Third Trimester Complications

1. Complications affecting fluid-gas transport
   • Placenta previa - abnormal implantation; near or over internal cervical os. Increased incidence with multiparas, multiple gestation, previous uterine surgery.
     1. Assessment:
        • Painless vaginal bleeding (may be intermittent); absence of contractions, abdomen soft.
        • If in labor, contractions usually normal.
        • Boggy lower uterine segment - palpated on vaginal exam. (Note: If placenta previa is suspected, internal examinations are contraindicated.)
        • Medical diagnosis-procedure: sonography - to determine placental site.
     2. Analysis/nursing diagnosis:
        • Anxiety related to bleeding, outcome.
        • Fluid volume deficit related to excessive blood loss.
        • Altered tissue perfusion related to blood loss.
        • Altered urinary elimination related to hypovolemia.
        • Fear related to fetal injury or loss.
     3. Nursing care plan/implementation:
        • Medical management
          1. Sterile vaginal examination under double setup.
          2. Vaginal birth possible if bleeding minimal, marginal implantation; if fetal vertex is presenting so that presenting part acts as tamponade.
          3. Cesarean birth for complete previa.
        • Nursing management. Goal: safeguard status.
     4. Evaluation/outcome criteria: see following section on abruptio placentae and Table 4-9.
   • Abruptio placentae - premature separation of normally implanted placenta.
     1. Assessment:
     • Sudden onset, severe abdominal pain.
     • Increased uterine tone - may contract unevenly, fails to relax between contractions; very tender.
     • Shock usually more profound than expected on basis of external bleeding or internal bleeding.
     • Medical evaluation - procedures: DIC screening (bleeding time, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen); sonogram to see placental hemoseparation.
     2. Analysis/nursing diagnosis:
        • Fluid volume deficit related to bleeding.
        • Potential for fetal injury related to uteroplacental insufficiency.
        • Fear related to unknown outcome.
     3. Potential complications:
        • Afibrinogenemia and DIC.
        • Couvelaire uterus - bleeding into uterine muscle.
        • Amniotic fluid embolus.
        • Hypovolemic shock.
        • Renal failure.
        • Uterine atony, hemorrhage, infection in postpartum.
     4. Nursing care plan/implementation:
        • Medical management
          1. Control: hemorrhage, hypovolemic shock, replace blood loss.
          2. Cesarean birth.
          3. Fibrinogen, crystalloids, blood replacement.
          4. IV heparin - by infusion pump - to reduce coagulation and fibrinolysis.
        • Nursing management. Goal: safeguard status.
     5. Evaluation/outcome criteria:
        • Experiences successful termination of pregnancy.
          1. Woman gives birth to viable newborn (by vaginal or cesarean method).
          2. Woman has minimal blood loss.
          3. Womans assessment findings within normal limits.
          4. Woman retains capacity for further childbearing.
        • No evidence of complications (anemia, hypotonia, DIC) during postpartal period.