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1. PLACENTAL PREVIA abnormal low implantation of the placenta ○ Causing fetal head to descent
- low implantation of the placenta so that it overlays affecting mech., pressure @
some/all of the internal cervical OS placental site ctrl of bleeding
Incidence: “ most common cause of bleeding @ 3rdtrimester” ✔ DOUBLE SETUP: I/E in suspected placental previa
Predisposing factors: (DIMM) 2 setups
○ Multiparity-single most impt factor ✔ DELIVERY: vaginal or CS if placental placement
○ Decreased vascularity of upper uterine segment d/t prevents vaginal delivery and if the conditions for
tumor or narrowing watchful waiting are absent
○ Increased age above 35 y/o ✔ HOME MNGT:
○ Multiple Pz *Monitor fetal well-being
TYPE 1 & 2= home mngt
TYPES/ DEGRESS OF P.PREVIA:
Type 3 & 4= hosp for continuous
TYPE 1: LOW LYING
monitoring
placenta @ lower 3rd of uterus not encroach of margins of OS
NURSING CARE:
TYPE 2 : MARGINAL
Placenta lies over the margins of os • Bed & Px’ position: left side lying
TYPE 3 : PARTIAL R: to prevent pressure in the vena cava
Placenta partially covers the os • Assessment(FOBV)
TYPE 4 : COMPLETE/TOTAL Fetal well being
Placenta totally covers the os w/c completely Onset & progress of labor
obstructs the birth canal Blood Loss
S/SX: V/S
*fetal well being: FHT, mov’t., passage of meconium(thru
• painless vaginal bleeding in 3rd trimester(7mos)
vaginal d/c)
• intermittent pain 2nd to uterine contractions • Don’t perform I/E or V/E R: it will increase bleeding
DX:
• Prepare for UTZ to detect placental site
UTZ –95% accuracy
• Institute shock measures prn
Detects site of placenta
○ Bleeding is rarely severe life-threatening but
TX:
may become profuse with I/E
✔ watchful waiting/ expectant mngt/conservative if:
*mother is not in labor • Psychologic and phys. Comfort
*fetus is STABLE; no distress, premature • Conservative mngt = double setup/ CS
*bleeding is not severe Classical CS performed bcoz of LUS is
occupied by placenta
• Observe for bleeding after delivery
2. ABRUPTIO PLACENTA – premature partial/complete separation of the LUS, the site of placental detachment = not
contractile as U.fundal portion
Placenta from its implantation TYPE 2 MARGINAL/OVERT/EXTERNAL BLEEDING
– occurs after 20th wk AOG Placenta separates at the margin
– also called “accidental hemorrhage” and “ablation
c. External placenta”
bleeding, proportional to the amount of internal bleeding
incidence: 2ND leading cause of 3rd trimester bleeding
S/Sx: (SPER)
predisposing factors: MAMST Painful vaginal bleeding @ 3rd trimester
maternal HPN : PIH & renal dse (+) shock
Rigid, boardlike, painful abdomen
sudden uterine decompression as inEnlarged
PZ and polyhydramnios
uterus d/t concealed bleeding
@ labor: titanic contractions c. the absence of alternating contraction & relaxation of uterus.
Advanced age due to insufficiency
Dx: of hormone
Multiparity CLINICAL Dx: s/sx
Short umbilical cord – may pull the
UTZplacenta
says the retroplacental bleeding
Trauma & fibrin defects Clotting studies: reveal “Disseminated Intravascular Coagulation”(DIS)
e.g. massive bleeding causing depletion of blood
Thromboplastin from supply
retroplacental clot enters maternal circulation and
depletion of fibrin Consumes maternal fibrinogen r/t:
*villi separates containing cotyledons that are
*DICattached
– small fibrin clots in the circulation
*villi detachment causing bleeding & rupture of blood vessels of mother
*HYPOFIBRINOGENEMIA & fetus
- normal fibrinogen r/t absence of
Normal blood coagulation
ACTIVEBLEEDING – Blood coagulation
Complications:
Hemorrhagic shock
BLOODInfection
CLOTS
DIC
Fibrin becomesCVABIGGER
from DIC
Couvelaire Uterus – bleeding behind the placenta which may cause some
EMBOLUS Of blood to enter the uterine musculature causing uterine
Mngt: Muscles not to contract well once the placenta is delivered.
O2 inhalation L E A D S TO
CS delivery UTERINE ATONY (+) bleeding
Fluid replacement and plasma
Renal expanders
failure
Hypofibrinogenemia
TYPES Fetal distress/demise
TYPE 1 CONCEALED/COVERT/CENTRAL/INTERNAL BLEEDING
Placenta detaches/separates
Nursing @ center causing blood to
Mngt.:
accumulate behind the placentaMaintain bedrest @ LLR
External bleeding is not evident
Careful monitoring of:
Signs of shock not proportional to the amountv/s
Maternal of external bleeding
Uterine pain
FHT Bleeding not proportional to shock
NRSG. MNGT: Labor once/progress
I&O = oliguria/anuria
[
CRYOCRECIPITATE- blood products that are rich in blood clotting factors
type 4- “Secondary”
Packs of thrombocyte replacement
Administer fluid, –plasma,
Occurs due
blood asto pancreatic tumor/infections or other endocrine disorders due to very slow metabolism
ordered
– Hypothyroidism secretions leads to HYPERGLYCEMIA
Prepare for Dx exams – explain results
Provide psychological
HPL- Humansupport – explain
Placental what is
Lactation = happening,
blocks actionprepare for all exams
of insulin
And inform/explain results.
PhysicallyNORMAL
and emotionally prepare
METABOLIC for emergency
CHANGES birthDM:
affecting either per vagina/CS
Observe for associated problems after delivery
✔ Hormonal production by placenta
*Couvelaire= poorly contracting uterus
*DIC
*neonatal sepsis
✔ Metabolic rate in Pzcausing # of Islets of Langerhans insulin production but rendered ineffective by
PRE & CO-EXISTING DSES “insulin
OF PZ antagonists” (HPL/HCS)
✔ Activity of the APG tolerance for sugar
DIABETES MELLITUS
✔ BMR and Co2 combining power raise the tendency of acidosis
, metabolic disorder characterized by a deficiency of insulin production by
✔ Vomiting during pz= CHON intake = ACIDOSIS
Pancreas’ islets of langerhans resulting to improper metabolic interaction of
carbohydrates, Muscular
✔ Fats, activity
proteins, in labor depletes maternal glucose including glycogen stores = requires
and insulin. CHON intake
✔ Hypoglycemia is common
hyperglycemia due to lack or inadequate insulin In puerperium as involution and lactation occur.
caused by ✔ If pancreas
heredity, cannot
envi and respond by producing more insulin, glucose crosses the placenta to the fetus where fetal
lifestyle
insulin metabolizes it and by resembling the growth hormone, causing MACROSOMIA
EFFECTS
INCIDENCE: concurrent dseOFin PzPREGNANCY IN DM@ pz
or have its onset
PREDISPOSING FACTORS:
• DM is more difficult to control = difficult to maintain blood sugar
○ Family HX
• Insulin shock and ketaacidosis
○ Rapid hormonal change in Pz
• N-V are predispose to keta-acidosis
○ Tumor/infection of the pancreas –produces insufficient insulin
• Insulin requirements:
○ Obesity
○ Stress ○ 1st 3mos: stable
CLASSIFICATIONS OF D.M. Insulin may not be
Type 1 – “juvenile-onset”or Dose
“insulin may drop in 1st trimester
dependent”
nd
– Occurs below 2 3mos:
40 y/o rapid
starts @ youth
Type 2 – “maturity-onset”
rd
3 3mos: or “non-insulin
rapid dependent”
– after 40 y/o Postpartum :rapid to prepregnant level
Type 3 - “GESTATIONAL D.M.” Need insulin in the first 24h AC delivery
- onset during pz and ends after termination of pz
-however she becomes DIABETIC after Pregnancy