Placenta Previa

Description of the Disease Process

The placenta is the organ created during pregnancy to nourish the fetus, remove its waste, and produce hormones to sustain the pregnancy. The placenta is attached to the wall of the uterus by blood vessels that supply the fetus with oxygen and nutrition and remove waste from the fetus and transfer it to the mother. The fetus is attached to the placenta by the umbilical cord. Through the cord, the fetus receives nourishment and oxygen and expels waste. On one side of the placenta, the mother's blood circulates, and on the other side, fetal blood circulates. The mother's blood and fetal blood usually don't mix in the placenta.

The placenta is usually attached to the upper part of the uterus, away from the cervix, the opening which the baby passes through during delivery. On rare occasions, the placenta lies low in the uterus, partly or completely blocking the cervix -- called a placenta previa. Placenta previa may be observed in as many as one in every three pregnancies before the 20th week of pregnancy. As the uterus grows, the placenta usually moves higher in the uterus, away from the cervix. But if it remains near the cervix as your due date nears -- which happens in about one in 200 pregnancies -- you're at risk for bleeding, especially during labor as the cervix thins (effaces) and opens (dilates). This can cause major blood loss in the mother. For this reason, women with a placenta previa usually deliver their babies before their due date by cesarean delivery. There are several types of placenta previa:

A low-lying placenta is near the cervical opening but not covering it. It will often move upward in the uterus as your due date approaches. A partial placenta previa covers part of the cervical opening. A total placenta previa covers and blocks the cervical opening.

Etiology
The cause of placenta previa is usually unknown, although it occurs more commonly among women who are older, smoke, have had children before, have had a cesarean section or other surgery on the uterus, or have scars inside the uterus. Women with placenta previa -- specifically if they have a placenta previa after having delivered a previous baby by cesarean section -- are at increased risk of placenta accreta, placenta increta, or placenta percreta.

Pathophysiology
Placental implantation is initiated by the embryo (embryonic plate) adhering in the lower (caudad) uterus. With placental attachment and growth, the developing placenta may cover the cervical os. However, it is thought that a defective decidual vascularization occurs over the cervix, possibly secondary to inflammatory or atrophic changes. As such, sections of the placenta having undergone atrophic changes could persist as a vasa previa. A leading cause of third trimester hemorrhage, placenta previa presents classically as painless bleeding. Bleeding is thought to occur in association with the development of the lower uterine segment in the third trimester. Placental attachment is disrupted as this area gradually thins in preparation for the onset of labor. When this occurs, bleeding

occurs at the implantation site as the uterus is unable to contract adequately and stop the flow of blood from the open vessels. Thrombin release from the bleeding sites promotes uterine contractions and leads to a vicious cycle of bleeding-contractionsplacental separation-bleeding.

Clinical Manifestation

Sudden, painless vaginal bleeding that ranges from slight to heavy. The blood is often bright red. Bleeding can occur as early as the 20th week of pregnancy but is most common during the third trimester. Symptoms of preterm labor, such as regular, menstrual-like cramps, or a feeling of pressure in your lower abdomen. The bleeding from placenta previa can cause the uterus to contract. Bleeding from placenta previa may taper off and even stop for a while. But it nearly always starts again days or weeks later. Some women with placenta previa do not have any symptoms. In this case, placenta previa may only be diagnosed by an ultrasound done for other reasons.

Nursing Management
1. Ensure the physiologic well-being of the client and fetus a. Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh perineal pads before and after use to estimate blood loss. b. Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin and a drop in blood pressure c. Monitor the FHR d. Enforce strict bed rest to minimize risk to the fetus e. Observe for additional bleeding episodes. 2. Provide client and family teaching a. Explain the condition and management options. To ensure an adequate blood supply to the mother and fetus, place the woman at bed rest in a side-lying position. Anticipate the order for a sonogram to localize the placenta. If the condition of mother or fetus deteriorates, a cesarean birth will be required. b. Prepare the client for ambulation and discharge ( may be within 48 hours of last bleeding episode)

c. Discuss the need to have transportation to the hospital available at all times. d. Instruct the client to return to the hospital if bleeding recurs and to avoid intercourse until after the birth. e. Instruct the client on proper handwashing and toileting to prevent infection. 3. Address emotional and psychosocial needs a. Offer emotional support to facilitate the grieving process, if needed b. After birth of the newborn, provide frequent visits with the newborn so that the mother can be certain of the infants condition

Mastitis
Description of the Disease Process
Mastitis is a condition that causes a woman's breast tissue to become painful and inflamed. Mastitis is most common in breastfeeding women, although women who aren't breastfeeding can develop it. About 1 in 10 breastfeeding women are affected by mastitis. In these cases, it usually develops in the first three months after giving birth. Doctors often refer to it as lactation mastitis or puerperal mastitis. Mastitis usually affects one breast. As well as the breast being painful and swollen, some women may also experience flu-like symptoms such as a high temperature (fever), aches and chills. Read more about the symptoms of mastitis. You should visit your GP immediately if you think you might have mastitis. They should be able to diagnose it. If you're breastfeeding, they may ask you to demonstrate your technique. Try not to feel as if you are being tested or blamed, breastfeeding correctly can take time and practice. In non-breastfeeding women, your GP will want to rule out other conditions, see breast lumps for more information. Read more about how mastitis is diagnosed.

Etiology
Mastitis can be caused by an infection or milk remaining in the milk tissue (milk stasis). Milk stasis can occur for a number of reasons, such as your baby not being properly attached to your breast during feeding. Infectious mastitis may develop if a bacterium gets into your milk ducts. This can be because your milk ducts are blocked or, in non-breastfeeding women, because of a cracked or sore nipple, or nipple piercing. Left untreated, non-infectious mastitis can develop into infectious mastitis. This may be due to bacteria infecting milk that remains in the breast tissue. Read more about the causes of mastitis.

Pathophysiology
The mammary glands arise along the milk lines that extend along the anterior surface of the body from the axilla to the groin. During puberty, pituitary and ovarian hormonal influences stimulate female breast enlargement, primarily due to accumulation of adipocytes. Each breast contains approximately 15-25 glandular units know as breast lobules, which are demarcated by Cooper ligaments. Each lobule is composed of a tubuloalveolar gland and adipose tissue. Each lobule drains into the lactiferous duct,

which subsequently empties onto the surface of the nipple. Multiple lactiferous ducts converge to form one ampulla, which traverses the nipple to open at the apex. Below the nipple surface, lactiferous ducts form large dilations called the lactiferous sinuses, which act as milk reservoirs during lactation. When the lactiferous duct lining undergoes epidermalization, keratin production may cause plugging of the duct, resulting in abscess formation. This may explain the high recurrence rate (an estimated 39-50%) of breast abscesses in patients treated with standard incision and drainage (I&D), as this technique does not address the basic mechanism by which breast abscesses are thought to occur. Postpartum mastitis is a localized cellulitis caused by bacterial invasion through an irritated or fissured nipple. It typically occurs after the second postpartum week and may be precipitated by milk stasis. There is usually a history of a cracked nipple or skin abrasion. Staphylococcus aureus is the most common organism responsible, but Staphylococcus epidermidis and streptococci are occasionally isolated. Drainage of milk from the affected segment should be encouraged and is best achieved by continuing breastfeeding or use of a breast pump. Nonlactating infections may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections consist of active inflammation around nondilated subareolar breast ductsa condition termed periductal mastitis. Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma.[1] Primary skin infections of the breast (cellulitis or abscess) most commonly affect the skin of the lower half of the breast and often recur in women who are overweight, have large breasts, or have poor personal hygiene. Breast masses can involve any of the tissues that make up the breast, including overlying skin, ducts, lobules, and connective tissues. Fibrocystic disease, the most common breast mass in women, is found in 60-90% of breasts during routine autopsy. Fibroadenoma, the most common benign tumor, typically affects women younger than 30 years. Infiltrating ductal carcinoma is the most common malignant tumor; however, inflammatory carcinoma is the most aggressive and carries the worst prognosis.

1. Acute Pain related to increased uterine contractility, hypersensitivity. Goal: pain reduced client Nursing Interventions: 1. Warm the abdomen. Rational: may cause vasodilation and reduce the spasmodic contractions of the uterus. 2. Massage the abdominal area that feels pain. Rational: reduce pain due to the stimulus of therapeutic touch. 3. Perform light exercise Rational: it can improve blood flow to the uterus and muscle tone. 4. Perform relaxation techniques. Rational: reduce the pressure to get relaxed. 5. Give the natural diuresis (vitamin) sleep and rest. Rational: reduce congestion. 2. Ineffective individual coping related to emotional excess. Nursing Interventions: 1. Assess client's understanding of her illness. Rational: maternal anxiety of the pain will be greatly influenced by knowledge. 2. Determine the additional stress that accompanies it. Rational: stress can impair the autonomic nervous response, so it is feared to increase the pain. 3. Provide an opportunity to discuss how the pain. 4. Help clients identify coping skills during the period covered. Rational: the use of behavior management techniques can help clients adapt to the pain they experienced. 5. Give the period of sleep or rest. Rational: the pain and fatigue due to spending a lot of body fluids tends to be a problem that must mean a lot of the body tends to be significant problems that must be addressed immediately. 6. Push the skills of stress, such as relaxation techniques, visualization, guidance, imagination and deep breathing exercises. Rational: it can reduce pain and distract the client to pain.