ACKNOWLEDGEMENT

This project would not be made possible without the help and guidance of our Almighty
Father, who conveyed our group adequate knowledge, sufficient vigor and bravery to
face innovative and peculiar defy during the entire course of this project. Our never-
ending thanks to Almighty Father the most High for the love and care he showered upon
us.

Our genuine gratitude to our beloved parents for always supporting us physically,
mentally, emotionally and financially in regards to this venture. Warmth thanks for
entrusting to us their confidence and understanding not only in times of need but in
everyday of our lives. They used to complain that we are getting too sovereign and
matured; however we live in the ideology that letting go of their children is the hardest
part of being a parent. Though it is not easy for us to acknowledge the fact that we are
getting old bit by bit, we have to separate from them in order to understand the true
essence of being a human, and still our love for them remains the same. To our dear
parents, rest guaranteed that what we are doing right now will serve as a stepping stone
towards a philosophical future and sagacious life, and that is being a nurse.

INTRODUCTION
Pregnancy is an exciting time in any parent's life. It's a time of change, growth, discovery
and a lot of questions. One of the most important factors of having a healthy baby is the
mother’s health especially during the 9 months where the child’s development has
already started. The mother’s nutrition, activity etc. greatly affect the developing fetus
inside her womb such that any move could put the child at risk resulting to
abnormalities, poor health or even death to the precious being anytime or even during
pregnancy if mother’s health is being taken for granted.

Complications may occur at any time during pregnancy and can result from pre-existing
maternal medical problems or from the pregnancy itself. Early and consistent prenatal
care results in improved fetal and maternal outcomes, regardless of complications that
may occur. One of these complications, placenta previa, is a condition in which the

1
placenta is implanted close to or covers the cervical os. Normally, the placenta implants
in the upper uterine segment, but in the case of placenta previa, the placenta implants in
the lower part of the uterus.

Placenta previa is experienced in 1 out of 200 pregnancies around the world. Maternal
morbidity rate is approximately 5% and mortality rate is less than 1%. In the Philippines
, it reached to 6,341 out of the 86,241,697 population estimate used in the year 2004.
The mortality rate of placenta previa in the
country is 0.17% according to DOH.

During our duty in the Ob ward at Ospital Ning Angeles (ONA) , we decided to take the
case of Mrs. Nicole Kidman in which she was diagnosed with placenta previa totalis
because we would like to have a deeper understanding about this condition so that we
could render the care the patient needed to arrive with a good prognosis. Management
should therefore always be based on appropriate clinical judgment. We would like to
apply all the things that we’ve learned through our lectures for the benefit of our patient
and to enhance our skills as well.

We hope that this case study will enable us, student nurses to better understanding
about the disease process and that we will be more sensitive in attending to our patient’s
need. For the community, we hope that this will increase the level of awareness among
the members of the community so that it could help in the prevention of further
pregnancy complications.

OBJECTIVES

General
This case study aims that the students and the readers will gain knowledge and further
understanding about Placenta Previa.

Specific To be able to:

1. Establish rapport with our client including her family members

2
2. Gather all necessary information regarding her and her family members as may be
related to our case study
3. Ascertain client’s past and present health history
4. Trace her genogram or family tree
5. Trace the development data of the client
6. perform physical assessment on client’s condition so as to attain baseline data
7. Present the definitions of the complete diagnosis that would explain the illness of our
client
8. Study the anatomy and physiology of female reproductive system
9. Trace the pathophysiology of placenta previa
10.Determine the diagnostic tests our client has undergone including their implications
and nursing responsibilities
11.identify the drugs prescribed to our client, their action, side effects, indications,
contraindications and nursing responsibilities
12.Identify and prioritize the need of our patient
13.Formulate an appropriate nursing care plan based on the assessment
identified needs and problems of the patient
14.Render health teachings as part of our holistic care to alleviate problems identified
15.Evaluate complications to nursing practice, education and research

PATIENT’S DATA
Name: Mrs. Nicole Kidman
Address: 160 Abacan, Malabanias Angeles City
Age: 38 y/o.
Birthday: 7-12-1971
Birthplace: Angeles City
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: High School Graduate
Occupation: Housewife
Date Admitted: October 17, 2009
Time Admitted: 1:55pm

3
 Ward: OB
Bed no.: 22
Admitting Diagnosis: Pregnancy uterine 6 – 7 weeks AOG G5P4 UTI,
Placenta Previa

Student Nurse Centered:

After the completion of the case study, the student nurse shall be able to:

• Present a comprehensive and detailed report regarding the patient’s illness

• Have a complete picture of the patient’s physical, psychosocial and mental
status through daily assessment
• Have a well-structured nursing diagnosis of the client’s status based from an
integration of data gathered
• Understand the factors that might have contributed to the development of the
disease
• Provide organized and structured nursing interventions as a response to the
patient’s anticipated needs
• Provide relevant information on available alternative therapies and
management

III. Nursing Process

4
 A. Assessment

1. Personal History

a. Demographic Data

Mrs. Nicole Kidman is a 38 years old Mother. She was born on July 12, 1971 in
160 Abacan St, Malabanias Angeles City, she is a Filipino Citizen and a Roman
Catholic. She is the youngest child among the three children. This is her 5th
pregnancy on her G5P4 6-7 weeks Age of Gestation. She has a Four Children the
3 boys aged 11, 7, and 4 years old and girl is 9 years old. They live in a compound
together with their relatives according to the husband of Mrs. Nicole Kidman
they are very crowded in their compound because there are 8 families in their
compound and each family they have a range of 3-4 children in each families.

b. Socio Economic and Cultural Factors

As a Roman Catholic Mrs. Nicole Kidman also going to church every Sunday

and she also pray before she going to sleep. Although they are Roman Catholic
they believe in Herbularyos and Hilots, according to them that one time in her
pregnancy she consulted a Hilot in Mabalacat. She never consulted for a prenatal
check up in any medical institution or health center in there barangay during her
past pregnancy. She is giving birth only in there home and was delivered by a
midwife. But all her previous pregnancy she never had a problem like vaginal
bleeding but she have a previous problem with serious of Urinary Tract Infection

5
which she only treated by a antibiotic and was only OTC medicine which she
never consulted a physician.

The couples are practicing family planning method Mrs. Nicole Kidman used
to drink a type of Pills before she got pregnant on her 5th child. She told us that
she suddenly stop drinking pills because she just forgot to buy the next set of
tablets. Then she told us that the couple just plan to have an another child so she
got pregnant.

Mrs. Nicole Kidman is a plain housewife and her husband is working as a

permanent welder in a Construction Company here in Angeles City he earn P 400
a day. Both of them finish High School and there 3 children are studying in a
public school at Don Teodoro Elementary School in Abacan, Angeles City.

2. Family Health – Illness History

Mrs. Nicole Kidman diseases has no direct connection with the past illnesses.
Her Placenta Previa meaning is a complication of pregnancy in which the
placenta grows in the lowest part of the womb (uterus) and covers all or part
of the opening to the cervix.

Mrs. Nicole Kidman mother died in a Cancer at 56 years old. Her father has
arthritis. Aside from these illnesses no significant disease was mentioned by
the client.

6
 Father Mother

(Arthritis) Died (Cancer)

Older 2nd Brother Mrs. Nicole

Brother Kidman

3. History of Past Illness

Mrs. Nicole Kidman have no medical record of any hospitalization in her

life. She told us that her common illness is Fever and colds only. She told us that
this is the first time she will be hospitalize that why she feel anxious about the
situation.

4. History of Present Illness

According to the Client in the morning of October 17, 2009 she is complaining
of back pain to her husband who is about to going to work. But her husband think
it’s only normal in her 5th pregnancy so he neglect it and tell her to just take a rest.
She just take a rest in that morning but in the afternoon she experienced vaginal
bleeding and dizziness. Then she was later admitted in Ospital Ning Angeles
(ONA) on October 17, 2009 at 1:55pm with Chief Complain of Vaginal Bleeding /
Dizziness and was Medically diagnosed UTI and T/C Threatened Abortion. Upon

7
her admission she experienced heavy vaginal bleeding and later that day she has
fever of 39 OC and she has difficulty of breathing that why they hooked an O2
Nasal Canulla and IVF D5LRS FD 200CC.

5. Physical Examination

PHYSICAL EXAMINATION

October 17, 2009 (Saturday)

Upon Admission

Appearance and Behavior: Appears well when not moving but shows slight
facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 36.6 OC

PR: 80 BPM

RR: 20 CPM

BP: 100/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

8
Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

Abdomen: Flabby, soft & non tender

Genitalia: dosed cervix x 1(4) Spotting

October 18, 2009

Actual Physical Examination

Appearance and Behavior: Appears well when not moving but shows slight
facial grimaces upon movement and approachable

Mental Status: Conscious and Coherent

Language: Kapampangan

Posture: On a Semi Fowlers position

Vital Signs:

T: 37.3 OC

PR: 85 BPM

RR: 18 CPM

BP: 90/70 mmhg

Skin: with no pallor; no jaundice

Head: No lesions noted, no palpable nodules, symmetrical

Hair: Shoulder length, black and curly hair. No presence of dandruff

Eyes: Anictenic Sclerae, Pink Conjunctiva

9
Chest & Lungs: SCE, with retractions

Abdomen: Flabby, soft & non tender

Genitalia: painless, Heavy Vaginal Bleeding

Extremities: full and equal pulses

10
 DIAGNOSTIC AND LABORATORY EXAMS

A. URINALYSIS

Actual Normal Nursing

Date Test Values Values Implications Rationale Responsibilities
10-17-09 PHYSICAL - To examine 1. Tell the patient
EXAMINATION the patient’s that the test is for
Color Straw Clear straw to Liver problems urine for sign the detection or
colored liquid or jaundice migh of renal or renal and urinary
have occur urinary tract tract disorders
disease. and assessment
of body function.
- To help
Appearance Clear Clear to slightly normal discover 2. Notify the
hazy diseases patient that the
that is not in procedure
relation with requires a urine
Reaction 6.5 4.6-8 renal sample. Urine
To demonstrate disorders. must be acquired
Specific Gravity 1.010 1.005-1.025 the most likely on the

44

11
12
 concentrating first void in the
and diluting - To identify morning.
In normal ability of the drugs or
condition there kidneys. substances 3. Notify the
is no protein that has laboratory and
that can be been taken. physician of any
detect drugs that the
patient has taken
CHEMICAL that may affect
EXAMINATION the results.
Albumin Negative Normal

Sugar Negative Presence of

sugar in urine
may indicate
diabetes,
chronic kidney
disease

45

13
MICROSCOPIC
EXAMINATION
Epithelial Cells Pus cells and May be a sign of
Squamous 0.2 hpf bacteria should swelling in the
Renal be absent in kidney and
Pus Cells urine pelvic region,
urethral
ulceration and
chronic specific
inflammatory of
the bladder

RBC Blood in the

urine may
sometimes a
serious urinary
tract problem

Mucous Threads
Bacteria #

46

14
 Yeast Cells
Oil Globules
Spermatozoa

B. BLOOD TYPING

47

15
 Nursing
Date Test Result Normal Results Implications Rationale Responsibilities
10-17-09 Blood Type A (+) In forward typing, if None known - To check 1. Inform the
(ABO+Rh) there’s agglutination compatibility patient that the
patient’s RBC’s are of the donor test determines
mixed with anti-A and and the her blood group.
anti-B serum, the A patient before
and B antigen is transfusion. 2. Notify the
present, thus blood patient that the
type is O test blood
sample thus
venipuncture is
done.

3. Check the
patient’s history
for recent
administration of
blood, dextran or
I.V.

48

16
 4. After the
procedure apply
direct pressure
to the
venipuncture to
the site until
bleeding stops.

C. COMPLETE BLOOD COUNT

Normal Nursing

49

17
Date Test Result Values Implications Rationale Responsibilities
10-17-09 WBC H 15.19 5-10 Leukemia, - To verify 1. Explain to the
x10^3/uL x10^3/uL bacterial infection or patient the necessity
infection, severe inflammation in of undergoing the
sepsis the body and test that it helps
observe its detect occurrence of
responses to anemia and
specific polycythemia.
therapies.
2. Notify the patient
that the test requires
Hemoglobin 122g/L 115-155 Normal - To recognize blood sample as well
g/L Low HCT, the amount of as the person who
suggest anemia, O2 carrying will perform the
hemodilution or protein venipuncture and the
enormous blood contained within time.
loss. the RBC
3. Inform the patient
that the procedure is
Hematocrit L 0.35 0.36-0.48 Rule out anemia - To identify the of slight discomfort
due to percentage of and may feel a little

50

18
 pain.
nutritional the blood
deficiencies, volume
blood loss. occupied by red 4. After the
blood cells. procedure, apply
direct pressure to the
venipuncture until
RBC L 4.02 4.20-6.10 Low RBC is due - To know the bleeding stops.
x10^6/uL x10^6/ uL to enormous amount of RBC
blood loss which in the blood. 5. Refer if
results to venipuncture
anemia. develops hematoma
Leukemia, and monitor the
hemorrhage. pulses distal to the
site.

Differential
Count

Neutrophil 73% 55-75% Normal - To point out

the presence of

51

19
 bacterial
infection and
amount of
Leukocyte

Lymphocytes L 18% 20-35% Leukemia, -To recognize if

systemic lupus there is an
erythematosus unusual amount
of lymphocyte
that may
indicate viral
infection such
as HIV.

Monocytes 7% 2-10% Normal -Increase of

these may
respond to
corticosteroid,
with pus
conditions,

52

20
 hemorrhage

Eosinophil 2% 1-6% Normal -High

percentage of
eosinophil, may
indicate
bacterial
infestation or
allergies

Basophil 0% 0-1% Normal -Increase of

basophil may
indicate
parasite,
hypersensitiven
ess and
heartworm
causing
endocrine
disease, chronic
liver disease

53

21
MCV 88.1fl 79.40- Normal -To determine
94.80 fl the ratio of
hematocrit to
RBC count

-To identify the

MCH 30.3 25.60- Normal average mass
pg 32.20 pg of hemoglobin
per RBC

MCHC 34.5 g/dL 32.20- Normal -Indicates the

35.30 g/dL nature and
volume of
hemoglobin, to
high may
indicate
spherocytosis or
in vitro

54

22
 hemolysis

D. ULTRASOUND

Nursing
Date Test Result Impression Rationale
Responsibilities
U -Presentation : Cephalic Single, live - To know fetal 1. Assure a
10-17--09
L -Number: single intrauterine and consent form
2:35 pm
T - Amniotic fluid: AFI 11.1 cm pregnancy, pregnancy signed by the
R -Placental location: anterior cephalic abnormalities patient. Explain

55

23
A -Placental grade: III presentation, with and that the procedure
S -Sex: male good cardiac and measurement is painless and
O -AOG: 32W 3D somatic activities; of organ size safe and that no
U -EDD: 10-11-08 BPD= 32 weeks and structure. radiation
N -FHB: 147bpm and 5 days; FL= To identify and exposure is
D Estimated Fetal Weight: 2233 g 31 weeks and 1 differentiate involved.
-normohydramnios (11.1 cm) day cyst and solid
-amniotic fluid volume: normal Placenta anterior, tumor. 2. Emphasize the
-previa: placenta previa totalis early grade III, importance of
totally covering - To ensure remaining still
Biophysical profile: the OS (Placenta the during the scan to
-amniotic fluid: 2 previa totalis) presentation prevent distorted
-fetal tone: 2 and identify image.
-fetal breathing: 2 complications
-gross movement: 2 of the fetus. 3. Assist the
Total =8 To detect if patient into a
there is risk of supine position; if
pregnancy. possible use
pillows to support
the area to be
examined. Coat

56

24
 the target area
with a water-
soluble jelly. If
necessary to

assist the patient

into lateral

positions for

consequent view.

57
26
 THE FEMALE REPRODUCTIVE SYSTEM

 GENERAL
The organs of the reproductive systems are concerned with the general process of
reproduction, and each is adapted for specialized tasks. These organs are unique in that
their functions are not necessary for the survival of each individual. Instead, their
functions are vital to the continuation of the human species. In providing maternity
gynecologic health care to women, you will find that it is vital to your career as a
practical nurse and to the patient that you will require a greater depth and breadth of
knowledge of the female anatomy and physiology than usual. The female reproductive
system consists of internal organs and external organs. The internal organs are located
in the pelvic cavity and are supported by the pelvic floor. The external organs are located
from the lower margin of the pubis to the
perineum. The appearance of the external
genitals varies greatly from woman to woman,
since age, heredity, race, and the number of
children a woman has borne determines the
size, shape, and color. See figure 1-1 for the
female reproductive organs.

58
  TERMS AND DEFINITIONS

These are only a few terms and definitions that will be used in this lesson. Other
terms and definitions will be dispersed throughout the lesson.

A. Broad Ligaments. Two wing-like structures that extend from the lateral
margins of the uterus to the pelvic walls and divide the pelvic cavity into an
anterior and a posterior compartment.

B. Corpus Luteum. The yellow mass found in the graafian follicle after the ovum
has been expelled.

C. Estrogen. The generic term for the female sex hormones. It is a steroid
hormone produced primarily by the ovaries but also by the adrenal cortex.

D. Fimbriae. Fringes; especially the finger-like ends of the fallopian tube.

E. Follicle. A pouch like depression or cavity.

F. Follicle Stimulating Hormone. The follicle stimulating hormone (FSH) is a

hormone produced by the anterior pituitary during the first half of the menstrual
cycle. It stimulates development of the graafian follicle.

G. Graafian Follicle. A mature, fully developed ovarian cyst containing the ripe
ovum.

H. Hormone. A chemical substance produced in an organ, which, being carried to

an associated organ by the bloodstream excites in the latter organ, a functional
activity.

I. Lactation. The production of milk by the mammary glands.

J. Luteinizing Hormone. A hormone produced by the anterior pituitary that

stimulates ovulation and the development of the corpus luteum.

59
K. Oocyte. A developing egg in one of two stages.

L. Ovum. The female reproductive cell.

M. Progesterone. The pure hormone contained in the corpora lutea whose

function is to prepare the endometrium for the reception and development of the
fertilized ovum.

N. Reproduction. The process by which an off- spring is formed.

Anterior view of the uterus and related structures

60
 Wall of the uterus

 INTERNAL FEMALE ORGANS

The internal organs of the female consist of the uterus, vagina, fallopian tubes,
and the ovaries.

A. Uterus. The uterus is a hollow organ about the size and shape of a pear. It
serves two important functions: it is the organ of menstruation and during
pregnancy it receives the fertilized ovum, retains and nourishes it until it expels
the fetus during labor.

61
(1) Location. The uterus is located between the urinary bladder and the rectum. It
is suspended in the pelvis by broad ligaments.

(2) Divisions of the uterus. The uterus consists of the body or corpus, fundus,
cervix, and the isthmus. The major portion of the uterus is called the body or
corpus. The fundus is the superior, rounded region above the entrance of the
fallopian tubes. The cervix is the narrow, inferior outlet that protrudes into the
vagina. The isthmus is the slightly constricted portion that joins the corpus to the
cervix.

(3) Walls of the uterus (see figure 1-3). The walls are thick and are composed of
three layers: the endometrium, the myometrium, and the perimetrium. The
endometrium is the inner layer or mucosa. A fertilized egg burrows into the
endometrium (implantation) and resides there for the rest of its development.
When the female is not pregnant, the endometrial lining sloughs off about every
28 days in response to changes in levels of hormones in the blood. This process is
called menses. The myometrium is the smooth muscle component of the wall.
These smooth muscle fibers are arranged. In longitudinal, circular, and spiral
patterns, and are interlaced with connective tissues. During the monthly female
cycles and during pregnancy, these layers undergo extensive changes. The
perimetrium is a strong, serous membrane that coats the entire uterine corpus
except the lower one fourth and anterior surface where the bladder is attached.

B. Vagina.

(1) Location. The vagina is the thin in walled muscular tube about 6 inches long
leading from the uterus to the external genitalia. It is located between the bladder
and the rectum.

(2) Function. The vagina provides the passageway for childbirth and menstrual
flow; it receives the penis and semen during sexual intercourse.

C. Fallopian Tubes (Two).

62
(1) Location. Each tube is about 4 inches long and extends medially from each
ovary to empty into the superior region of the uterus.

(2) Function. The fallopian tubes transport ovum from the ovaries to the uterus.
There is no contact of fallopian tubes with the ovaries.

(3) Description. The distal end of each fallopian tube is expanded and has finger-
like projections called fimbriae, which partially surround each ovary. When an
oocyte is expelled from the ovary, fimbriae create fluid currents that act to carry
the oocyte into the fallopian tube. Oocyte is carried toward the uterus by
combination of tube peristalsis and cilia, which propel the oocyte forward. The
most desirable place for fertilization is the fallopian tube.

D. Ovaries (2) (see figure 1-4).

(1) Functions. The ovaries are for oogenesis-the production of eggs (female sex
cells) and for hormone production (estrogen and progesterone).

(2) Location and gross anatomy. The ovaries are

about the size and shape of almonds. They lie against the lateral walls of the
pelvis, one on each side. They are enclosed and held in place by the broad
ligament. There are compact like tissues on the ovaries, which are called ovarian
follicles. The follicles are tiny sac-like structures that consist of an immature egg

63
surrounded by one or more layers of follicle cells. As the developing egg begins to
ripen or mature, follicle enlarges and develops a fluid filled central region. When
the egg is matured, it is called a graafian follicle, and is ready to be ejected from
the ovary.

(3) Process of egg production--oogenesis (see figure 1-5).

(a) The total supply of eggs that a female can release has been determined by the
time she is born. The eggs are referred to as "oogonia" in the developing fetus. At
the time the female is born, oogonia have divided into primary oocytes, which
contain 46 chromosomes and are surrounded by a layer of follicle cells.

(b) Primary oocytes remain in the state of suspended animation through

childhood until the female reaches puberty (ages 10 to 14 years). At puberty, the
anterior pituitary gland secretes follicle-stimulating hormone (FSH), which
stimulates a small number of primary follicles to mature each month.

64
(c) As a primary oocyte begins dividing, two different cells are produced, each
containing 23 unpaired chromosomes. One of the cells is called a secondary
oocyte and the other is called the first polar body. The secondary oocyte is the
larger cell and is capable of being fertilized. The first polar body is very small, is
nonfunctional, and incapable of being fertilized.

(d) By the time follicles have matured to the graafian follicle stage, they contain
secondary oocytes and can be seen bulging from the surface of the ovary. Follicle
development to this stage takes about 14 days. Ovulation (ejection of the mature
egg from the ovary) occurs at this 14-day point in response to the luteinizing
hormone (LH), which is released by the anterior pituitary gland.

(e) The follicle at the proper stage of maturity when the LH is secreted will
rupture and release its oocyte into the peritoneal cavity. The motion of the
fimbriae draws the oocyte into the fallopian tube. The luteinizing hormone also
causes the ruptured follicle to change into a granular structure called corpus
luteum, which secretes estrogen and progesterone.

(f) If the secondary oocyte is penetrated by a sperm, a secondary division occurs

that produces another polar body and an ovum, which combines its 23
chromosomes with those of the sperm to form the fertilized egg, which contains
46 chromosomes.

(4) Process of hormone production by the ovaries.

(a) Estrogen is produced by the follicle cells, which are responsible secondary sex
characteristics and for the maintenance of these traits. These secondary sex

65
characteristics include the enlargement of fallopian tubes, uterus, vagina, and
external genitals; breast development; increased deposits of fat in hips and
breasts; widening of the pelvis; and onset of menses or menstrual cycle.

(b) Progesterone is produced by the corpus luteum in presence of in the blood. It

works with estrogen to produce a normal menstrual cycle. Progesterone is
important during pregnancy and in preparing the breasts for milk production.

 EXTERNAL FEMALE GENITALIA

66
The external organs of the female reproductive system include the mons pubis,

labia majora, labia minora, vestibule, perineum, and the Bartholin's glands. As a
group, these structures that surround the openings of the urethra and vagina
compose the vulva, from the Latin word meaning covering. See Figure 1-6.

a. Mons Pubis. This is the fatty rounded area overlying the symphysis pubis and
covered with thick coarse hair.

b. Labia Majora. The labia majora run posteriorly from the mons pubis. They are
the 2 elongated hair covered skin folds. They enclose and protect other external
reproductive organs.

c. Labia Minora. The labia minora are 2 smaller folds enclosed by the labia
majora. They protect the opening of the vagina and urethra.

d. Vestibule. The vestibule consists of the clitoris, urethral meatus, and the
vaginal introitus.

(1) The clitoris is a short erectile organ at the top of the vaginal vestibule whose
function is sexual excitation.

67
(2) The urethral meatus is the mouth or opening of the urethra. The urethra is a
small tubular structure that drains urine from the bladder.

(3) T e. Perineum. This is the skin covered muscular area between the vaginal
opening (introitus) and the anus. It aids in constricting the urinary, vaginal, and
anal opening. It also helps support the pelvic contents.

f. Bartholin's Glands (Vulvovaginal or Vestibular Glands). The Bartholin's glands

lie on either side of the vaginal opening. They produce a mucoid substance, which
provides lubrication for intercourse.

 BLOOD SUPPLY

The blood supply is derived from the uterine and ovarian arteries that extend
from the internal iliac arteries and the aorta. The increased demands of
pregnancy necessitate a rich supply of blood to the uterus. New, larger blood
vessels develop to accommodate the need of the growing uterus. The venous
circulation is accomplished via the internal iliac and common iliac vein.

 FACTS ABOUT THE MENSTRUAL CYCLE

Menstruation is the periodic discharge of blood, mucus, and epithelial cells from
the uterus. It usually occurs at monthly intervals throughout the reproductive
period, except during pregnancy and lactation, when it is usually suppressed.

 The menstrual cycle is controlled by the cyclic activity of follicle

stimulating hormone (FSH) and LH from the anterior pituitary and
progesterone and estrogen from the ovaries. In other words, FSH
acts upon the ovary to stimulate the maturation of a follicle, and
during this development, the follicular cells secrete increasing
amounts of estrogen (see figure 1-7).
 Hormonal interaction of the female cycle is as follows:

68
(1) Days 1-5. This is known as the menses phase. A lack of signal from a fertilized
egg influences the drop in estrogen and progesterone production. A drop in
progesterone results in the sloughing off of the thick endometrial lining which is
the menstrual flow. This occurs for 3 to 5 days.

(2) Days 6-14. This is known as the proliferative phase. A drop in progesterone
and estrogen stimulates the release of FSH from the anterior pituitary. FSH
stimulates the maturation of an ovum with graafian follicle. Near the end of this
phase, the release of LH increases causing a sudden burst like release of the
ovum, which is known as ovulation.

(3) Days 15-28. This is known as the secretory phase. High levels of LH cause the
empty graafian follicle to develop into the corpus luteum. The corpus luteum
releases progesterone, which increases the endometrial blood supply.
Endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo
produces human chorionic gonadotropin (HCG). Thehuman chorionic
gonadotropin signals the corpus luteum to continue to supply progesterone to
maintain the uterine lining. Continuous levels of progesterone prevent the release
of FSH and ovulation ceases.

 Additional Information.

(1) The length of the menstrual cycle is highly variable. It may be as short as 21
days or as long as 39 days.

(2) Only one interval is fairly constant in all females, the time from ovulation to
the beginning of menses, which is almost always 14-15 days.

(3) The menstrual cycle usually ends when or before a woman reaches her fifties.
This is known as menopause.

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  Ovulation

Ovulation is the release of an egg cell from a mature ovarian follicle (see figure 1-
5 for ovulation). Ovulation is stimulated by hormones from the anterior pituitary
gland, which apparently causes the mature follicle to swell rapidly and eventually
rupture. When this happens, the follicular fluid, accompanied by the egg cell,
oozes outward from the surface of the ovary and enters the peritoneal cavity.
After it is expelled from the ovary, the egg cell and one or two layers of follicular
cells surrounding it are usually propelled to the opening of a nearby uterine tube.
If the cell is not fertilized by union of a sperm cell within a relatively short time, it
will degenerate.

 MENOPAUSE

As mentioned in paragraph 1-6c (3), menopause is the cessation of menstruation.

This usually occurs in women between the ages of 45 and 50. Some women may
reach menopause before the age of 45 and some after the age of 50. In common

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use, menopause generally means cessation of regular menstruation. Ovulation
may occur sporadically or may cease abruptly. Periods may end suddenly, may
become scanty or irregular, or may be intermittently heavy before ceasing
altogether. Markedly diminished ovarian activity, that is, significantly decreased
estrogen production and cessation of ovulation, causes menopause.

DESCRIPTION OF THE DISEASE

Placenta previa is an obstetric complication in which the placenta is lying unusually

low in the uterus, next to or covering the cervix. The placenta is the pancake-

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shaped organ — normally located near the top of the uterus — that supplies the
baby with nutrients through the umbilical cord.

Placenta previa is a placental attachment that is too low in the uterus and covers the
cervix. Normally the placenta is attached to the uterus above the cervix. The placenta
completely covers the internal os in slightly more than 10 percent of placenta previa
cases. Under these circumstances the placenta precedes the fetus in vaginal delivery.
This can be life-threatening to the unborn child and mother if untreated. It occurs to
some degree in 1 of 200 pregnancies.

Placenta previa is not usually a problem early in pregnancy. But if it persists into later
pregnancy, it can cause bleeding, which may require the pregnant woman to deliver
early and can lead to other complications. If a woman has placenta previa when it's
time to deliver her baby, she’ll need to have a c-section.

If the placenta covers the cervix completely, it's called a complete or total previa. If it's
right on the border of the cervix, it's called a marginal previa. (You may also hear the
term "partial previa," which refers to a placenta that covers part of the cervical opening
once the cervix starts to dilate.) If the edge of the placenta is within 2 centimeters of the

72
cervix but not bordering it, it's called a low-lying placenta. The location of the placenta
will be checked during the midpregnancy ultrasound exam.

It depends on how far along the client is in pregnancy. Don't panic if her second
trimester ultrasound shows that she has placenta previa. As her pregnancy progresses,
the placenta is likely to "migrate" farther from the cervix and no longer be a problem.
(Since the placenta is implanted in the uterus, it doesn't actually move, but it can end up
farther from the cervix as theuterus expands. Also, as the placenta itself grows, it's likely
to grow toward the richer blood supply in the upper part of the uterus.)

Only about 10 percent of women who have placenta previa noted on ultrasound at
midpregnancy still have it when they deliver their baby. A placenta that completely
covers the cervix is more likely to stay that way than one that's bordering it (marginal)
or nearby(low-lying).

Even if previa is discovered later in pregnancy, the placenta may still move away from
the cervix (although the later it's found, the less likely this is to happen). You'll have a
follow-up ultrasound early in your third trimester to check on the location of your

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placenta. If the client has any vaginal bleeding in the meantime, an ultrasound will be
done then to find out what's going on.

If the follow- up ultrasound reveals that the placenta is still covering or too close to the
cervix, the client will be monitored carefully, has regular ultrasounds, and need to watch
for vaginal bleeding. She'll be put on "pelvic rest," which means no intercourse or
vaginal exams for the rest of her pregnancy. And she'll be advised to take it easy and
avoid activities that might provoke bleeding, such as strenuous housework or heavy
lifting.

Bleeding from a placenta previa happens when the cervix begins to thin out or dilate
(even a little) and disrupts the blood vessels in that area. It's usually painless, can start
without warning, and can range from spotting to extremely heavy bleeding. If her
bleeding is severe, she may have to deliver her baby right away, even if he's still
premature. The pregnant woman may also need a blood transfusion.

It's unusual for bleeding to start before late in the second trimester, and about half the
time it doesn't begin until you're nearly full-term (37 weeks). The bleeding will often
stop on its own, but it's likely to start again at some point. (If she has bleeding and she’s
Rh negative, she'll need a shot of Rh immune globulin, unless the baby's father is Rh
negative,too.)

If the client start bleeding or has contractions, she'll need to be hospitalized. What
happens then will depend on how far along you are in her pregnancy, how heavy the
bleeding is, and how you and your baby are doing. If she is near full-term, the baby will
be delivered by c-section right away. If the baby is still premature, he'll be delivered by
c-section immediately if his condition warrants it or if the client have heavy bleeding
that doesn't stop.

Otherwise, she'll be watched in the hospital until the bleeding stops. If she’s less than
34 weeks, the client may be given corticosteriods to speed up her baby's lung
development and to prevent other complications in case he ends up being delivered
prematurely.
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If the bleeding stops, and both the mother and her baby are in good condition, she'll
probably be sent home. But she'll need to return to the hospital immediately if the
bleeding starts again. If she and her baby continue to do well and she doesn't need to
deliver early, she'll have a scheduled c-section at 37 weeks.

No matter when she delivers, if she still has placenta previa, she'll need a c-section.
With a complete previa, the placenta blocks the baby's way out. And even if it's only
bordering the cervix, she'll still need a c-section in most cases because the placenta
could bleed profusely if the cervix dilated.

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PATHOPHYSIOLOGY

No specific cause of placenta previa has yet been found but it is hypothesized to be
related to abnormal vascularisation of the endometrium caused by scarring or atrophy
from previous trauma, surgery, or infection.

In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower
segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding.
If the placenta does overlie the lower segment, it may shear off and a small section may
bleed.

Women with placenta previa often present with painless, bright red vaginal bleeding.
This bleeding often starts mildly and may increase as the area of placental separation
increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation.
Abdominal examination usually finds the uterus non-tender and relaxed. Leopold's
Maneuvers may find the fetus in an oblique or breech position or lying transverse as a
result of the abnormal position of the placenta. Praevia can be confirmed with an
ultrasound. In parts of the world where ultrasound is unavailable, it is not uncommon to
confirm the diagnosis with an examination in the surgical theatre.

The proper timing of an examination in theatre is important. If the woman is not

bleeding severely she can be managed non-operatively until the 36th week. By this time
the baby's chance of survival is as good as at full term.

Placenta previa is classified according to the placement of the placenta:

• Type I or low lying: The placenta encroaches the lower segment of the uterus but
does not infringe on the cervical os.
• Type II or marginal: The placenta touches, but does not cover, the top of the
cervix.
• Type III or partial: The placenta partially covers the top of the cervix
• Type IV or complete: The placenta completely covers the top of the cervix

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Placenta previa is itself a risk factor of placenta accreta.

Placenta Previa

Painless Vaginal Bleeding

Ultrasound
Risk Factors

Late Maternal Age Infection (UTI) Multiparity

Complete Previa Marginal Previa

Partial Previa Bleeding stops Low-lying place
Fetus stable

Bed Rest

Observe

Urine Output Pale, cool skin

Hypotension Bleeding continues Capillary refill

Maternal Hemorrhage Bleeding Restarts tachycardia

Pulse
Complications:
Congenital Anomalies
Maternal Mortality
Intrauterine Growth

Cesarian Birth Vaginal or

77
 Cesarian Birth

S O A P I E
October 17, 2009 7–3

S> ”Masakit ang puwerta ko” as verbalized by the patient

O> Guarding behavior

> Facial grimace

> Generalized body weakness

> Pain Scale 4/5

> (+) DOB

A> Acute Pain r/t Inflammatory Response

P> After 4O of nursing intervention, the patient will report pain is

relieved/controlled

I> Established rapport

> Monitored v/s taken and recorded

> Morning Care Rendered

> Instructed patient to exercise deep breathing every time the pain occur

> Encouraged the patient verbalization of feelings about pain

> Instructed the patient to have proper hygiene

> Position the patient in Semi fowler’s position

> Provided safety and comfort

E> Goal met as evidenced by the pt. report pain is relieved/controlled

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79
 b. PLANNING (Nursing Care Plan)

Nursing Scientific Expected

Cues Objectives Interventions Rationales
Diagnosis explanation outcomes

S>”Masakit ang >Acute pain r/t Acute pain is described Short term: >Establish rapport >To gain pt. Short term:
puwerta ko” as Inflammatory as an unpleasant After 4 hrs. of trust Goal met as
verbalized by the Response sensory or emotional NI, patient will evidenced by the
experience
patient verbalized the >Monitor v/s >To have pt. verbalized the
associated with actual
or pain is baseline data pain is controlled
O> The pt. may potential tissue controlled or or disappear
manifested the ffg: damage disappear >Encourage pt. >To decrease
or injury as lasting deep breathing the pain
>Pain, 4/5 from Long term: exercise when pain Long term:
>Guarding second to 6 months. In After 2 days of occur Goal met as
behavior cases of fracture, pain NI, pt. will evidenced by the
>Facial grimace is continuous & maintain the >Promote safety >To pt. maintain the
>Generalized increasing in severity absence of pain and comfort absence of pain
until bone fragments
Body Weakness
are immobilized. In
> (+) DOB this type of fracture, >Avoid >To avoid the
> Perspiration the environmental pain to occur
> main medical stimulant
management is open
reduction with internal
fixation (ORIF),
wherein
the fracture fragments
are reduced & internal
fixation devices are
used to hold the bone
fragment in position
until
solid bone healing
occurs.

80
 Nursing Scientific
Cues Planning Intervention Rationale Evaluation
diagnosis explanation

S>“Pakiramdam ko >Hyperthermia Hyperthermia is an Short term: > Establish > To gain the Short term:
mainit buong related to elevated body rapport trust of the
katawan ko” as inflammatory temperature due to After 4 hours of patient Goal met AEB
verbalize by the process. failed NI, patient will the patient
patient thermoregulation. decrease temperature
Hyperthermia occurs temperature decrease from
O> The pt. from 38.9 c to > to have 38.9 c to 37.5 c
when the body >Monitor vital
manifested the ffg: 37.5 c baseline data
produces or absorbs sign
more heat than it can
>skin warm to
dissipate. When the Long term:
touch
elevated body >to decrease
>provide TSB heat Goal met AEB
>dry lips temperatures are
sufficiently high, Long term: the patient
>fatigue hyperthermia is a maintain the
After 2 days of absence of
medical emergency > make safety
>redness NI, patient will hyperthermia
and requires and relax the
maintain >promote
immediate treatment patient
absence of comfort and
to prevent disability
hyperthermia safety
and death.

> treatment for

mild to
moderate
>Promote hyperthermia
ventilation of the
skin by means of
undressing

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 Cues Nursing Scientific Planning Intervention Rationale Evaluation
diagnosis Explanation

S> >impaired The movement Short term: >establish >to gain Short term:
“Nahihirapan physical of body rapport patient trust
akong mobility structures is After 3 Goal met AEB
gumalaw kasi related to accomplished hours of NI, > to have the patient
masakit yung pain by the patient will baseline verbalize
verbalize >monitor vital data understanding
bahay bata contraction of
understandi sign for individual
ko” as muscles.
ng for > to situation
verbalize by Muscles may
individual promote
the patient move parts of
situation safety and Long term:
the skeleton >promote
O> (+) pain, relax
relatively to comfort and Goal met AEB
4/5 Long term:
each other, or safety > to assess the patient
may move parts After 2 days and treat maintain the
>facial
of internal NI, patient patient absence of pain
grimace
organs will >assess patient problem
>guardianing
relatively to maintain complain
behavior
each other. All the absence > to
>limited such of pain understand
movement movements are the patient
> explain to her/his
classified by the
patient the condition
directions in
condition
which the
affected
structures are > to
moved. In decrease the
human pain
anatomy, all
descriptions of >encourage
position and patient to
movement are exercise deep
based on the breathing every
assumption that time pain occur
the body is its
complete
medial and > to
abduction stage > Avoid decrease
82
in anatomical Environmental pain
position. stimulant
83
c. Drugs

84
 Type of Diet Date Ordered: General Indication / Client’s
Date Started: Description Purpose Response /
reaction to the
Name of Drugs Date ordered Route of admin General action Indication Client’s
diet
response to the
Medication with
actual Side
DAT DO: 10-17-09 There is a dietary sodium Effectto
To facilitate reduction of The patient refuses
Generic name: Date taken/given: Dosage: >Inhibits synthesis
restriction on patient sodium in>Lower respiratory
the body, eat. Patient response
Cefuroxime 10/17/09
DS: 10-17-09 Adults: of bacteria cell
thus reducing edemacaused by
infections effectively with no
>250 mg bid for wall, causing cell S. Pneumoniae, H. side effect noted.
and ascites.
Brand name: Date changed: severe infections, death. Para influenza, H.
Ceftin maybe increased to Influenza
500 mg bid
Frequency of
It also aide in the
admin:
reduction of conjunction
of vascular fluids since
Generic name: Date taken/given: Dosage: >Reduces fever by attracts
sodium >Analgesic anti
water. Patient response
Acetaminophen 10/17/09 Adults acting directly on pyretics in patients effectively with no
>by supporting 365- the hypothalamic with aspirin allergy, side effect noted.
Brand name: Date changed: 600 mg q 4-6 hr. or heat regulating hemostatic
Paracetamol P.O, 1000 mg tid to center to occur disturbances
qid. Do not exceed vasodilator and bleeding diatheses,
4 q/day sweating which quoty artitis
helps dissipate
heat.
Generic name: Date taken/given: Dosage: >Stimulate normal >To prevent Patient response
Follic acid 10/17/09 Adults: erythropoiesis and megaloblastic anemia effectively with no
>up to 1 mg P.O, nucleoprotein during pregnancy to side effect noted.
Brand name: Date changed: I.M or S.C daily synthesis prevent fetal damage
Folvite throughout
pregnancy

85
Nursing Responsibilities:

• Explain the purpose.

• Assess for patient condition, how he respond diet.
• Provide variety of choices of foods low sodium.
• Be sure patient is taking / eating foods he can tolerate.
• Explain importance of compliance.

86
HEALTH TEACHINGS
* Encourage patient to express feelings and concerns
® So that relief measure may be instituted
89
* Teach family / significant others to foster independence, and to intervene if the
patient becomes fatigued, is unable to perform task or becomes excessively
frustrated
® Demonstrates caring / concern
* Teach patient perineal hygiene
® to decrease risk of ascending infections
* Splint incision when moving or coughing
® to decrease pain and to prevent wound separation
* Encourage the patient to comply with medications given
® The use of medicines is a pharmacologic method that aids in the recovery of
the client
*Encourage the client to eat foods to stimulate the production of milk
· temperature exceeding 38C
· painful urination

· lochia heavier than normal period

· wound separation

· redness or oozing at the incision site

· severe abdominal pain

· use relaxation techniques such as music, breathing, and dim lights

· apply heating pad to the abdomen
*GAS
pain
walk as often as you can
· Don't drink or eat gas-forming foods, carbonated beverages, or whole milk
· Take antiflatulence medication if prescribed

· Lie on your left side to expel gas

· Emphasize to client to regularly perform wound dressing
® Prevent infection

87
· Inculcate to the client the importance of proper hand washing
® Hand washing if the single most effective way in controlling infection

DISCHARGE PLAN

Medications:
· Teach patient and her family or significant others the proper dosage and
the right time to take the medication.
· Emphasize to the patient the importance of obediently taking the
prescribed medications and the disadvantages or complications that may
arise if these are not taken properly.
· Inform and discuss the possible side effects and reactions that these
drugs might produce and seek medical attention immediately is these
arise
· Discourage to use of OTC medications or at least inform the physician if
she’s taking other OTC medications. This is essential to prevent any
occurrence of drug interactions.
Exercise:
· Tell client to refrain from straining activities
· Encourage ambulation as a form of light exercise that would help in the
progression of her recovery and wound healing.
· Range of motion. Encouraging the patient to do some exercises would
allow good blood circulation as well as the prevention of the occurrence of
bed sores.
· Encourage patient to do some stretching exercise to prevent stiffness of

the bone due to less activity performed.

· Encourage patient to first sit up and dangle feet before standing from a
lying position to prevent orthostatic hypotention

Treatment
· Discussing the purpose of treatments to be done and continued at home
and report to the health professional when there is bleeding to alleviate

88
symptoms of the patient’s condition and monitor for her recovery.
· Encourage patient to have a sufficient rest and sleep to maintain internal
equilibrium
· . Provide a safe and comfortable environment because it could make the
patient more relaxed which is also needed to arrived with a good
prognosis
Hygiene:
· Discuss the significance of personal hygiene and proper hand washing in
preventing infections
· Give client some lectures about proper wound care through changing the

dressing as often as possible so as to protect the wound from invasion of

microorganisms as well as to reduce the risk of microorganism
transmission to others.
Outpatient Care:
· A follow up check-up is necessary for wound evaluation and to assess the
progression of wound healing.

Diet:
· Encourage the patient to increased fluid intake and to include fruits and
vegetables rich in vitamin C for the production of milk needed for lactation.
· Taking food rich in protein is also helpful for tissue repair.

89
 JOSE C. FELICIANO COLLEGE
INSTITUTE OF NURSING, MIDWIFE AND NURSING AIDE
DAU EXIT, DAU EXPRESSWAY DAU MABALACAT PAMPANGA

PLACENTA PREVIA
(A CASE STUDY IN OBSTETRIC WARD)
BSN II – A (GROUP 2)

SUBMITTED BY:
AGUIRRE, ROXANNE
BACANTE, CIELITO JOHN
BISCO, MICHELAN
CANIEL, JOSEPH
CORTEZ, KAREN
ESPIRITU, PRECIOUS ANN
GUTIERREZ, NICKKY MARK
LIWANAG, JEEANNE
NAVARRO, JOEL
SANTOS, MATTHEW FAITH
SANTIAGO, KAREN KRISTA
TEODORO, JOHNNA CLAIRE

SUBMITTED TO:
MS. GENICIA R. MORALESRN MSN
CLINICAL INSTRUCTOR (OB WARD)

90