CASE:

Admitted F/20, single. Only child. With a case of dizziness, profuse sweating, cold clammy skin,
fainting spells and vaginal bleeding. “Maul-ulaw nak ken naawanan nak pay ti puot”, as claimed by
the patient. Temp 36.1, PR-101, RR-22, O2sat-98%, and BP-90/60mmhg. Wt-55kgs, LMP-July
20,2022. OB score: G1-P0-T0-P0-A0-L0. No allergies. Mother died of breast CA. Father had a recent
stroke/CVA and is DM2. She loves to party and comes home late like early in the morning. Binge
drinking alcohol with friend occasionally and smokes cannabis once a week.

MIDWIFERY NOTES:

ASSESSMENT:

Subjective data:

“maul-ulaw nak ken naawanan nak pay ti puot” as verbalized by the patient.

Dizziness

Objective data:

Vaginal bleeding, profuse sweating and cold clammy skin

V/S:

BP: 90/60mmhg

PR:101bpm

RR:22

Temp: 36.1

DIAGNOSIS:

Risk for deficient fluid volume related to bleeding during pregnancy

Risk for infection

Risk for hemorrhage

PLANNING:

Patient will experience minimal blood loss and be free from infection; patient will develop coping
skills to effectively manage emotional loss of pregnancy.

INTERVENTION:

Placed the woman flat in bed on her side and monitored uterine contractions and fetal heart rate
through an external monitor to prevent profuse bleeding; Administered IV fluids and medications as
ordered by the doctor; Measured intake and output to establish renal function; assessed patients
vital signs to establish maternal response to blood loss; Measured the maternal blood loss by saving
and weighing the used pads; Offered emotional support and provided resources for counselling and
support groups to help develop coping techniques; Advised the effect of alcohol and smoking to her
and her baby.
EVALUATION:

 Restored maternal blood volume and the source of the bleeding stopped.

 The client’s blood pressure  maintained above 100/60 mmHg.

 The pulse rate is below 100 beats per minute and the fetal heart rate is at normal level of
120-160 beats per minute.

 The client’s urine is more than 30 mL/hr.

 Patient have demonstrated behaviours, lifestyle changes to regain and maintain healthy
pregnancy.

 Endorsed to next shift for continuity of care.

VITAL SIGNS:

8AM 12AM 4PM 8PM 12PM

BP:90/60 BP:90/60 BP:90/60 BP:80/60 BP:90/60

PR:110 PR:105 PR:118 PR:112 PR:105

RR:22 RR:22 RR:21 RR:22 RR:21

TEMP:37.8 TEMP:37.9 TEMP:38 TEMP:37.9 TEMP:38

 PLACENTA PREVIA CASE STUDY
I.INTRODUCTION:

The placenta is implanted in the lower uterine segment near or over the internal cervical os. The
degree to which the internal cervical os is covered by the placenta has been used to classify four
types of placenta previa; total, partial, marginal and low–lying. In total previa the internal os is
entirely covered by the placenta. Partial placenta previa implies incomplete coverage of the internal
os. Marginal placenta previa indicates that only an edge of the placenta extends to the margin of the
internal os. And the last is the low – lying placenta has been used when the placenta is implanted in
the lower uterine segment but not reach the os. The more descriptive classification that includes
placenta previa is in the third trimester.

The incidence of placenta previa is approximately 0.5% of births. The most important risk factors
are previous placenta previa, previous caesarean birth, and suction curettage for miscarriage or
induced abortion, possible related to endometrial scarring. The risk also increases with multiple
gestations because of the larger placental area, closely spaced pregnancies, advanced maternal age
older than 34 years, African or Asian ethnicity, male fetal sex, smoking, cocaine use, multiparity, and
tobacco use.

Complications for the baby include:

 Problems for the baby, secondary to acute blood loss

 Intrauterine growth retardation due to poor placental perfusion

 Increased incidence of congenital anomalies

Clinical manifestations:

 Painless vaginal bleeding > occurs after 20 weeks of gestation, bright red in color associated
with the stretching and thinning of the lower uterine segment that occurs in third trimester.

 Adequately contract and stop blood flow from open vessels.

 Stop blood flow from open vessels

 Decreasing urinary output

II. OBJECTIVES:

 To upgrade knowledge about Placenta previa, it’s diagnosis, treatment and management
including midwifery management.
 To identify the cause, pathophysiology, clinical features and diagnostic investigation of
placenta previa.
 To prevent the patient from further complication of disease.
III. PATIENTS PROFILE:

NAME: Patient X
AGE: 20
SEX: female
RELIGION: Roman catholic
NATIONALITY: Filipino

IV. HISTORY

Admitted F/20, single. Only child. With a case of dizziness, profuse sweating, cold clammy skin,
fainting spells and vaginal bleeding. “Maul-ulaw nak ken naawanan nak pay ti puot”, as claimed by
the patient. Temp 36.1, PR-101, RR-22, O2sat-98%, and BP-90/60mmhg. Wt-55kgs, LMP-July
20,2022. OB score: G1-P0-T0-P0-A0-L0. No allergies. Mother died of breast CA. Father had a recent
stroke/CVA and is DM2. She loves to party and comes home late like early in the morning. Binge
drinking alcohol with friend occasionally and smokes cannabis once a week.

V. DIAGNOSTIC TESTS: TRANSABDOMINAL ULTRASOUND

Number of gestations: 1
Lie: longitudal
Position/Presentation: Right/cephalic
Fetal heart tones: 144 beats per minute
Fetal movements: Present
Placenta: Partial occlusion of internal cervical os.

VI. PHYSICAL EXAMINATION

 General appearance:
 Well oriented to time, place and person. Well conscious, co-operative, slightly anxiety and fear,
with pallor and anemic.

 Mental state:
Alert response appreciably

 Head:
Clean, dry and smooth hair, no lice, with complains of dizziness

 Eyes:
No discharge, no infection, no jaundice, eyes clean, conjunctiva pinkish.

 Nose:
Clear, no septal deformity, no crusts and discharge no cold.
  Mouth:
Tongue moist, lips dry, no artificial dentures, teeth clean and healthy, no congenital deformity

 Ears:
Normal shape, no swollen glands, no valve discharge

 Neck:
No swelling, no palpable nodes, no deformity, no pain in the neck.

 Chest:
Symmetric shape and size of the chest, breasts well developed, nipples normal, no scar, no
palpable lymph glands.

 Upper extremities:
Symmetrical and no deformity, no scar, no extra digits, nails pink and clean, pale, and cold
clammy.

 Lower extremities:
Symmetrical, no deformities, no varicose veins, no edema, no extra digits, no pain in calf muscles,
cold and clammy.

 Back:
No deformity

VII. ANATOMY AND PHYSIOLOGY:

Placental implantation is initiated by the

embryo (embryonic plate) adhering in the lower
(caudal)uterus. With the placental attachment
and growth, the developing placenta may cover
the cervical os. However, it is thought that a
defective decidual devascularisation occurs over
the cervix, possibly secondary to inflammatory
or atrophic changes. As such placenta
undergone atrophic changes could persist as a
vasa previa. A leading cause of third trimester
bleeding/haemorrhage, placenta previa present
classically, a painless bleeding. Bleeding is
thought to occur in association with the
development of the lower uterine segment in
third trimester. Placental attachment is
disrupted at this area gradually in the
preparation of the onset of labour. When this
occurs at implantation site as the uterus
is unable to contract adequately and stop the
flow of blood from the open vessels. Thrombin release from the bleeding site promotes uterine
contraction and a vicious circle of bleeding, uterine contraction placental separation and bleeding
persists.

VIII. MIDWIFERY CARE PLAN

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE  To restore  Initiate IV fluids  Replacement of  Patient was

DATA: maternal blood and administer fluid and blood able to
Vaginal volume and to medications loss demonstrate
bleeding, stop the source given as improved fluid
profuse of the bleeding. ordered by the balance as
sweating, cold doctor. evidenced by
clammy skin stable vital
 Place patient in  This position helps signs and
lateral position relieve pressure experienced
on strict bed on the vena cava minimal blood
rest. and helps reduce loss.
bleeding. Bed rest
is required to limit
blood loss and
help with pain
management.

 Monitor Vital  Monitor for

signs. hyper/hypotension,
tachycardia and
shortness of
breath. Note if
fever is present
which may indicate
infection.

 Assess patient  Weigh or count

for bleeding, number of
amniotic fluid saturated pads
and passage of each hour. Note
pregnancy amniotic fluid or
tissue. tissue being
expelled from the
vagina that
indicates
spontaneous
abortion.
 Assist with  Helps to
ultrasound or determine fetal
amniocentesis maturity and
viability in the
presence of fetal
heart rate.
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE After giving  Instruct the  To prevent  Patient reveals

DATA: “maul- treatments and patient to limit dizziness and to an increase in
ulaw nak ken health care, long periods of increase activity
naawanan nak patient will standing and circulation. tolerance.
pay ti puot” as regain her take her time
verbalized by the strength. getting up from
patient. sitting.

Dizziness and  Instruct the  To prevent

fainting spells patient to sleep blockage from
and rest on her the inferior
left side. vena cava that
causes
dizziness.
 Instruct the  To avoid low
patient to eat blood sugar
healthy foods and
and drink plenty dehydration.
of water.
 Give  To treat
supplements conditions that
and medications causes
as dizziness.
recommended
by the doctor.

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE DATA:  After giving  Giving  To stop the  Patients body

V/S medications, medications as cause of temperature
BP-90/60mmhg the patient will ordered by the infection decreased.
RR-22 be able to doctor.  Patients’ blood
PR-101 establish  Provide tepid  To help reduce pressure
TEMP-38 normal core sponge bath the core body maintained
temperature temperature. above
and to maintain Monitor vital  Changes in 100/60mmhg.
patient’s blood signs, compare blood pressure
pressure above with patients may be used
100/60mmhg. normal or for rough
previous estimate of
readings, take blood loss.
blood pressure
when possible.
IX. DRUG STUDY

NAME OF MECHANISM INDICATIO CONTRAINDICATIO ADVERSE/ MIDWIFE

DRUG S OF ACTION N N SIDE EFFECTS RESPONSIBILIT
Y
Generic Its primary Pregnancy Contraindicated in Side effects: Advise the
name: role is to anemia, known  Constipatio patient to
Ferrous store ad Iron hypersensitivity, n take the iron
sulfate transport deficiency hemochromatosis,  Diarrhoea on an empty
iron anemia hemosiderosis,  Stomach stomach.
Brand throughout anemia not caused cramps Advise the
name: the body. by iron deficiency.  Green patient to
Ferron, Parenteral iron is stools take iron with
Fersulfate , contraindicated in  Nausea or vitamin c for
Hemovit untreated stomach better
pyelonephritis and upset absorption.
in acute liver  Metallic
Dosage: disease. taste
200mg 1
tab once a Adverse
day. effect:
 Numbness,
Drug class: pain, or
Iron tingling of
supplement hands or
, Vitamins feet.
 Swelling of
mouth or
throat
 Troubled
breathing
 Chest pain
 Fast
heartbeat
 flushing
NAME OF MECHANISM INDICATION CONTRAINDICATIO SIDE/ MIDWIFE
DRUG S OF ACTION N ADVERSE RESPONSIBILIT
EFFECT Y
Generic Folic acid, Indicated in  Folic acid Side effects:  Advise the
name: whether the hypersensitivity  Feeling sick patient not to
Folic acid given by treatment of  Pernicious  Loss of take folic acid
mouth or megaloblasti anemia appetite within 2
Brand parenterally, c anemias of  Benzyl alcohol  Bloating hours before
name: stimulates pregnancy hypersensitivity, or after
Prevena, the neonates taking
Forameter production  Renal disease, Adverse indigestion
, Iberet of red blood renal failure, effect: remedies
folic, cells, white renal impairment.  Rash (antacids
folvite blood cells,  Swelling containing
and platelets (face, aluminum or
in persons tongue, magnesium),
Dosage: suffering throat) as they may
400mcg 1 from certain  Trouble stop the folic
cap once a megaloblasti breathing acid being
day c anemias, to properly
prevent absorbed.
Drug neural tube  Advise the
class: defects in patient to
Vitamins, pregnancy. take folic acid
water during the
solluble day as it
digests
better.
 Advise the
patient to
avoid
drinking
coffee or tea,
it will be
harder for
the body to
absorb the
medicine.
NAME OF MECHANISM INDICATI CONTRAINDICATI SIDE/ MIDWIFE
DRUG OF ACTION ON ON ADVERSE RESPONSIBILITY
EFFECT
Generic Dexamethaso Provides  Active, Side effects: Keep away
name: ne effects on relief for untreated TB  Upset from people
Dexamethaso the body inflamed  Inactive TB stomach with an
ne occurs in a areas of  Herpes simplex  Stomach infectious
variety way. the infection of the irritation disease,
Brand name: It works by body, eye  Vomiting especially
Dexpak, suppressing for lung  An infection  Headache measles,
Decadron the migration maturity due to a fungus  Dizziness chickenpox
of  A condition  Insomnia or shingles,
Dosage: 6mg neutrophils with low  Restlessne taking
IM every 12 and thyroid ss dexamethas
hours X 4 decreasing hormone levels one makes
doses. lymphocytes  Diabetes Adverse you more
colony  High effect: likely to
Drug class: proliferation. cholesterol  Unusual catch
Corticosteroi tiredness infections
ds  Unusual such as flu,
dizziness coronavirus
 Blood in (COVID-19).
your Advise the
stool or patient to
black avoid foods
stools. and
 Blood in beverages
urine that contain
 Unusual alcohol or
bleeding caffeine as it
or may cause
bruising some
 Infection stomach
irritation.
Observe for
signs and
adverse
reactions
Monitor
blood
pressure 2-3
times daily.
Advise the
patient to
take
dexamethas
one with
food or milk
to prevent
nausea and
heartburn.
X. DISCHARGE PLANNING:

Medication:

Iron plus folic acid 1 tab one a day

ECONOMY:

Patient X belongs to a middle standard family. There are two earning personals in her family
therefore, she can afford to buy medications for her pregnancy.

HEALTH TEACHINGS:

The main objective of health education is to change human behaviour to prevent disease and
maintain health. The people need to be educated about health practices; self-care nutrition and any
other subjects, so mother should be educated about the following things:

 Advised strict bed rest. Instructed family to arrange for easy access for TV, phone,
computer to limit woman getting out of bed.
 Encouraged patient to take positions of comfort or lie on her left.
 Educated patient about importance of complete bed rest with bathroom privileges.
 Avoid heavy lifting.
 Advised to avoid stress.
 Educated about fetal movements and when to inform doctor if fetal movements decrease.
 Advised mother to maintain good personal hygiene to prevent infection.
 Educated about the effects of alcohol and smoking to a pregnant woman.

DIET:

 Advised to take high calorie diet

 Educated about source of proteins, iron etc.
 Educated mother to take balanced diet.
 Advised mother to take enough of fluids.

OUTPATIENT:

 Regular follow up
 Advised mother and her family to visit hospital as advised by the doctor and educated about
warning signs when she must report to doctor.

XI. EVALUATION:

During the hospitalization of the mother, I had provided holistic care to her considering physical,
mental, social, spiritual and economic aspect. I had provided care. At the time of discharge, the
mother’s condition was improved, looking happy and cheerful. I gave health teachings to the patient
and her family about nutrition, personal hygiene, rest, medicines, follow up visit and high-risk
condition of mother.