Placenta Previa – Late Pregnancy Bleeding (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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    00:01 Now let's move on to talking about what could cause late pregnancy bleeding.

    00:06 We're going to review placenta previa, abruptio placenta, and vasa previa.

    00:13 Let's start with the placenta previa.

    00:15 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.

    00:24 This occurs in one pregnancy out of every 200.

    00:27 So let's look at a graphic of what that actually looks like.

    00:30 So we have a fetus and we have the umbilical cord, and then we have the placenta.

    00:36 Do you see the cervix down there? Oh, yeah.

    00:39 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.

    00:48 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.

    01:03 Multiple gestation.

    01:04 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.

    01:13 Closely spaced pregnancies, or smoking, or maybe this is baby number 8, 9 or 10.

    01:20 That also increases the risk of a placenta previa.

    01:24 And finally, previous uterine scarring.

    01:26 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.

    01:37 Let's think about the assessment.

    01:39 So what will we notice? Now this first one is key, you got to remember, bright red, painless, vaginal bleeding.

    01:46 So painless placenta previa, so remember those P's.

    01:50 Lots of P's today.

    01:51 Placenta previa is usually painless, and the bleeding is bright red, remember that.

    01:58 NCLEX loves this question, so seal that in your brain.

    02:02 The uterus is going to be soft because the uterus is not really contracting.

    02:06 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.

    02:22 We may find that we have increased fundal height measurements, because the fetus is sort of off kilter.

    02:30 We may have an unfavorable fetal presentation.

    02:33 Well, that's because the placenta is in the way.

    02:35 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.

    02:45 There may be changes in hemoglobin and hematocrit,especially if the placenta previa has started to produce a lot of bleeding.

    02:52 So if someone presents late from placenta previa, then we may find that their hemoglobin has dropped pretty significantly.

    03:00 Now a Kleihauer-Betke test is going to be a test we mention throughout all of these procedures.

    03:04 What is Kleihauer-Betke? Well, what it does is it detects fetal cells or fetal blood inside the maternal bloodstream.

    03:12 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.

    03:20 In labor, if someone is laboring with placenta previa, we may notice that we have heart rate changes, so we'll have poor perfusion.

    03:28 So what type of changes might we notice? Hopefully, you're remembering this from fetal monitoring, what is it? Late decelerations, you got it.

    03:39 And finally, we may have changes in vital signs.

    03:42 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.

    03:57 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.

    04:05 and why are we doing an ultrasound? because we're looking for the location of the placenta.

    04:09 The placenta should be up in the fundus, where it is in a placenta previa is down low.

    04:15 So remember, it'll be over the cervix or near the cervix.

    04:19 We want to monitor the client and the fetus for their status.

    04:22 So we want to make sure that everybody's well oxygenated.

    04:25 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.

    04:33 We also want to monitor for placenta accreta.

    04:36 So a placenta accreta is when the placenta actually grows into the muscle layer of the uterus.

    04:42 So we want to make sure that we monitor for that.

    04:44 And that can be done on ultrasound, or it may be diagnosed after the baby comes out.

    04:49 What is the nurse doing? Well, the nurse is going to monitor for bleeding.

    04:53 They're going to monitor for fetal well-being, how is our fetus doing in there.

    04:58 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.

    05:05 So no intercourse or anything else in the vagina at all because that can disrupt the placenta.

    05:12 Bedrest might be ordered, nothing vaginally.

    05:15 Can I say that enough? I cannot.

    05:18 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.

    05:33 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.

    05:55 So if the client's not bleeding at all, we may not need to do all of these things.

    05:58 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

    About the Lecture

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

    Included Quiz Questions

    1. Multiparity
    2. History of smoking
    3. Complaining of bright red blood
    4. 33 years old
    5. History of infertility
    1. Near or above the cervix
    2. Deep in the uterine wall
    3. Through the uterus
    4. Below the uterus
    1. Advanced maternal age
    2. Smoking
    3. Close pregnancy spacing
    4. First pregnancy
    5. Single birth

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

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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