Now let's move on to talking about what
could cause late pregnancy bleeding.
We're going to review placenta previa,
abruptio placenta, and vasa previa.
Let's start with the placenta previa.
A placenta previa occurs when the placenta
attaches near or actually covers the OS
rather than in the fundus, so
we're thinking about implantation.
This occurs in one pregnancy out of every 200.
So let's look at a graphic of
what that actually looks like.
So we have a fetus and we have the umbilical
cord, and then we have the placenta.
Do you see the cervix down there?
So in order for that baby to come
out, they'd actually have to go,
well through the placenta, which wouldn't work
really well considering that's their lifeline.
Risk factors for placenta previa include
having a previous placenta previa,
advanced maternal age, and this
is not just because you're older,
but if you remember, as we get older, we tend
to have more abnormalities, so that's why.
So if we have to fight for space, then
sometimes the egg may find its way down
instead of in the fundus just
because they ran out of room.
Closely spaced pregnancies, or smoking,
or maybe this is baby number 8, 9 or 10.
That also increases the risk of a placenta previa.
And finally, previous uterine scarring.
So any kind of surgery that's done on the uterus
- removal of fibroids, previous cesarean delivery,
any of those things can actually increase
the chances of a placenta previa.
Let's think about the assessment.
So what will we notice?
Now this first one is key, you got to remember,
bright red, painless, vaginal bleeding.
So painless placenta previa, so remember those P's.
Lots of P's today.
Placenta previa is usually painless, and
the bleeding is bright red, remember that.
NCLEX loves this question,
so seal that in your brain.
The uterus is going to be soft because
the uterus is not really contracting.
The cervix passively opens just a
little bit as we get closer to delivery,
doesn't involve a lot of painful contractions
so the uterus is going to be nice and relaxed,
but we're going to get the bleeding
because as the cervix begins to open,
the placenta is going to be
detaching from the uterine wall.
We may find that we have increased
fundal height measurements,
because the fetus is sort of off kilter.
We may have an unfavorable fetal presentation.
Well, that's because the placenta is in the way.
So the baby may not rotate to being head
down, it may end up transverse or breech
just because the positioning
doesn't work any other way.
There may be changes in hemoglobin and
hematocrit,especially if the placenta previa
has started to produce a lot of bleeding.
So if someone presents late from placenta
previa, then we may find that their hemoglobin
has dropped pretty significantly.
Now a Kleihauer-Betke test is going to be a test
we mention throughout all of these procedures.
What is Kleihauer-Betke?
Well, what it does is it detects fetal cells
or fetal blood inside the maternal bloodstream.
So this is going to let us know that
the bleeding is particularly heavy
and this is also going to be important in
cases of someone who may be RH negative.
In labor, if someone is
laboring with placenta previa,
we may notice that we have heart rate
changes, so we'll have poor perfusion.
So what type of changes might we notice?
Hopefully, you're remembering this
from fetal monitoring, what is it?
Late decelerations, you got it.
And finally, we may have changes in vital signs.
If someone's laboring, they have a
placenta previa, we didn't know it,
and their blood loss is becoming pretty
significant, then we may see an increase initially
in the heart rate, or we may see a
drop in heart rate if we catch it late.
Now thinking of medical management,
one of the things we'll do
if we notice that painless, bright
red bleeding is to do an ultrasound.
and why are we doing an ultrasound?
because we're looking for
the location of the placenta.
The placenta should be up in the fundus,
where it is in a placenta previa is down low.
So remember, it'll be over
the cervix or near the cervix.
We want to monitor the client
and the fetus for their status.
So we want to make sure that
everybody's well oxygenated.
So we're looking for changes in
vital signs for the pregnant person,
and we're going to look in changes for
fetal heart rate tracing for the baby.
We also want to monitor for placenta accreta.
So a placenta accreta is when the placenta
actually grows into the muscle layer of the uterus.
So we want to make sure that we monitor for that.
And that can be done on ultrasound, or it
may be diagnosed after the baby comes out.
What is the nurse doing?
Well, the nurse is going to monitor for bleeding.
They're going to monitor for fetal
well-being, how is our fetus doing in there.
We're going to educate the client
if they have placenta previa
and it's diagnosed in the antepartum
period, not to put anything in the vagina.
So no intercourse or anything else in the vagina
at all because that can disrupt the placenta.
Bedrest might be ordered, nothing vaginally.
Can I say that enough? I cannot.
And the most important thing in terms of
nursing is if you see someone who presents
with painless, bright red bleeding, painless
placenta previa, do NOT do a vaginal exam,
because putting your fingers into the
vagina can actually disrupt the placenta.
So if you don't know for sure where that
placenta is, and someone presents with
painless, bright red bleeding, then you get on
the phone and call the provider and let them know,
'I think we need an ultrasound because I'm
concerned about the kind of bleeding that I'm seeing.'
We may need to also provide IV
fluids or oxygen or medications
depending on how significant the bleeding is.
So if the client's not bleeding at all,
we may not need to do all of these things.
But if they come in and they're on
active bleeding, and we know that
we're going to have to do a Caesarean
delivery in order to get the baby out safely,
then we're going to have to prepare for that