Placenta accreta occurs when the placenta—the organ that provides nutrients and other support to a developing fetus—attaches too deeply to the uterine wall. This often leads to two major complications: the placenta cannot normally deliver after the baby’s birth, and attempts to remove the placenta can lead to heavy bleeding. This is a serious condition that can cause complications for the baby and mother, especially during the delivery. With supervision by experienced clinicians, however, these complications and risks can be managed effectively.
Placenta Increta and Percreta
Placenta increta and placenta percreta are similar to placenta accreta, but more severe.
- Placenta increta is a condition where the placenta attaches more firmly to the uterus and becomes embedded in the organ's muscle wall.
- Placenta percreta is a condition where placenta attaches itself and grows through the uterus and potentially to the nearby organs (such as the bladder).
Obstetricians seek to make a specific diagnosis of accreta, increta or percreta before delivery using ultrasound and MRI imaging, but this is not always possible.
Who is at Risk for Placenta Accreta?
Placenta accreta, often referred to as simply “accreta,” occurs in about 0.2 percent of all pregnancies. Women who have experienced one or more of the following factors are at a higher risk for this condition:
- Previous Cesarean section
- Abnormal position of the placenta within the uterus, including placenta previa (a condition where the placenta sits low in the uterus, usually over the cervix)
- Maternal age greater than 35
- Previous surgery on the uterus, such as fibroid removal or treatment of uterine scar tissue
- In vitro fertilization
- Some accreta patients have none of these known risk factors – we are in the process of learning more about this challenging condition.
Symptoms and Complications of Placenta Accreta
Placenta accreta generally has no symptoms. However, placenta previa, which often develops along with accreta, often presents with vaginal bleeding. Extreme cases of placenta accreta, in which the placenta begins to invade the bladder or nearby structures (known as placenta percreta) can present with bladder or pelvic pain, or occasionally with blood in the urine.
During a normal delivery, the placenta detaches from the uterus during the last stage of labor. This can also be referred to as the “afterbirth.” With accreta, the placenta is tightly attached to the uterine wall and does not separate naturally during delivery. This causes several complications for the baby and mother.
Complications and risks for the baby
- When placenta accreta occurs with placenta previa, or when there is suspicion for percreta, the delivery is often scheduled prematurely. This will usually occur between 34 and 37 weeks gestation (3-6 weeks early), depending on the severity of the accreta.
- Babies born at these gestational ages often require admission to a newborn intensive care unit, but their overall prognosis is good.
- If there is early, heavy bleeding, then the delivery may need to occur even earlier. If heavy bleeding from a previa makes the mother unstable, then the baby can become unstable as well. The accreta itself is not directly harmful to the baby.
Complications and risks for the mother
- Hemorrhaging (severe bleeding) may occur from an associated placenta previa, or from attempts to remove the placenta when it is stuck to the uterus. If not managed and treated carefully, this may be life threatening.
- A vaginal birth is not always possible. Women who do deliver vaginally may require specialized procedures to remove the placenta and control hemorrhaging. If a placenta accreta is diagnosed before labor, the provider may recommend a Cesarean section.
- A hysterectomy (the surgical removal of the uterus) may be required after delivery to remove the placenta and end blood loss.
Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus. It is the most common cause of painless bleeding in the third trimester of pregnancy. It occurs in four degrees: low-lying placenta, which is implantation in the lower rather than in the upper portion of the uterus; marginal implantation, in which the placenta edge approaches that of the cervical os; partial placenta previa, which is implantation that occludes a portion of the cervical os; and total placenta previa, in which the implantation totally obstructs the cervical os.
Increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestations, and perhaps a male fetus are all associated with placenta previa.
"Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa."Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa. The bleeding in placenta previa doesn’t usually begin, however, until the lower uterine segment starts to differentiate from the upper segment late in pregnancy (week 30) and the cervix begins to dilate. At this point, because the placenta is unable to stretch to accommodate the different shapes of the lower uterine segment or the cervix, a small portion loosens, and damaged blood vessels begin to bleed.
Nursing Care Plans
Nursing care management and treatment of placenta previa is designed to assess, control, and restore blood loss and to deliver a viable infant. Immediate therapy includes starting an IV line using a large bore catheter.
Here are four (4) placenta previa nursing care plans and nursing diagnoses:
The bleeding of placenta previa, like that of ectopic pregnancy, creates an emergency situation as the open vessels of the uterine decidua place the client at risk for hemorrhage. Postpartum hemorrhage may occur because the lower uterine segment, where the placenta was attached, has fewer muscle fibers than the upper uterus. The resulting weak contraction of the lower uterus does not compress the open blood vessels at the placental site as effectively as would the upper segment of the uterus.
Nursing Diagnosis
- Risk for Deficient Fluid Volume
Risk Factors
- Excessive vaginal bleeding
- Damaged uterine blood vessels
Possibly evidenced by
- (Not applicable; the presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes
- The client will maintain fluid volume at a functional level, possibly evidenced by adequate urinary output and stable vital signs.
- The client will display homeostasis as evidenced by the absence of bleeding.
Nursing Assessment and Rationales
1. Assess color, odor, consistency, and amount of vaginal bleeding.
Inspect the perineum for bleeding and estimate the present rate of blood loss. The bleeding with placenta previa is usually abrupt, painless, bright red, and sudden. The bleeding may be provoked by intercourse, vaginal examinations, or labor, and at times there may be no identifiable cause (Anderson-Bagga & Sze, 2019).
2. Monitor the client’s vital signs.
Obtain baseline vital signs to determine whether symptoms of hypovolemic shock are present. Continue to assess blood pressure every 5 to 15 minutes or continuously with an electronic cuff. Signs of hypovolemic shock include hypotension, tachycardia, and tachypnea.
3. Assess hourly intake and output.
Monitor urine output frequently, as often as every hour, as an indicator that the client’s blood volume is remaining adequate to perfuse her kidneys.
4. Assess abdomen for tenderness or rigidity- if present, measure abdomen at the umbilicus (specify time interval).
A thorough abdominal examination to identify uterine tenderness can be useful in differentiating other causative factors for vaginal bleeding, including uterine rupture and placental abruption. Measure the abdominal girth to determine if the bleeding is progressing (Bakker & Smith, 2018).
5. Monitor the fetal heart rate and uterine contractions continuously.
Attach external monitoring equipment to record fetal heart sounds and uterine contractions; however, avoid the use of an internal monitor for either fetal or uterine assessment to prevent hemorrhage. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.
Nursing Interventions and Rationales
1. Weigh perineal pads to estimate blood loss.
Weighing perineal pads before and after use and calculating the difference by subtraction is a good method to determine vaginal blood loss.
2. Avoid vaginal examinations.
Because of the risk of provoking life-threatening hemorrhage, a digital examination of the vagina is absolutely contraindicated until placenta previa is excluded. Instruments should not be placed near the cervix because uncontrolled bleeding can result (Bakker & Smith, 2018). If placenta previa is suspected and ultrasound is unavailable, the provider may perform a vaginal examination with preparations for both vaginal and cesarean births (a double set-up) in place.
3. Position the client supine with hips elevated if ordered or in a left side-lying position.
To ensure an adequate blood supply to the client and fetus, place the client immediately on bed rest in a left side-lying position. The left side-lying position decreases pressure on the placenta and cervical os and improves placental perfusion.
4. Review ultrasound and laboratory results.
Routine sonography in the first and second trimesters of pregnancy provides early identification of placenta previa. A follow-up sonogram is recommended at 28 to 32 weeks of gestation to look for persistent placenta previa (Bakker & Smith, 2018). If there is a concern for placenta previa, then a transvaginal sonogram should be performed to confirm the location of the placenta. Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time, fibrinogen, platelet count, type and cross-match, and antibody screen is assessed to establish baselines, detect a possible clotting disorder, and ready blood for replacement if necessary.
5. Perform an Apt or Kleihauer-Betke test.
If there is concern about fetal-maternal transfusion, a Kleihauer-Betke test can be performed. These are test strip procedures that can be used to detect whether the blood is fetal or maternal in origin.
6. Provide supplemental O2 as ordered via face mask or nasal cannula @ 10-12 L/min.
Have oxygen equipment available in case the fetal heart sounds indicate fetal distress, such as bradycardia or tachycardia, late deceleration, or variable decelerations during the exam. Oxygen supplementation increases available oxygen to saturate decreased hemoglobin.
7. Initiate IV fluids as ordered (specify fluid type and rate).
Administer intravenous fluid as prescribed, preferably with a large-gauge catheter to allow for blood replacement through the same line. Attach Ringer’s lactate or normal saline at a rapid rate if a shock is present. Reduce the infusion rate to 3 ml/min when the pulse slows down to less than 100 beats/min and systolic BP increases to 100 mm Hg or higher (World Health Organization, 2015).
8. Administer tocolytic agents as prescribed.
Tocolysis may be considered in cases of minimal bleeding and extreme prematurity in order to administer antenatal corticosteroids. One study appeared to suggest that the use of tocolytics increases the pregnancy duration and the baby’s birth weight without causing adverse effects on the mother and the fetus (Bakker & Smith, 2018).
9. Administer blood and blood products as indicated.
In instances where significant bleeding ensues, rapid replacement of blood products is a priority. Activation of the Massive Transfusion Protocol is warranted, allowing for stabilization of the client’s hemodynamic status by way of a rapid supply of blood products (Bakker & Smith, 2018).
10. Prepare for a vaginal or cesarean birth.
Vaginal birth is always safest for the infant. If the previa is under 30% by abdominal or transvaginal ultrasound, it may be possible for the fetus to be born past it. If over 30% and the fetus is mature, the safest birth method for both mother and baby is often cesarean birth.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
Other care plans related to the care of the pregnant mother and her baby:
References and Sources
Recommended resources to further your reading and research about placenta previa nursing care plans and nursing diagnosis:
- Anderson-Bagga, F., & Sze, A. (2019, April). Home. YouTube. Retrieved September 13, 2022.
- Bakker, R., & Smith, C. V. (2018, January 8). Placenta Previa: Practice Essentials, Pathophysiology, Etiology. Medscape Reference. Retrieved September 13, 2022.
- Balayla, J., Desilets, J., & Shrem, G. (2019, July 13). Placenta previa and the risk of intrauterine growth restriction (IUGR): a systematic review and meta-analysis. Journal of Perinatal Medicine, 47(6), 577-584.
- Bany, F. M., & Rosenkrantz, T. (2018, May 8). Chorioamnionitis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved September 14, 2022.
- Hassan, S. S. (2010). The frequency and clinical significance of intra-amniotic infection and/or inflammation in women with placenta previa and vaginal bleeding: an unexpected observation. PubMed. Retrieved September 14, 2022.
- Klabunde, R. E. (2021). Cardiovascular Physiology Concepts (R. E. Klabunde, Ed.). Lippincott Williams & Wilkins.
- Kolecki, P., & Brenner, B. E. (2022, September 1). Hypovolemic Shock Treatment & Management: Prehospital Care, Emergency Department Care. Medscape Reference. Retrieved September 13, 2022.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
- Udeani, J., & Geibel, J. (2018, September 12). Hemorrhagic Shock: Background, Pathophysiology, Epidemiology. Medscape Reference. Retrieved September 14, 2022.
- World Health Organization. (2015). Emergency Treatments for the Woman – Pregnancy, Childbirth, Postpartum and Newborn Care. NCBI. Retrieved September 13, 2022.