Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse in triage. Maria, 32 weeks pregnant, arrives stating, "I just started bleeding, and it's bright red." She denies pain. Her vital signs are BP 118/74, HR 92, RR 18. She is placed on a monitor, and the fetal heart rate (FHR) is 150s with minimal variability.
Nursing Intervention Strategy:- 1Immediate Assessment & SafetyPlace her in left lateral position. Apply continuous external fetal and tocodynamic monitoring. Establish two large-bore IV lines with normal saline. Obtain vital signs frequently (every 5-15 min initially). Quantify bleeding (pad count).
- 2Communication & PreparationNotify the obstetrician immediately. Have the ultrasound machine brought to the bedside for confirmation—do not transport the patient unnecessarily. Prepare for potential emergency Cesarean section: ensure consent forms are ready, lab work (CBC, type & crossmatch) is drawn, and the operating room is alerted.
- 3Ongoing Monitoring & SupportContinuously assess for signs of shock (tachycardia, hypotension, pallor) and fetal distress (late decelerations, bradycardia, loss of variability). Provide emotional support and clear explanations to the patient and family.
Patient Safety and Precautions:
• Key Point! Under NO circumstances should anyone perform a digital cervical examination until placenta previa is ruled out by ultrasound.
• Limit patient movement. Bed rest with bathroom privileges may be ordered if bleeding subsides.
• Monitor for uterine activity. Contractions can worsen bleeding.
Nursing Procedure & Medication Flow
• Procedure: Continuous Fetal Monitoring Setup: Place the ultrasound transducer over the area of loudest FHR and secure it. Place the tocodynamometer on the uterine fundus. Document a 20-minute baseline strip. Interpret the tracing for reassuring signs (baseline 110-160, moderate variability, presence of accelerations) and non-reassuring signs (recurrent late or variable decelerations, bradycardia).
• Medication: Anticipated Orders:
- IV Fluids: Isotonic crystalloids (e.g., Lactated Ringer's) for volume expansion.
- Rhogam: If the mother is Rh-negative, administer after any bleeding episode.
- Betamethasone: May be ordered if delivery is imminent but can be delayed for 48 hours, to promote fetal lung maturity.- NOT Ordered: Tocolytics (like magnesium sulfate) are typically contraindicated in active bleeding as they can mask signs of shock.
A Word from Your Senior Nurse
"Placenta previa is one of those OB emergencies where your knowledge directly saves lives. Remember, your hands can do harm if you perform a routine check that becomes catastrophic. Your first instinct should always be to stabilize, monitor, and notify. In clinicals, if you see 'bright red bleeding' on an OB chart, your mental alarm bells should ring 'PLACENTA PREVIA' and 'NO VAGINAL EXAMS.' This isn't just for the test; it's a fundamental safety rule that you will carry with you to every labor and delivery unit."