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Placenta Previa Nursing Guide

This course is intended as a Quick Reference for Placental Previa and will cover an overview and nursing considerations utilizing the nursing process.

Etiology and Epidemiology

Placenta Previa Definition

The placenta attaches to the wall of the uterus and provides nutrients and oxygen to the fetus. Placenta previa occurs when the placenta attaches in the lower part of the uterus and partially or completely covers the internal cervical os. Placenta previa presents in approximately one out of every 250 deliveries. 

 

There are three types of placenta previa: 

  • Complete: The placenta covers all of the cervical opening. 
  • Marginal: The placenta is next to the cervix but does not cover the opening. 
  • Partial: The placenta covers part of the cervical opening. 

In a low-lying placenta, the edge is within 2 to 3.5 cm of the internal os. A low-lying placenta or a placenta previa occurring early in pregnancy will usually resolve within 28 weeks as the uterus enlarges, and the placenta migrates. 

 

Risk factors for placenta previa include: 

  • Abnormally shaped uterus 
  • Cocaine use 
  • In vitro fertilization 
  • Multifetal pregnancy 
  • Multiparity 
  • Older maternal age 
  • Prior cesarean delivery 
  • Prior uterine surgery 
    • Myomectomy 
  • Prior uterine procedure 
    • Multiple dilation and curettage [D and C] procedures 
  • Smoking 
  • Uterine abnormalities that inhibit normal implantation 
    • Fibroids 
    • Prior curettage 

Complications caused by placenta previa include: 

  • Fetal growth restriction 
  • Fetal malpresentation 
  • Postpartum hemorrhaging 
  • Preterm premature rupture of the membranes 
  • Vaginal bleeding, which if not treated can lead to: 
    • Anemia 
    • Fetal anemia 
    • Hemorrhage 
    • Shock 
  • Vasa previa 
  • Velamentous insertion of the umbilical cord 

In women with a prior cesarean delivery, placenta previa increases the risk of placenta accrete. This risk increases as the number of prior cesarean deliveries increases (Dulay, 2020): 

  • 1 cesarean section: 6 to 10% risk 
  • More than 4 cesarean sections: > 60% risk 

 

Placenta Previa ICD-10 Code: O44.0

  • Complete placenta previa NOS or without hemorrhage.

 

Placenta Previa Diagnosis 

  • If any vaginal bleeding is present after 20 weeks’ gestation, it is important to rule out placenta previa. 
  • A digital vaginal exam should NOT be conducted until a placenta previa is ruled out by an ultrasound. 
  • A transabdominal ultrasound can be done first. 
    • If placenta previa is suspected, a transvaginal ultrasound should be completed to determine the location of the placenta. 

 

Management 

The management of placenta previa varies depending on gestational age and complications. Vaginal delivery may be possible for women with a low-lying placenta, if the placental edge is within 1.5 to 2.0 cm of the cervical os. For all other placenta previas, a cesarean section is required to prevent massive vaginal bleeding. 

If the placenta is near or covering part of the cervix, an individual may be advised as follows: 

  • Modified bed rest 
  • Pelvic rest 
    • Nothing in the vagina 
  • Reduced activity 

If an individual has vaginal bleeding prior to 36 weeks gestation, but is stable, with no further bleeding, hospitalization and modified activity may be required. The individual may be discharged, but a second episode of bleeding usually makes hospitalization until delivery necessary. Delivery is indicated for any of the following: 

  • Heavy or uncontrolled bleeding 
  • Maternal hemodynamic instability 
  • Non-reassuring results fetal heart rate 

Those with placenta previa, without bleeding or other obstetric complications, should deliver at 36-37 6/7 weeks gestation (Gyamfi-Bannerman & SMFM, 2018). 

Administer antenatal corticosteroids to those who are eligible and managed expectantly if the following conditions apply: 

  • Delivery likely within 7 days 
  • Gestational age between 34 0/7 and 36 6/7 weeks 
  • Antenatal corticosteroids not administered previously 

In cases with active hemorrhage in the late preterm period, do not delay delivery in order to administer antenatal corticosteroids. 

 

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnosis, interventions, expected outcomes, and education for individuals with placenta previa are listed below. 

 

Assessment 

  • History 
    • Abnormally shaped uterus 
    • Age 
    • Drug and smoking history 
    • In vitro fertilization 
    • Multifetal pregnancy 
    • Multiparity 
    • Prior cesarean delivery 
    • Prior uterine surgery 
    • Prior uterine procedure 
    • Uterine abnormalities 
  • Physical Examination 
    • Abdominal pain 
    • Fetal status 
    • Uterine contractions 
    • Vaginal bleeding 
      • Do not perform vaginal exam 
    • Vital signs 

 

Nursing Diagnosis/Risk For 

  • Fear 
  • Ineffective coping 
  • Pain 
  • Fetal injury 
  • Fluid volume deficit 
  • Impaired fetal gas exchange 
  • Infection 

 

Interventions 

  • Fear and ineffective coping 
    • Administer medications, as ordered. 
    • Explain diagnosis, side effects, and treatment. 
    • Maintain calm environment. 
    • Provide support to the individual and explain what is happening. 
  • Pain 
    • Administer medications, as ordered. 
    • Assist with spinal anesthesia, if necessary. 
  • Risk for fetal injury and risk for impaired fetal gas exchange 
    • Administer oxygen to individual. 
    • Continuously monitor fetal heart rate. 
    • Evaluate the cause, response to therapy, and fetal condition. 
    • Prepare for emergency cesarean section. 
    • Prepare for neonatal resuscitation. 
  • Risk for fluid volume deficit 
    • Insert a Foley catheter. 
    • Insert and maintain IV, per protocol and order. 
    • Prepare for blood transfusion. 
    • Restore circulating volume using one or more IV lines. 
  • Risk for infection 
    • Administer antibiotics, as ordered. 
    • Maintain surgical asepsis in OR. 

 

Expected Outcomes 

  • Decrease pain and fear 
  • Elicit effective coping 
  • Prevent or treat: 
    • Fluid volume deficit 
    • Impaired fetal gas exchange 
  • Prevent: 
    • Infection 
    • Fetal injury 

 

Individual/Caregiver Education 

  • General education while pregnant: 
    • A cesarean section delivery will likely be required. 
    • Delivery likely will be performed from 36 to 37 full weeks in uncomplicated cases. 
    • Individual may require: 
      • Bed rest 
      • Pelvic rest 
        • Avoiding intercourse 
        • Avoiding digital examinations 
    • Individuals with placenta previa should go to the emergency room if they have any episodes of vaginal bleeding. 
  • Discharge instructions/planning after delivery: 
    • Call if any complications or adverse effects arise, such as: 
      • Bleeding 
      • Infection 
      • Pain 
    • Follow up with physician as directed. 
  • For future pregnancies, it is important to know that prior history of placenta previa and a history of cesarean sections may increase an individual's risk for placenta accreta. 
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Additional Information

Content Release Date 

4/1/2022

Content Expiration

10/31/2027

 

Course Contributor 

The content for this course was created by Kelly LaMonica, DNP, RNC-OB, C-EFM. Kelly LaMonica received her Associate’s Degree and RN from Muhlenberg School of Nursing in New Jersey 20 years ago. She began her career in Labor and Delivery 16 years ago. She earned her BSN and MSN from the University of Phoenix and her DNP from Grand Canyon University. She is certified in Inpatient Obstetrics (C-OB) and Electronic Fetal Monitoring (EFM). She is a neonatal resuscitation (NRP) Instructor. She has been a clinical leader for the past 11 years at Penn Medicine Princeton. She is also a Clinical Instructor at Rutgers University and Chamberlain School of Nursing. 

 

Resources 

 

References