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Ateneo de Naga University
Collge of Nursing
CASE STUDY OF ABRUPTIO PLACENTA
Submitted by:
Jovan Conde
Mary Joy Luistro

2. Glaiza Quintana
Lily Tadeo
Keran Toledo
Submitted to:
CHRISTY MARISSA AGUILAR, RN
Clinical Instructor
July 1, 2011
I. INTRODUCTION
Placental abruption (also known as abruptio placentae) is an obstetric catastrophe
(complication of pregnancy), wherein the placental lining has separated from the uterus of
the mother. It is the most common cause of late pregnancy bleeding. In humans, it refers to
the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of
pregnancies world wide with a fetal mortality rate of 20-40% depending on the degree of
separation. Placental abruption is also a significant contributor to maternal mortality. Many
women can die from this type of abnormality. The heart rate of the fetus can be associated
with the severity.
Placental abruption is suspected when a pregnant mother has sudden localized
abdominal pain with or without bleeding. The fundus may be monitored because a rising
fundus can indicate bleeding. An ultrasound may be used to rule out placenta praevia but is
not diagnostic for abruption. The mother may be given Rhogam if she is Rh negative.
Treatment depends on the amount of blood loss and the status of the fetus. If the
fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may
simply be monitored in hospital until a change in condition or fetal maturity whichever
comes first.

3. Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus
or mother are in distress. Blood volume replacement and to maintain blood pressure and
blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is
usually preferred over caesarean section unless there is fetal distress. Caesarean section is
contraindicated in cases of disseminated intravascular coagulation. Patient should be
monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy
if family size is completed.
II. OBJECTIVES
General
This case study aims that the students and reader will gain more knowledge and further
understanding about Abruptio Placenta
Specific
The students should be able to:
1. Study the anatomy and physiology of female reproductive system
2. Trace the pathophysiology of Abruptio Placenta
3. Determine the diagnostic test needed for a client including their implications and
nursing responsibilities
4. Identify the possible drugs to be prescribed, their actions, indications, contraindications
and nursing responsibilities.
5. Formulate a possible nursing care plan based from the prioritized nursing diagnosis.
III. Patient’s Profile
A. 1. Initial Name of Patient
2. Age
3. Occupation
4. Address
B. 1. Admission Complaints
2. Admission Diagnosis
3. Final/Discharge Diagnosis
4. Clinical Impression
IV. Assessment

4. A. Observation of Patient
B. Physical Examination
V. Assessment from Chart
A. Patient’s Health History
B. Admission Sheet
C. Laboratory Results
The following laboratory tests are necessary for the patient with Placenta Previa
condition:
1. Urinalysis
Purpose: Urinalysis will examine the patient’s urines for signs of renal or
urinary tract disease, to help discover diseases that are not related with renal
disorders. Alterations in the following components will have some
implications:
a. Abnormal color: Liver problems or jaundice may occur
b. Specific Gravity: To demonstrate the concentrating and diluting
ability of the kidneys.
c. Sugar: Presence of sugar may indicate diabetes and chronic kidney
disease
d. Pus cells: May be a sign of swelling in the kidney and pelvic region,
urethral ulceration and chronic inflammatory of the bladder.
e. RBS: Blood in the urine may sometimes a serious urinary tract
problem
Nursing Responsibilities:
a. Tell the patient that the test is for the detection of renal and urinary
tract disorders and assessment of body function.
b. Notify the patient that the procedure requires a urine sample. Urine
must be acquired most likely on the first void in the morning.
2. Blood Typing
Purpose: To check compatibility of the donor and patient before blood
transfusion
Nursing Responsibilities:
1. Inform the patient that test determines her blood group.

5. 2. Notify the patient that the test requires blood sample thus
venipuncture is done.
3. Check the patient’s history for recent administration of blood ,
dextran or IV.
4. After the procedure apply direct pressure to the venipuncture site
until bleeding stops.
5. Refer if venipuncture develops hematoma and monitor the pulse
distal to the site.
3. Ultrasound
Purposes:
1. To know fetal an pregnancy abnormalities and measurement
of organ size and strucutre. Obtain a consent from signed by a
patient. Explain that the procedure is painless and safe and
no radiation is involved.
2. To identify and differentiate cyst and solid tumor. Emphasized
the importance of remaining still during the scan and to
prevent distorted image.
3. To ensure the presentation and identify complications of the
fetus the detect if there is a risk for pregnancy. Assist the
patient into a supine position; possible use of pillow to
support the area to be examined.
VI. Assessment from Textbooks
A. Anatomy and Physiology

6. External Structures
A. Visible Organs of the Vulva
 Mons pubis—covered with pubic hair—located over pubic bones, serves a
protective function
 Labia major and labia minora—two pairs of tissue surrounding the outer part of
the vulva.
 Vestibule—surrounded by the labia it contains the vaginal opening and
urethra.
 Vaginal opening
 Clitoris—erectile tissue analagous to the penis
 Urethral orifice
 Perineum—the region of the genital area between the vulva and the anus. This is
the location of an episiotomy if performed during birth.
B. Breasts—mammary glands
 Function is to secrete milk for infant—lactation.
 After delivery, the withdrawal of estrogen and progesterone due to the expulsion of
the placenta cause prolactin to be produced, which stimulates milk formation.
Oxytocin is a hormone that stimulates the release of milk.

7. Internal Reproductive Organs
A. Located in the Pelvic Cavity
 Ovaries—female gonads located on
each side of the uterus. Functions
include
(1) Development and release of the
ovum (egg)
(2) Secretion of the hormones
estrogen and progesterone
 Fallopian tubes
(1) Carry the ovum from the ovary to
the uterus.
(2) Fimbriae sweep ovum into the
tube.
 Uterus
(1) Hollow pear-shaped organ that stretches and enlarges during
pregnancy to support the fetus.
(2) Other functions include menstruation and expelling of the fetus
during labor.
(3) Divisions of the uterus are: fundus—uppermost portion; corpus—the
body; cervix—lower third that exits into the vagina through the
cervical os.
 Vagina
(1) Curved tube leading from the uterus to the vestibule.
(2) Functions as a passageway for menstrual flow, organ of copulation,
and birth canal.
Pelvis
A. Bones—support and protect pelvic contents
 Sacrum—wedge-shaped bone formed by the fusion of five vertebrae
 Coccyx—small triangular bone at bottom of the vertebral column.
 Innominate bones
(1) Ilium—upper prominence of the hip
(2) Ischium—L-shaped bone below the ischium. Distance between the
ischial spines is the shortest diameter of the pelvic cavity.
(3) Pubis—slightly bowed front portion of the innominate bone. The
pubis meet at the front of the pelvis to make up the joint called the
symphysis pubis. Below the symphysis is a triangular space called
the pubic arch, under which the fetal head passes during birth.
B. Pelvic floor—muscular floor of bony pelvis, supports pelvic contents

8.  Levator ani—major portion, made up of four muscles
(1) Ileococcygeus
(2) Puboccygeus
(3) Puborectalis
(4) Pubovaginalis
 Coccygeal muscle—underlies sacrospinous ligament a thin muscular
sheet which helps the levator ani support the pelvic contents
C. Pelvic shapes—vaginal birth is never ruled out because of pelvic type
without a trial of labor.
 Android—narrow, heart shaped, similar to shape of male pelvis—not
favorable for vaginal birth
 Anthropoid—widest from front to back—usually adequate for vaginal
birth
 Platypelloid—widest from side to side—not favorable for vaginal birth
 Gynecoid—“classic” female pelvis—approximately 50 percent of
women and it’s the best for vaginal birth
Functions of the Female Reproductive System
1.External Genitalia
•The mons pubic protects the pubic bone from trauma.
•The clitoris provides for sexual arousal and orgasm.
•The labia majora and minora protect the external genitalia, urethra, and distal vagina.
•Secretions from Bartholin’s glands lubricate the external vulva during coitus and
improve sperm survival.
•Secretions from Skene’s glands lubricate the external genitalia during coitus.
•The urethral meatus is the external opening of the female urethra.
•The perineal muscle expands during childbirth to enlarge the vagina, allowing for
passage of the fetal head.
2.Internal genitalia
•The vagina aids in conception by conveying sperm to the cervix and helps in childbirth
by serving as a passageway for the fetus.
•The uterus receives the fertilized egg, provides for implantation, nourishes and
protects the growing fetus, and contacts to expel the fetus during childbirth.
•The ovaries produce and release mature ova and regulate the menstrual cycle through
the production of estrogen and progesterone.
•The fallopian tubes move the sperm toward the ova and the ova toward the uterus,
thereby aiding in fertilization.

9. 3.The pelvis supports and protects the reproductive and other pelvic organs. During the
late months of pregnancy, the false pelvis supports the uterus and helps direct the fetus
into the true pelvis for birth.
4.The breasts serve to produce and secrete (Lactate) milk for the infant.
B. Pathophysiology
Classificationof abruptionsaccordingtoseverity:
 Grade 0: Asymptomaticandonlydiagnosedthroughpostpartumexaminationof the
placenta.
 Grade 1: The mothermayhave vaginal bleedingwithmilduterinetendernessortetany,but
there isno distressof motherorfetus.
Trauma/hypertension/coagulopathy
Bleeding into the decidua
basalis/hematoma
Separation of the placenta from
the uterine wall (compression,
blood supply to the fetus is
compromised)
Overt/External vaginal bleeding or
poolingof bloodbehindthe placenta
(concealed/internal abruption
placenta)
Fetal distress/death
Mother may experience
abdominal/backpain,abnormal or
premature contractions

10.  Grade 2: The motherissymptomaticbutnotin shock.There issome evidence of fetal
distresscanbe foundwithfetal heartrate monitoring.
 Grade 3: Severe bleeding(whichmaybe occult) leadstomaternal shockand fetal death.
There may be maternal disseminatedintravascularcoagulation.Bloodmayforce itsway
throughthe uterine wall intothe serosa,aconditionknownas Couvelaireuterus.
C. DESCRIPTION OF THE DISEASE
Abruptio placenta is premature separation of the normally implanted placenta
after the 20th week of pregnancy, typically with severe hemorrhage.
Two types of abruption placentae:
Concealed hemorrhage - the placenta separation centrally, and a large amount of blood
is accumulated under the placenta.
External hemorrhage – the separation is along the placental margin, and blood flows
under the membranes and through cervix.
Risk Factors:
1. Uterine anomalies
2. Multiparity
3. Preeclampsia
4. Previous cesarean delivery
5. Renal or vascular disease
6. Trauma to the abdomen
7. Previous third semester bleeding
8. Abnormally large placenta
9. Short umbilical cord
Common Clinical Manifestations:
1. Intense, localized uterine pain, with or without vaginal bleeding
2. Concealed or external dark red bleeding
3. Uterus firm to boardlike, with severe continuous pain
4. Uterine contractions
5. Uterine outline possibly enlarged or changing shape
6. FHR present or absent
7. Fetal presenting part may be engaged
Nursing Management:
1. Continuous evaluate maternal and fetal physiologic status, particularly:
o Vital Signs

11. o Bleeding
o Electronic fetal and maternal monitoring tracings
o Signs of shock – rapid pulse, cold and moist skin, decrease in blood pressure
o Decreasing urine output
o Never perform a vaginal or rectal examination or take any action that
would stimulate uterine activity.
2. Asses the need for immediate delivery. If the client is in active labor and bleeding
cannot be stopped with bed rest, emergency cesarean delivery may be indicated.
3. Provide appropriate management.
o On admission, place the woman on bed rest in a lateral position to prevent
pressure on the vena cava.
o Insert a large gauge intravenous catheter into a large vein for fluid
replacement. Obtain a blood sample for fibrinogen level.
o Monitor the FHR externally and measure maternal vital signs every 5 to 15
minutes. Administer oxygen to the mother by mask.
o Prepare for cesarean section, which is the method of choice for the birth
4. Provide client and family teaching.
5. Address emotional and psychosocial needs. Outcome for the mother and fetus
depends on the extent of the separation, amount of fetal hypoxia and amount of
bleeding.
NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Ineffective
Tissue
Perfusion
related to
Excessive
blood loss
secondary to
premature
placental
separation
Goal: Client will
maintain adequate
tissue perfusion by
(date/time).
Outcome:
1. Client will
maintain
BP and
pulse
(specify:
BP
>100/60
and pulse
between
60-90
beats per
minute),
warm skin
and dry.
 Assess
patient’s
condition
especially the
SaO2, BP,PR
and RR.
 Monitor for
restlessness,
anxiety, air
hunger and
changes in
LOC.
 Monitor
accurately
input and
output.
 Assessment
provides
baseline
information
about
client’s
present
condition.
 S/Sx of the
said
condition
provides
information
of
developing
indications
of
inadequate
cerebral
tissue
Patient’s blood
pressure was
maintained(100/60)
Patient’s pulse was
at least 60 beats per
minute.

12. 2. Urine
output not
less than
30cc/hour.
3. Client will
remain
alert and
oriented,
FHR
pattern
remains
reassuring.
Evaluate also
blood loss by
weighing
pads.
 Continuously
monitor FHR
pattern
compare to
baseline data
from prenatal
record.
Inform other
health care
team for any
signs of non
reassuring
changes.
 Assess for
uterine
irritability,
abdominal
pain, rigidity
and increase
abdominal
girth.
 Assess
client’s skin
color,
temperature,
moisture,
turgor and
capillary
refill.
 Initiate IV
access with
gauge 18
catheter and
provide
fluids, blood
products, or
perfusion.
 Monitoring
provides
data about
renal
perfusion
and
function
and the
extent of
blood loss.
 The fetus
may
initially
respond
reassuring
to decrease
placental
perfusion
by raising
the FHR
above the
normal
baseline.
Non
reassuring
FHR is an
indication
for delivery.
 Assessment
gives
information
about the
severity of
placental
abruption.
Bleeding
may be
occult
causing
abdominal
rigidity and
pain.
 Assessment
provides
information
about
peripheral
tissue
perfusion.

13. blood as
ordered.
 Monitor
laboratory
results (Hgb,
Hct, Clotting
studies).
 Observe client
for signs of
spontaneous
bleeding.
 Keep client
and
significant
others
informed of
the condition
and plan of
care.
 Notify
caregivers and
prepare for
immediate
delivery and
neonatal
resuscitation
for maternal
and fetal.
Hypovolem
ia results in
shunting of
blood away
from
peripheral
circulation
to the brain
and vital
organs.
 Intervention
provides
venous
access to
replace
fluids.
 Laboratory
studies
provide
information
on extent of
blood loss
and signs of
impeding
DIC.
 This
provides
information
about the
depletion of
clotting
factors and
developmen
t of DIC.
 Information
of the
condition of
the client
will
promote
understandi
ng and
cooperation.
 Continued
blood loss
or
developmen

14. t of DIC
may lead to
maternal or
fetal injury
or death.
DRUG STUDY
DRUG
NAME
ACTION INDICATION SIDE
EFFECTS
and
ADVERSE
EFFECTS
NURSING
CONSIDERATIONS
& RESPONSIBILITIES
Generic
Name:
Oxytocin
Inducing labor
in women with
Rh problems,
diabetes,
preeclampsia,
or when it is in
the best interest
of the mother
or fetus. It is
also used to
help abort the
fetus in cases
of incomplete
abortion or
miscarriage,
produce
contractions
during the third
stage of labor,
and control
bleeding after
childbirth.
Oxytocin is a
uterine stimulant.
It works by
causing uterine
contractions by
changing calcium
concentrations in
the uterine muscle
cells.
Nausea;
vomiting; more
intense or
abrupt
contractions of
the uterus.
Do NOTuse Oxytocin if:
 you are allergic to
any ingredient in
Oxytocin
 your birth canal is
too small
compared with the
fetus's head
 the fetus is in a
difficult position
within the womb
or is in distress
and delivery is not
progressing
 you have other
complications that
require medical
intervention for
birth
 you have bacteria
in the blood
VII. DISCHARGE PLANNING
Medication
Emphasized the importance of medication compliance.
Exercise
Needs to adequate her time with her child to be certain he or she is all right, and nurse c
an states hearing fetal heart beat helps to reassure her about baby’s health.

15. Attach contraction and fetal heart rate monitoring for continuous evaluation of
contractions of fetal response.
Treatment
Used of drugs
Catheterization
Health Teaching
Maintain a bed rest
Maintain a 8 glasses of water
Ongoing Assessment
Assess client’s home surrounding to determine whether they are appropriate for bed
rest and continuing monitoring at home. Administer oral dose and home monitoring
requires professional supervision.
Diet
She might to begin to neglect her diet or her supplementary vitamins because “It
doesn’t matter anymore”.
Spiritual
Assess anxiety level of client over preterm labor possible feelings.
Determine whether client wants a support person to be wit her, to the presence of a
support person can offer additional comfort to a client.
References:
 Maternal & Child Nursing Seventh Edition Vol.1
 Maternity nursing, Lowdermilk Perry, seventh edition.
 Maternal Neonatal Nursing Lippincott manual of Nursing Practice
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