Placenta previa is the development of placenta in the lower uterine segment,

partially or completely covering the internal cervical os. The cause is unknown, but a
possible theory states that the embryo will implant in the lower uterine segment if the
deciduas in the uterine fundus is not favorable. Complications are immediate
hemorrhage, shock, and maternal death; fetal mortality; and post partum hemorrhage.

Predisposing Factors:

1. Multiparity (80% of affected clients are multiparous)

2. Advanced maternal age (older than 35 years old in 33% of cases
3. Multiple gestation
4. Previous Cesarean birth
5. Uterine Incisions
6. Prior placenta previa ( incidence is 12 times greater in women with previous
placenta previa)

Nursing Management

1. Ensure the physiologic well-being of the client and fetus

a. Take and record vital signs, assess bleeding, and maintain a perineal pad count.
Weigh perineal pads before and after use to estimate blood loss.

b. Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin
and a drop in blood pressure

c. Monitor the FHR

d. Enforce strict bed rest to minimize risk to the fetus

e. Observe for additional bleeding episodes.

2. Provide client and family teaching

a. Explain the condition and management options. To ensure an adequate blood

supply to the mother and fetus, place the woman at bed rest in a side-lying position.
Anticipate the order for a sonogram to localize the placenta. If the condition of mother
or fetus deteriorates, a cesarean birth will be required.

b. Prepare the client for ambulation and discharge ( may be within 48 hours of last
bleeding episode)

c. Discuss the need to have transportation to the hospital available at all times.

d. Instruct the client to return to the hospital if bleeding recurs and to avoid
intercourse until after the birth.

e. Instruct the client on proper handwashing and toileting to prevent infection.

3. Address emotional and psychosocial needs

 a. Offer emotional support to facilitate the grieving process, if needed

b. After birth of the newborn, provide frequent visits with the newborn so that the
mother can be certain of the infant’s condition

NCP – Placenta Previa

lower uterine segment

n.
The isthmus of the uterus, the lower extremity of which joins with the cervical canal and
during pregnancy expands to become the lower part of the uterine cavity.

Placenta Previa
Author: Patrick Ko, MD, Clinical Assistant Professor, Department of Emergency Medicine, New York
University Medical School; Assistant Program Director, Department of Emergency Medicine, North Shore
University Hospital
Coauthor(s): Young Yoon, MD, Associate Director, Assistant Professor, Department of Emergency
Medicine, Mount Sinai Medical Center
Contributor Information and Disclosures
Updated: Aug 10, 2009

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Introduction

Background
Placenta previa is an obstetric complication that occurs in the second and third trimesters of
pregnancy. It may cause serious morbidity and mortality to both the fetus and the mother. It is one
of the leading causes of vaginal bleeding in the second and third trimesters.
Placenta previa.
Placenta previa is generally defined as the implantation of the placenta over or near the internal os
of the cervix.

• Total placenta previa occurs when the internal cervical os is completely covered by the
placenta.
• Partial placenta previa occurs when the internal os is partially covered by the placenta.
• Marginal placenta previa occurs when the placenta is at the margin of the internal os.
• Low-lying placenta previa occurs when the placenta is implanted in the lower uterine
segment. In this variation, the edge of the placenta is near the internal os but does not
reach it.
• A recent study concluded that more than two thirds of women with a distance of more than
10 mm from the placental edge to cervical os have vaginal delivery without an increased
risk of hemorrhage.1

Pathophysiology
The exact etiology of placenta previa is unknown. The condition may be multifactorial and is
postulated to be related to multiparity, multiple gestations, advanced maternal age, previous
cesarean delivery,2 previous abortion, and possibly, smoking. Unlike first trimester bleeding, second
and third trimester bleeding is usually secondary to abnormal placental implantation.

Frequency
United States

Placenta previa complicates approximately 5 of 1,000 deliveries and has a mortality rate of 0.03%.
Data recorded from 1989-1997 indicated placenta previa occurs in 2.8 per 1000 live births in the
United States.

Mortality/Morbidity
The maternal mortality rate secondary to placenta previa is approximately 0.03%. Babies born to
women with placenta previa tend to weigh less than babies born to women without placenta
previa. The risk of neonatal mortality is higher for placenta previa babies compared with
pregnancies without placenta previa. The great majority of deaths are related to uterine bleeding
and the complication of disseminated intravascular coagulopathy. In early pregnancy, a partial
previa can often self-correct as the uterus enlarges and the placental site moves cephalad.

Race
Significance of race is somewhat controversial. Some studies suggest an increased risk of
placenta previa among blacks and Asians, whereas other studies cite no difference.

Age
Women older than 30 years are 3 times more likely to have placenta previa than women younger
than 20 years.

Clinical

History
Placenta previa is one of the leading causes of vaginal bleeding.

• Vaginal bleeding is apt to occur suddenly during the third trimester.

 • Bleeding is usually bright red and painless. Some degree of uterine irritability is present in
about 20% of the cases.
• Initial bleeding is not usually profuse enough to cause death; it spontaneously ceases,
only to recur later.
• The first bleed occurs (on average) at 27-32 weeks' gestation.
• Contractions may or may not occur simultaneously with the bleeding.

Physical

• Profuse hemorrhage
• Hypotension
• Tachycardia
• Soft and nontender uterus
• Normal fetal heart tones (usually)
• Vaginal and rectal examinations
o Do not perform these examinations in the ED because they may provoke
uncontrollable bleeding.
o Perform examinations in the operating room under double set-up conditions (ie,
ready for emergent cesarean delivery).

Causes

• Prior uterine insult or injury

• Risk factors
o Prior placenta previa (4-8%)
o First subsequent pregnancy following a cesarean delivery
o Multiparity (5% in grand multiparous patients)
o Advanced maternal age
o Multiple gestations
o Prior induced abortion
o Smoking

Understanding Placenta Previa - the Basics

What Is Placenta Previa?
The placenta is the organ created during pregnancy to nourish the fetus, remove its waste,
and produce hormones to sustain the pregnancy. The placenta is attached to the wall of the
uterus by blood vessels that supply the fetus with oxygen and nutrition, and which remove
waste from the fetus and transfer it to the mother.
The fetus is attached to the placenta by the umbilical cord. Through the cord, the fetus
receives nourishment and oxygen and expels waste. On one side of the placenta, the
mother's blood circulates, and on the other side, fetal blood circulates. The mother's blood
and fetal blood usually don't mix in the placenta.
The placenta is usually attached to the upper part of the uterus, away from the cervix, the
opening which the baby passes through during delivery. On rare occasions, the placenta lies
low in the uterus, partly or completely blocking the cervix -- called a placenta previa.
As many as 1 in every 3 to 5 pregnancies has some form of placenta previa before the 20th
week of pregnancy. As the uterus grows, the placenta usually moves higher in the uterus,
away from the cervix. But if it remains near the cervix as your due date nears -- which
happens in about 1 in 200 pregnancies -- you're at risk for bleeding, especially during labor as
the cervix thins (effaces) and opens (dilates). This can cause major blood loss in the mother.
For this reason, women with a placenta previa are usually delivered by cesarean delivery.
There are several types of placenta previa:

• A low-lying placenta is near the cervical opening but not

covering it. It will often move upward in the uterus as your due
date approaches.
• A partial placenta previa covers part of the cervical opening.
• A total placenta previa covers and blocks the cervical opening.
What Causes a Placenta Previa?
The cause of placenta previa is usually unknown, although it occurs more commonly among
women who are older, smoke, have had children before, have had a cesarean section or
other surgery on the uterus, or have scars inside the uterus.
Women with placenta previa -- specifically if they have a placenta previa after having
delivered a previous baby by cesarean section -- are at increased risk of placenta accreta,
placenta increta, or placenta percreta.
In placenta accreta, the placenta is firmly attached to the uterus. In placenta increta, the
placenta has grown into the uterus; and in placenta percreta, it has grown through the uterus.
This condition is often first suspected because the woman has both a previa and a prior
cesarean section. It can be confirmed by ultrasound, CT scan, or MRI, though those tests are
not completely reliable. Women with one of these conditions usually require a hysterectomy
after delivery of the baby, because the placenta does not separate from the uterus.

Definition
By Mayo Clinic staff

Placenta previa

Placenta previa is an uncommon pregnancy complication that can cause excessive bleeding
before or during delivery.

Soon after conception, the placenta begins to form. This oval, flat organ provides oxygen
and nutrients to your growing baby and removes waste products from your baby's blood. It
attaches to the wall of your uterus, and your baby's umbilical cord arises from it, forming a
vital connection between you and your baby.

Placenta previa occurs when the placenta attaches to the lower part of your uterine wall,
partially or totally covering your cervix. When the cervix starts to open in preparation for
labor, the placenta is detached, which can trigger severe vaginal bleeding. Thankfully,
placenta previa is nearly always detected before a woman or her baby is in significant
danger.
 Causes
By Mayo Clinic staff

Early in pregnancy, the placenta may implant in the lower part of the uterus. As the uterus
grows, the placenta usually moves up and away from the opening of the uterus (cervix). If
it doesn't, the cervix may be blocked. This is placenta previa.

Placenta previa is associated with:

 Scars in the lining of the uterus (endometrium)

 A large placenta, such as with a multiple pregnancy

 An abnormally shaped uterus

Risk factors
By Mayo Clinic staff

Placenta previa is more common among women who:

 Have already delivered at least one baby

 Had a previous C-section

 Had placenta previa with a previous pregnancy

 Are age 35 or older

 Are Asian

 Smoke

 Are carrying twins, triplets or other multiples

 Have had a previous uterine surgery, such as myomectomy to remove uterine fibroids or
dilation and curettage (D and C) to scrape the uterine lining

Complications
By Mayo Clinic staff
 If you have placenta previa, your health care provider will monitor you and your baby
carefully to reduce the risk of these serious complications:

 Bleeding. One of the biggest concerns with placenta previa is the risk of severe vaginal
bleeding (hemorrhage) during labor, delivery or the first few hours after delivery. The
bleeding can be heavy enough to cause maternal shock or even death.

 Premature birth. Severe bleeding may prompt an emergency C-section before your baby
is full term.

 Placenta accreta. If the placenta implants too deeply and firmly into the uterine wall, the
placenta may not spontaneously detach from the uterus after delivery — an uncommon
condition known as placenta accreta. This can result in severe bleeding and, often, the
need for surgical removal of the uterus (hysterectomy).

Preparing for your appointment

By Mayo Clinic staff

If you're pregnant beyond 12 to 13 weeks' gestation and develop any vaginal bleeding, call
the doctor who is caring for you during pregnancy (obstetrical care provider). Depending
on your symptoms, your personal health history and how far along you are in the
pregnancy, your doctor may recommend immediate medical care. But don't panic. If you
have placenta previa, it can be managed with a good outcome for both you and your baby
90 percent of the time.

Here's some information to help you get ready for your appointment, and what to expect
from your doctor.

What you can do

 Ask about pre-appointment restrictions. In most cases you'll be seen immediately.

However, if your appointment will be delayed for a day or two, ask whether you should
restrict your activity while you wait to come in.

 Share your medical history. Depending on your prior care, your doctor likely will already
know important medical details about this pregnancy and much of your reproductive
history. But if you haven't yet told your doctor about previous uterine surgeries, including
dilation and curettage (D and C) following a miscarriage or abortion, it's important for your
health and your baby's health to share this information now.

 Find a family member or friend who can join you for your appointment. The fear
you may be feeling about bleeding during pregnancy can make it difficult to focus on what
the doctor says. Take someone along who can help soak up all the information.

 Write down questions to ask your doctor. Creating your list of questions in advance can
help you make the most of your time with your doctor.

Tests and diagnosis

 By Mayo Clinic staff

Placenta previa is diagnosed through ultrasound, either during a routine prenatal

appointment or after an episode of vaginal bleeding. Placenta previa is nearly always
detected before a woman or her baby is in significant danger.

Diagnosis before 20 weeks of pregnancy

It's not unusual to detect a low-lying placenta or to see the placenta covering the cervix
during a routine midpregnancy ultrasound. Most of these cases resolve on their own before
delivery, as the uterus grows and the placenta migrates away from the cervix. You may
need additional ultrasounds to track the position of your placenta. The longer placenta
previa persists, the more likely it will be present at delivery.

Diagnosis after 20 weeks of pregnancy

Your health care provider may detect placenta previa later in pregnancy during an
ultrasound for an unrelated reason. At this stage of pregnancy, however, vaginal bleeding
is usually the tip-off.

If you experience vaginal bleeding during the second or third trimester, call your health
care provider right away. You'll likely need to go to your doctor's office or the hospital to
determine the cause of the bleeding. In most cases, your health care provider can use an
abdominal ultrasound to quickly confirm or rule out placenta previa.

A definitive diagnosis may require a combination of abdominal ultrasound and transvaginal

ultrasound, which is done through a wand-like device (transducer) placed inside your
vagina. Your health care provider will closely monitor the location of the transducer in your
vagina to prevent any bleeding. Rarely, magnetic resonance imaging (MRI) may be used to
diagnose placenta previa.

If your health care provider suspects that you may have placenta previa, he or she will
avoid routine vaginal exams to reduce the risk of heavy bleeding. You may need additional
ultrasounds or, rarely, an MRI to determine the exact location of your placenta before
delivery. Your baby's heartbeat may be tracked as well.

Related conditions
Two uncommon conditions are often grouped with placenta previa because they can cause
vaginal bleeding in the late second or third trimester. If you have vaginal bleeding late in
your pregnancy, your health care provider will also consider these conditions before
making a diagnosis:

 Placental abruption. Rarely, the placenta separates from the uterus before birth. This
can deprive the baby of oxygen and nutrients and cause heavy bleeding that may be
dangerous for both mother and baby.

 Vasa previa. The umbilical cord usually develops in the center of the placenta. If the
umbilical cord attaches to the placenta in an unusual way, a portion of the blood vessels
normally inside the umbilical cord may be left unprotected. If these unprotected blood
vessels cross the cervix, it's known as vasa previa. If these blood vessels rupture, the baby
faces life-threatening bleeding.

Treatments and drugs

By Mayo Clinic staff

Treatment for placenta previa depends on various factors, including:

 The amount of vaginal bleeding

 Whether the bleeding has stopped

 Your baby's gestational age

 Your health

 Your baby's health

 The position of the placenta and the baby

For little or no bleeding

If you have marginal placenta previa or another form of placenta previa but little or no
bleeding, your health care provider may recommend bed rest at home. Depending on the
circumstances, you may need to lie in bed most of the time —sitting and standing only
when necessary. You'll need to avoid sex and vaginal exams, which can trigger bleeding.
Exercise is usually off-limits, too. Discuss the do's and don'ts with your health care
provider — and be prepared to seek emergency medical care if you begin to bleed.

If your placenta doesn't cover your cervix, you may be allowed to attempt a vaginal
delivery. If you begin to bleed heavily, you may need an emergency C-section.

For heavy bleeding

If you're bleeding, you may need bed rest in the hospital. If the bleeding is severe, you
may need a blood transfusion to replace lost blood. You may also benefit from medications
to prevent premature labor.

Your health care provider will likely plan a C-section as soon as the baby can be safely
delivered, ideally after 36 weeks of pregnancy. If it's not possible to wait, you will need an
earlier C-section. In this case, you may be given corticosteroids to speed your baby's lung
development. In as little as 48 hours, these potent medications can help your baby's lungs
prepare for life outside the uterus.

For bleeding that won't stop

If your bleeding can't be controlled or your baby is in distress, you may need an
emergency C-section — even if the baby is premature.

Coping and support

By Mayo Clinic staff

Pregnancy is supposed to be a time of awe and anticipation. If you're diagnosed with

placenta previa, you're sure to be worried about how your condition will affect your baby.
Some of these strategies may help:

 Learn about placenta previa. Gathering information about your condition may help you
feel less scared. Talk to your health care provider, do some research on your own and
connect with other women who've had placenta previa.

 Prepare for a C-section. Placenta previa may prevent you from delivering your baby
vaginally. Ask your health care provider every C-section question that comes to mind. If
you're disappointed that you may not have a vaginal birth, remind yourself that your
baby's health and your health are more important than the method of delivery.
 Make the best of bed rest. If your health care provider recommends bed rest, fill your
days by planning for your baby's arrival. Read about newborn care or purchase newborn
necessities, either online or from catalogs. Or use the time to balance your checkbook,
organize old photo albums or catch up on thank-you notes.

 Take care of yourself. Surround yourself with things that bring you comfort, such as a
good book or a favorite pair of pajamas. Give your partner, friends and loved ones concrete
suggestions for ways to help, such as bringing a favorite food or simply stopping by for a
visit.

A condition that could cause excessive bleeding before or during delivery isn't part of any
mother's vision of the perfect pregnancy. Yet most women who have placenta previa go on
to deliver a healthy baby — which is far better than a perfect pregnancy.