Maternity - Pregnancy, part 11: Complications: Cervical Insufficiency, Placenta Previa, Abruptio Placenta
by Meris Shuwarger BSN, RN, CEN, TCRN September 13, 2021 Updated: August 09, 2023 5 min read
This article continues our discussion of the various complications of pregnancy, this time focusing on cervical insufficiency, placenta previa, and abruptio placentae.
This series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Cervical insufficiency, sometimes called an incompetent cervix, is the premature dilation of the cervix. Although the baby is not due yet, the cervix has begun to dilate. This is a serious condition that can lead to preterm birth and even the loss of the baby.
Signs and symptoms of cervical insufficiency
The signs and symptoms of cervical insufficiency include increased pelvic pressure, vaginal bleeding or pink-tinged discharge, a gush of fluid from the vagina (a particularly serious sign), and cervical dilation (something that the provider would likely find rather than the patient).
Diagnostics of cervical insufficiency
Diagnosis may be made with a transvaginal ultrasound, which is used to assess cervical length.
Most patients who are having their first baby will have a transvaginal ultrasound to measure the length of the cervix, usually at the beginning of the third trimester. This is to establish that the cervix appears to be a good length. The patient will likely not repeat this ultrasound in subsequent pregnancies, unless the patient has gone on to have a preterm birth or complications during that initial pregnancy.
Treatment for cervical insufficiency
Treatment for cervical insufficiency includes a cervical cerclage. A cerclage is a “purse-string”-like suture used to close the cervix, essentially cinching the cervix closed like a purse string. This suture is usually placed at 12 to 14 weeks gestation, and removed at 36 to 38 weeks of gestation.
Further treatments may include placing the patient on bed rest or bringing the patient into the hospital for different medication management.
Patient teaching for cervical insufficiency
A patient who is on bed rest for cervical insufficiency is also probably on pelvic rest, which means educating them to avoid any penetrative sexual activity. Patients should also be encouraged to drink enough fluids daily.
Placenta previa is when the placenta is implanted near or over the opening of the cervix, which is called the cervical os. This can cause bleeding during the third trimester.
Types of placenta previa
There are four types of placenta previa: complete (or total), partial, marginal, and low-lying.
Complete (total) placenta previa
Complete (total) placenta previa is when the placenta completely covers the cervical os.
Partial placenta previa
Partial placenta previa is when the placenta partially covers the cervical os.
Marginal placenta previa
Marginal placenta previa is when the placental edge is within 2 cm of the cervical os.
Low-lying placenta previa
Low-lying placenta previa is when the placenta is implanted on the lower uterus near the cervical os (within 2 - 3.5 cm).
Signs and symptoms of placenta previa
A patient experiencing placenta previa will have painless bright red bleeding during the second half of pregnancy.
Diagnostics of placenta previa
An ultrasound is used to diagnose placenta previa.
Commonly, placenta previa is noticed early in a pregnancy. If not, painless bright red bleeding may indicate the condition.
Treatment for placenta previa
The treatment for placenta previa includes bed rest at home when the mother and fetus are stable. If the condition occurs at 36 to 37 weeks, the patient will undergo a C-section delivery. For a patient experiencing excessive bleeding, an immediate delivery may be required.
Nursing care for placenta previa
In terms of nursing care, it is important not to perform a vaginal exam, which might cause further trauma and could introduce pathogens into the uterus.
If the baby is preterm and may be born imminently, corticosteroids may be administered to improve the lung maturation of the baby.
Abruptio placentae is the premature abruption — separation — of the placenta from the uterine wall. This occurs after 20 weeks of gestation and poses a very high risk of maternal and fetal morbidity or mortality.
In a normal birth, the placenta separates from the uterine wall after the baby is born. With abruptio placentae, the placenta separates from the uterine wall while the baby is still in utero. This means the placenta is no longer receiving blood flow, which means the baby is not receiving enough blood. Instead, the patient is bleeding into the space between the placenta and the uterine wall. This puts the mother at risk for hemorrhage, shock, and death.
Risk factors for abruptio placentae
Trauma could trigger a placental abruption, for example a car accident or falling down the stairs.
Multiparity — multiple fetuses — is another risk factor for abruptio placentae, that is, if the patient has a twin or a triplet pregnancy, for example.
Patients who are smokers are at risk, because blood flow is impaired when smoking.
And the use of cocaine or other stimulants could cause a premature separation of the placenta. That's because cocaine and stimulants in general cause vasoconstriction (constriction of blood vessels), which results in an inadequate blood flow to the placenta.
Signs and symptoms of abruptio placentae
Signs and symptoms of abruptio placentae include dark red vaginal bleeding as well as sudden, severe abdominal pain (“abruptio” means sudden or abrupt).
The patient may have a rigid board-like abdomen, because the blood is accumulating in that abdominal space, making it firm to the touch.
Diagnostics for of abruptio placentae
A patient experiencing abruptio placentae will show signs and symptoms of hypovolemic shock — shock caused by a hemorrhage (because the patient is losing blood) — for example, tachycardia, hypotension (low blood pressure), pallor, or tachypnea (breathing very fast).
Treatment for abruptio placentae
The treatment for abruptio placentae is an emergency C-section. It is crucial to deliver the baby and stop the bleeding.
Nursing care for abruptio placentae
In terms of nursing care, the priority is to deal with hemorrhagic shock: administer IV fluids, blood products, and oxygen as ordered. It will be important to monitor both mother and fetus. And, as with placenta previa, do not perform a vaginal exam.
Remember: It is important to understand that vaginal bleeding is not always the same — sometimes it can be a warning sign that requires an immediate call to the provider, while other times it may be something that can be monitored and still be treated urgently, without immediate intervention.
No matter what, if the patient is bleeding from their vagina during pregnancy, do not perform a manual cervical check.
Hi, I’m Meris, and in this video, I’m going to be talking to you about some complications of pregnancy, including cervical insufficiency, placenta previa, and abruptio placentae. I’m going to be following along using our maternity flashcards. These are available on leveluprn.com if you want a set for yourself. And if you already have your own, I would absolutely invite you to follow along with me. All right. Let’s get started.
So first up, we’re talking about cervical insufficiency. This is sometimes called an incompetent cervix. But what it is, is premature dilation of the cervix. So it’s not time for the baby to be born yet, but the cervix is still dilating. This is a big problem and can lead to preterm birth and even the loss of the baby.
So signs and symptoms would be increased pressure, like pelvic pressure; vaginal bleeding or pink-tinged discharge; gush of fluid from the vagina would be a really big bad sign; and then also cervical dilation, of course. That would be something that the provider would likely find, not so much the patient.
Now the diagnosis can be through a transvaginal ultrasound. So in most patients who are having their first baby, usually in the beginning of the third trimester, they will have a transvaginal ultrasound to measure the length of the cervix and make sure that it seems like it is a good length. They will not repeat that again in subsequent pregnancies unless that patient should go on to have a preterm birth or complications like that.
Now, treatment for it. Well, you can do something called a cervical cerclage. And cerclage is a purse-like string. It’s a type of suture that is placed into the cervix that allows it to be closed like a purse. So it’s kind of like a-- it cinches it closed like a purse string. And this is placed usually at 12 to 14 weeks. So this would be most of the time for someone who has had this complication previously. And then it would be removed at 36 to 38 weeks of gestation. So that is going to be one of the treatments.
Of course, there are other things like they may need to be placed on bed rest. They may need to be brought into the hospital for different medication management. But that is the kind of classic treatment for cervical insufficiency.
Now, of course, if we have a patient who is on bed rest for this, they are also probably on pelvic rest, which means that we need to educate them to avoid any penetrative sexual activity, as this could lead to complications.
All right. Moving on. We’re going to talk about two really important complications of pregnancy that can sometimes be confused for one another. So we’re going to talk about placenta previa first, and then we’re going to talk about placental abruption next.
So placenta previa. So this means that the placenta itself implanted near or over the opening of the cervix, which is called the cervical OS, O-S, and this can cause bleeding during the third trimester. The placenta, we don’t want it to be covering the opening of the cervix or even close to it for this reason, but it’s something that can happen.
We do list here the complete partial, marginal, and low-lying types of this condition, which you can read about, but I really want to focus on the signs and symptoms.
So your patient is going to have painless bright red bleeding. So placenta previa causes painless bleeding. That’s my way of remembering it. Placenta previa. Painless bleeding. So three P’s there to help you remember. It’s also going to be bright red blood.
And we can diagnose placenta previa usually with ultrasound. Very commonly, it is seen early in the pregnancy. We can anticipate this complication. We can monitor it. But sometimes it is not able to be detected early on and then your patient will present with this complication. And that’s how you might think, “Oh, okay. Painless bright red bleeding, placenta previa.
Really super-duper important thing to understand about any vaginal bleeding, if my patient is bleeding from their vagina during pregnancy, I should not perform a cervical check. So a manual check where I put my hands into the vagina to assess the cervix. I should not do that. I could cause further trauma. Even though I’m using sterile gloves and those sorts of things, there’s a source of bleeding. So I could be introducing pathogens. There’s a whole host of reasons why. But just remember, if my patient is actively bleeding vaginally, I should not put anything into their vagina to assess their cervix. That is not a good thing for them.
We will give them IV fluids and blood products as needed. And if the baby is pre-term and we think this baby is going to be born imminently, then we may want to give them corticosteroids to improve that lung maturation of that baby.
So how does that differ from placental abruption or what you will hear called abruptio placentae? So an abruption is the separation of the placenta from the uterine wall prematurely. So of course, eventually it’s going to separate from the uterine wall after the baby is born, but we’re talking about while the baby is still in utero. This is going to be after 20 weeks of gestation. And this has a very high risk of maternal-fetal mortality. So what happens is when that placenta pulls away from the uterine wall, first of all, I’m now not getting that blood flow, right? That part of that placenta is not receiving blood flow, which means the baby is not receiving enough blood. And also, I’m bleeding into this space between the placenta and the uterine wall. So now mom is at risk for hemorrhage, shock, and death. So very important to be able to assess for this as a possible condition.
So what does it look like? Well, dark red, vaginal bleeding, and severe abdominal pain. This is excruciatingly, exquisitely painful. So placenta previa is painless, right? And it’s bright red bleeding. But placental abruption very painful and dark red bleeding. The other thing is that the patient may have a rigid board-like abdomen, whereas you would not see that in placenta previa. This is because the blood is accumulating in that abdominal space there, and it is going to be firm to the touch. Rigid and board-like abdomen is never a good finding. This is really bad.
And then, of course, signs and symptoms of hypovolemic shock, right? Hemorrhagic shock. Your patient is losing blood. So things like tachycardia but hypotension, pallor, tachypnea, right? If they’re breathing very fast. Those are all signs and symptoms.
Now, who’s at risk for this? Someone who is a smoker, right? A patient who is a smoker because we don’t have really good blood flow when smoking. A patient with maternal hypertension. Again, lots of pressure in those vessels. A patient who experienced trauma, like a car accident or falling down the stairs. That could trigger a placental abruption. Multiparity, which means multiple fetuses. So if you have a patient who has a twin or a triplet pregnancy, for instance. And then use of cocaine or other stimulants like that. Remember, cocaine and stimulants, in general, are going to cause vasoconstriction. So we’re not going to be getting that adequate blood flow to the placenta. That is definitely something that we need to be aware of.
So the treatment is going to be an emergency C-section. There is essentially nothing that can be done other than deliver the baby and stop the bleeding.
And then, of course, we need to do the rest of the nursing care for hemorrhagic shock, too. So things like oxygen, IV fluids for the mom, blood products and, of course, avoiding vaginal exams in this case also.
So very important to know vaginal bleeding is not always the same, and it’s not always as detrimental as other types of vaginal bleeding. So you need to know when is this a warning sign that I need to call the provider immediately and when is this something that we can monitor and take with a little bit more urgency and less emergent treatment?
I hope that review was helpful. If it was, please like this video so that I know. I would love for you to leave me a comment if you have a really great way to remember things or a story that can help us with remembering some sort of clinical aspect. Please be sure that you subscribe to the channel too because you want to be the first to know when the next video in the series comes out. Thanks so much and happy studying.
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