BAGAMOYO SON

NMT 06101; Care of a

Woman With Abnormal
Pregnancy, Labour and
Puerperium
NTA LEVEL 6
 CARE OF A WOMAN WITH
PLACENTA PREVIA
Learning Tasks
At the end of this session learner is expected to be
able to:
• Define placenta previa.
• Explain the physiology of placenta previa.
• Identify the degrees and causes of placenta
previa.
• Outline the risk factors for placenta
previa.
• Assess maternal and foetal condition of a
woman with placenta previa.
• Describe the care of a woman with
placenta previa.
• Outline the complications of placenta
previa.
Definition Of Placenta Previa
• Placenta previa is the malposition of the
placenta in the lower uterine segment, either
anteriorly or posteriorly.
o The placenta is partially or totally
attached to the lower uterine segment.
Pathophysiology Of Placenta
Previa
• The lower uterine segment grows and
stretches progressively after the 12th week.
o In later weeks this may cause the
placenta to separate and severe bleeding can
occur.
o The bleeding is caused by shearing stress
between the placental trophoblast and
maternal venous blood sinuses.
Causes of Placenta Previa
• It occurs in 0.5% of all pregnancy.
• It is more common in multgravida with an
incidence of 1 in 90 deliveries and 1 in 250
deliveries in primigravida.
• The cause is unknown, but the incidence
increase with advancing age and parity. It may be
due to:
o Low implantation of the blastocyst.
o Development of the chorionic villi in the
decidua capsularis.
o Leading to attachment to the lower
uterine segment.
o Large placenta as in twin pregnancy.
 Degrees of Placenta Previa
• The degree of placenta previa are classified
into four types:
o The 1st and 2nd degrees are marginal
o The 3rd degree is partial placenta previa
o The 4th degree is total placental previa
Types of Placenta Previa
• Type 1 Placenta Previa
o The large part of the placental tissue is
situated in the upper uterine segment.
o In this case vaginal delivery is possible, usually
blood loss is mild and the mother and the fetus
remains in good condition
• Type 2 Placenta Previa
o The placenta is partially located in the
lower uterine segment near the internal
cervical os.
o Vaginal delivery is possible particularly if
the placenta is anterior.
o Blood loss is usually moderate, although
the conditions of the mother and fetus can
vary, fetal hypoxia is likely to be present than
maternal shock.
• Type 3 Placenta Previa
o The placenta is located over the internal
cervical os but not centrally.
o Bleeding is likely to be severe particularly
when the lower segment stretches and the cervix
begin to efface and dilate in late pregnancy.
o Vaginal delivery is inappropriate because the
placenta preceded the fetus
• Type 4 Placenta Previa
o The placenta is located centrally over the
internal cervical os and torrential hemorrhage
is very likely.
o Vaginal delivery should not be
considered.
o Caesarean section is essential in order to
save the life of the mother and fetus
Risk factors and indicators for Placenta
Previa
Risk factors for placenta previa
• Multiparity
• Maternal age greater than 35
• Previous placenta previa
• Previous uterine surgery, including caesarean
section (risk increases with increased number of
cesarean sections)
• Multiple pregnancy (larger placenta covering
the oss)
• Smoking (possible larger placenta)
Indicators of placenta previa
• Painless per vaginal bleeding
• Non tender and tense uterus
• The fetal head remain unengaged in a
primigravida
• There is malpresentation, usually breech
• The lie is transverse or oblique
• The lie is unstable, usually in a multigravida
• Localization of the placenta using ultrasonic
scanning will confirm the existence of the placenta
previa and establish it’s degree
Assessing the Maternal and Foetal
Condition
Assessing Maternal Condition
• The amount of vaginal bleeding is variable
• Some mother may have a history of a small
repeated blood loss at intervals throughout
pregnancy whereas other may have a sudden
episodes of vaginal bleeding after the 20thweek
• Severe hemorrhage occurs after 34th weeks
of pregnancy
• The color of the blood is bright red denoting
fresh blood
• All the blood loss should be quantified
• General Examination
o If the bleeding is slight, the blood pressure,
respiratory rate and pulse rate may be normal
o In severe bleeding blood pressure is low and
raised pulse rate due to shock
o The degree of shock correlates with the
amount of blood lost from the vagina
o Rapid respiration.
o The mother looks pale and her skin cold and
moist.
• Abdominal Examination
o The midwife may find the lie of the fetus is
oblique or transverse and fetal may be high in
primigravida near term
o No pain felt by the mother during palpation

NB: Vagina examination should never be

performed because torrential hemorrhage may
result and worsen the situation
Assessing the Fetal Condition
• Ask the mother if the fetal activity are
normal
• In severe fetal hypoxia fetal movements may
be diminished or ceased.
• An ultrasound fetal monitor such as
cardiotocograph (CTG) may be used
• Pinard fetal scope may also be used
• If fetal hypoxia is marked medical
assistance should be called urgently as this is
an emergency condition
• If the facility has no services for
resuscitation refer the woman immediately
Care of a Woman with Placenta
Previa
• The management depends on:
o The amount of bleeding
o The condition of the mother and the
fetus
o The location of the placenta
o The stage of the pregnancy
Conservative Management (NURSING CARE)
• It is appropriate if bleeding is slight and the
condition of the mother and fetus are well
• Keep the mother in hospital and rest the
mother in bed until bleeding is stopped
• It is usual for the woman to remain in hospital
for the rest of her pregnancy
• Monitor placental function by a means
of fetal kick chart and antenatal CTG.
• Ultrasound scan to observe the position
of the placenta in relation to the cervical os as
the lower segment grows
• Insure physical, social and psychological
support is important for those who are
admitted for some weeks
• If she have other children allow them to visit
their mother regularly as they may be anxious
• Some occupational therapy are important to
alleviate boredom in long stay to hospital
• The midwife, the obstetrician and the woman
may plan for how the birth will be managed.
• Vaginal delivery is possible with type 1
and 2, unless the placenta is situated
immediately above the sacral promontory
where is vulnerable to pressure from
advancing fetal head and may impede decent
• Correct anemia with oral iron
• Ensure blood is available for transfusion
Active Management
• Severe vaginal bleeding will necessitate
immediate delivery by caesarean section regardless
of the location of the placenta.
• Take blood for full blood count, cross
matching and clotting studies.
• Blood transfusion may be needed to be
transfused quickly, blood group O may be
necessary
• Insert an intravenous fluids.
• Keep input and output chart and record.
• Reassure the patient all the time as she
will be anxious, the partner should be involved
and supported.
• Prepare the patient for theatre but if the
condition is worsen the patient will be
examined in the operating theatre and the
caesarean section is done, “double set up”.
• In major degree of placenta previa (3rd&
4th) caesarean section is required even if the
fetus is died in utero.
• The aim is to prevent torrential
hemorrhage and possible maternal death.
Complications of Placenta Praevia
• The major maternal complication
associated with placenta previa is
hemorrhage.
• Another serious complication is
development of an abnormal placental
attachment (e.g., placenta accreta, increta, or
percreta)
• Maternal shock resulted from blood loss
and hypovolaemia
• Maternal death.
• Fetal death.
• Placenta accrete Abnormally adherent
placenta into the muscle layer of the uterus.
• Placenta increta Abnormally adherent
placenta into the perimetrium of the uterus.
• Placenta percreta Abnormally adherent
placenta through the muscle layer of the
uterus.
• Placenta accreta is an extremely rare form in
which the placenta is directly anchored to
the myometrium partially or completely
without any intervening decidua. The
probable cause is due to absence of decidua
basalis and poor development of fibrinoid
layer. Overall incidence of placenta accreta
Key Points
• Placenta previa is life threatening
emergency obstetric especially for type 3 and
4
• Assessment of maternal and fetal
condition is important in order to make
appropriate decision for the management as
well as prevention of complication.