soft and it's painless, and abruptio placenta is exactly the opposite.

    02:16 The pain is sharp, it's sudden, and it feels like stabbing pain right in the abdomen.

    02:21 So it is very, very painful.

    02:23 So abruptio is painful, placenta previa is not.

    02:29 We also may notice hypertonic or tachysystole on our fetal heart rate monitor, so the contractions are coming too close together.

    02:38 We may notice fetal distress.

    02:40 So again, we may see late decelerations from poor perfusion through the placenta, or we may just see plain old bradycardia.

    02:47 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.

    02:58 If the bleeding is profound, then we may notice that the client exhibit signs of shock so that will be from blood loss.

    03:05 We may see changes in the hemoglobin and hematocrit, and we may see issues with clotting.

    03:11 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.

    03:21 So we may see petechiae, we may see bleeding from the IV site and all kinds of things.

    03:28 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.

    03:38 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.

    03:48 So we're looking for blood collection that would let us know that there's been a premature separation.

    03:53 We may also do a biophysical profile to check on the well being of the fetus.

    03:57 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.

    04:10 In the case of a complete abruption, this is not going to allow for a vaginal birth.

    04:16 We will do a Caesarean birth so that we can get the baby out.

    04:20 Remember, if that placenta separates from the uterine wall, we have separated their ability to breathe so we've got to get them out.

    04:27 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.

    04:36 In terms of assessment for the nurse, One of our biggest things that we're going to do is to feel the uterus.

    04:42 Our best diagnostic tool is our hands.

    04:45 And so remember, for a placenta previa, the uterus is soft.

    04:49 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.

    04:58 So a rock hard, painful uterus is going to be what we notice.

    05:03 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.

    05:18 That lets us know what the uterus is doing.

    05:21 We also are going to monitor the hemodynamic status of the birthing person.

    05:25 So are we noticing changes in their hemoglobin and hematocrit? That might be a sign that we're going into shock.

    05:33 We're going to administer IV fluids and maybe blood products depending on what the amount of blood loss is.

    05:39 We're going to monitor urinary output.

    05:41 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.

    05:49 This is scary stuff.

    05:50 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.

    06:06 We need to prepare for the birth.

    06:08 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.

    06:17 So being prepared, making sure that we have a CBC and this patient is typed and crossed.

    06:23 If we're going to the emergency room for a crash Caesarean, that we're ready also for that.

    About the Lecture

    The lecture Abruptio Placenta – Late Pregnancy Bleeding (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Bleeding in Pregnancy (Nursing).

    Included Quiz Questions

    1. Uterus is hard
    2. Sharp, localized pain in the abdomen
    3. No pain
    4. Uterus is soft
    5. Painless, bright red blood
    1. Ultrasounds
    2. Biophysical profiles
    3. C-section if placenta completely detaches
    4. Fetal monitoring
    5. Administration of oxytocin
    1. Cocaine use
    2. Hypertension
    3. Abdominal trauma
    4. Hypotension
    5. Bradycardia

    Author of lecture Abruptio Placenta – Late Pregnancy Bleeding (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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