Characteristics of women with cesarean section due to placenta previa at national hospital of obstetric and gynecology in 2020
RESEARCH ARTICLE
CHARACTERISTICS OF WOMEN WITH CESAREAN SECTION DUE TO PLACENTA
PREVIA AT NATIONAL HOSPITAL OF OBSTETRIC AND GYNECOLOGY IN 2020
Nguyen Thi Thanh Huong1, Vu Dung2
1National Hospital for Obstetric and Gynecology, 2Thang Long University
ABSTRACT
participants had completed placenta previa
(85.2%) and 34.9% of them had Placenta
Accreta. 63.1% of women had a cesarean
section and preserved the uterus and 36.9%
of them undergo surgery of hysterectomy.
43.6% of the women experienced servere
bleeding and half of them had to have a
blood transfusion, the average amount of
transfusion was 3.11 ± 2.6 units of blood.
After surgery, 55% of pregnant women
recovered well. Conclusion: Most of the
women had better progress after surgery
in terms of mental status, breathing,
circulation, pain sensation. Health care staff
should provide post-cesarean care for the
woman with history of cesarean section due
to placenta previa, pregnancy with comorbid
diseases, placenta accreta, emergency
surgery and women with servere bleeding
pre-and post- surgery.
Objective: Describe the clinical,
subclinical, and resuscitation care after
placenta previa operations at the National
Hospital For Obstetric And Gynecology.
Method: Descriptive study design was
used to recruited 149 women who had a
cesarean section due to placenta previa at
the department of resuscitation anesthesia
in the National Hospital For Obstetric And
Gynecology from January to September
2020.Results:Theaverageageofpregnant
women was 32.5 ± 4.9 years old, mainly in
the 22 to 35 years old group (71.1%); 23.5%
of them had comorbidities; 40.9% get
pregnant up to 3 times; 61.7% of them had
ever a C-section. In the pregnancy, 42.8%
of the women had preterm birth and 4.1%
of them were pregnant with twins. While
admitted to the hospital, 49% of women
presented with vaginal bleeding and 34.9%
of them were anemia; 57% of women had
uterine contractions and most of them
presented with an open cervix. Almost of
Keywords: after cesarean section,
placeta previa, the National Hospital For
Obstetric And Gynecology.
1. INTRODUCTION.
The placenta previa resulted a high rate
of preterm birth due to premature bleeding,
making it difficult to continue the pregnan-
cy. One of the common indications in ce-
sarean section is placenta previa. In the
surgery, the risk of bleeding, difficult he-
mostasis and after surgery, bleeding may
still happen life-threatening for the wom-
en. Complications that may occur during
and after surgery are hemorrhage, uterine
atony, hypovolemic shock and finally stop
circulation, death [1]. Resuscitation care
is intensive care, requiring the nurse to be
professional, quickly and accurately assess
the pregnant woman’s condition, carefully
monitor and follow-up the patient, then, the
complications may be detected early. After
surgery, notice and timely implementation
of medical intervention from the doctor as
Cor. author: Vu Dung
Email: vuzung246@gmail.com
Received: Feb 08, 2021
Revised: Feb 15, 2021
Accepted: Mar 05, 2021
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RESEARCH ARTICLE
well as the optimal nursing care interven-
The minimum sample size calculated
tion, thereby avoiding complications, espe- was 130 women. In fact, the study took all
cially those that severely affect the life of 149 women who had cesarean section due
the woman. In order to describe the char- to placenta previa during the study period.
acteristics of the pregnant woman who had
a cesarean section due to the placenta and
the results of monitoring and providing care
- Sample selection method: convenient
sample selection
2.3. Methods of data collection: Data
were collected from patient medical records
and direct monitoring of each woman, infor-
mation was documented in the research
records.
of the woman during the tesuscitation care
period, the researcher conducted the study
with the objective to examine the clinical,
subclinical and post-operative regression of
women who underwent a cesarean section
at the National Hospital For Obstetric And
Gynecology
2.4. Measurements
- Classification of placenta previa was
according to the diagnostic lab results.
2. RESEARCH METHOD
2.1. Research settings, time and
participants
- Uterine contraction was evaluated 2
levels of good and not good
Research settings: the department of
resuscitation anesthesia in the National
Hospital For Obstetric And Gynecology
- Pain level was assessed on VAS scale
of 0 = painless; 1 to 3 = mild pain; 4 to 6 =
moderate pain and 7 to 10 = severe pain
Research time: from January to Sep-
tember 2020.
- Assess the status of pregnant women
in pregnant period was based on weight,
height, BMI calculation and WHO classifi-
cation: BMI <18.5 is thin; 18.5-22.9 is nor-
mal and BMI ≥23 is overweight
Participants: Women of all ages after
cesarean delivery (emergency surgery,
planned surgery). Except for pregnant
women with infectious diseases (surgery in
the Department of infected Obstetrics
- Classification of the women progress
with good resuscitation: the time spent in
the resuscitation room is less than or equal
to 3 hours and without complications; Wom-
en with poor resuscitation progress are
women who have been in the resuscitation
room for more than 3 hours and have com-
plications or no complications.
2.2. Methods:
Research design: Descriptive study de-
sign
Sample size and and sampling meth-
od
- Calculate the sample size according
to the formula to determine a rate with p =
0.93 (the rate of cesarean section due to
placenta previa in 2019 was listed at the
Department of Resuscitation anesthesia
in the National Hospital For Obstetric And
Gynecology). 95% confidence level and
permissible error d = 0.05.
2.5. Data analysis: Data were analysed
by software used in biomedical statistics.
Research results were presented in terms
of frequency, percentage, average. The
related factors were determined using OR
index with OR > 1 and within the 95% con-
fidence interval of CI and p <0.05.
p x (1-p)
n= z2(1- α/2)
d2
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3. RESULTS
13.4% of pregnant women got pregnant
for the first time. Regarding the history of
cesarean section, 24.8% of women had
one caesarean section, 32.9% had two
cesarean sections, and 4.0% of women had
3 or more cesarean sections.
3.1. Characteristics of women with
cesarean section due to placenta previa
Table 1. General characteristics,
comorbidities and pregnant history of
participants
Table 2. Clinical and subclinical
characteristics of women before
surgery
Characteristics
n
Percentage
Age:
Under 22
22 to 35
1
106
42
0,7
71,1
28,2
Characteristics
n
Percentage
Gestational age:
- Preterm
Above 35
49
100
32,9
67,1
32,5 ± 4,9
The average age
- Fullterm
Min:19 Max: 44
Number
of
Body status before
pregnancy:
- Normal
gestations:
- One gestation
- Twins
143
6
95,9
4,1
114
17
76,5
11,4
12,1
- Thin
- Overweight, obesity 18
Vaginal bleeding
73
49,0
Number of previous
pregnancies
Not yet
1-2 times
≥ 3 times
Cervical:
- Close
- Open
20
68
61
13,4
45,7
40,9
134
15
89,9
10,1
Uterine contractions:
- With contraction 85
There were
comorbidities
57,0
43,0
35
23,5
- No contractions
64
Number of cesarean
sections before
- Not yet
- 1 time
- 2 times
Blood pressure:
- Normal
144
2
3
96,6
1,3
2,0
57
37
49
6
38,3
24,8
32,9
4,0
- Hypotension
- Hypertension
There are signs of
shock
- 3 times and above
2
1,3
The average age of the participants was
32.5 ± 4.9 years, of which mainly the age
group from 22 to 35 years old, accounting
for 71.1%, the age group over 35 accounting
for 28.2% and only 1 women in the group of
under 22 years old, this woman was only 19
years old.
Anemia:
- Reduced number 69
of red blood cells
- Decreased Hb 52
concentration
46,3
34,9
Ultrasound
- Incomplete edge 19
placenta previa
- Incomplete lower
placenta previa
- Complete placenta 127
previa
12,8
2,0
Before this pregnancy, most of the
women were in a normal body status
(76.5%), 11.4% of them were underweight,
and 12.1% were overweight. 23.5% of
women had comorbidities. 40.9% of women
had ever had two or more pregnancies.
3
85,2
34,9
- Placenta accreta 52
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In this pregnancy, 4.1% of the pregnancy was twins and 32.9% of the woman had
the preterm birth. While admitted to hospital, 49.0% of women had vaginal bleeding;
57.0% had uterine contractions and 10.1% of women had an open cervix. Before surgery,
most women had normal blood pressure (96.6%) and 2 women had fast pulse, low blood
pressure. The results of blood tests showed that 43.6% of women had a decrease in the
red blood cell index and 34.9% of them had a decrease in hemoglobin. Most women had
the complete placenta previa (85.2%) and 34.9% had a placenta accreta.
Table 3. Indication of cesarean section due to placenta previa
and surgery method
Indication and surgery method
Caesarean section and uterus preservation
Caesarean section and hysterectomy
Complete hysterectomy
n
94
54
1
Percentage
63,1
36,2
0,7
Total
149
100,0
94 women underwent cesarean section and uterine preservation, accounting for 63.1%
and 55 women undergoing cesarean section and hysterectomy, accounting for 36.9% of
which 1 woman had a complete hysterectomy whose was with 17.2 week-pregnancy, 3rd
child, old age, complete placenta previa and placenta accreta, no amniotic fluid; complete
hysterectomy in controling blood loss.
3.2. Results of monitoring and proving care of pregnant women after surgery
Unconciuos
Hypotension
High pulse rate
Pale skin
100
80
60
40
20
0
Minutes
0
5
15
30
45
60
90 120 150 180
Figure 1. mental status and circulation of pregnant women after surgery (n=149)
Most women were conscious, stable blood pressure, normal pulse rate 3 hours after
surgery.
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Table 4. Respiratory condition, uterine contraction and postpartum fluid
at the time of follow-up
Percentage of women at any time
Min
Min
Min
Min
Min
Min
Min
Min
Min
0
15
30
45
60
90
120
150
180
Respiratory condition
34.9
57.7
24.2
0.7
17.4
8.7
7.4
5.4
0
4
0
3.4
0
3.3
0
Ventilator
With
endotracheal
tube
0
0
0
Oxygen with
nasal catheter
Spontaneous
breathing
7.4
34.9
25.6
19.5
15.4
13.4
10.1
6
5.5
0
0
57
98
71.8
98
77.2
99
81.2
99
85.9
100
90.6
100
91.2
100
96
98
SpO2 (%)
Uterine contraction (n=94)
- Good
- Not good
98,9
1,1
98,9
1,1
98,9
1,1
96,8
3,2
96,8
3,2
97,8
2,2
97,8
2,2
98,9
1,1
Postpartum fluid (n=94)
- Normal
- Much with bloody
96,8
3,2
96,8
3,2
96,8
3,2
95,7
4,3
95,7
4,3
96,8
3,2
96,8
3,2
96,8
3,2
The results of women with mechanical ventilation decreased from 34.9% to 3.3% after 3
hours; the rate of women breathing through the endotracheal tube decreased from 57.7%
to 0% after 30 minutes after surgery; the rate of women breathing on their own increased
from 0% to 91.2% after 3 hours. Good respiratory support enabled capillary blood oxygen
saturation with SpO2 always above 95% in all women. Most women were well progress,
good uterine contration and normal postpartum fluid ranged from 95.7% to 98.9%.
Table 5. Amount of blood loss and blood transfusion after surgery
Index
n
Percentage
Blood loss:
- Less (<250ml)
7
4,7
- Medium (250- <500ml)
- Servere (500- <1000ml)
- Very servere (≥ 1000ml)
77
38
27
51,7
25,5
18,1
Women with blood transfusion
- Yes
- No
75
74
50,3
49,7
Average units of transfused blood (n=75)
3,11 ± 2,6
(Min: 1 Max: 13)
18.1% of women experienced very servere blood loss; 25.5% of women had severe
blood loss and 51.7% had moderate blood loss. With the above blood loss, 75 women
experienced a blood transfusion and the average amount of transfusion was 3.11 ± 2.6
blood units. Especially, women had to transfuse up to 13 blood units (for two operations).
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Table 6. Progress of pain sensation of women after surgery
Grade of
VAS
Hour 1
n=149
Hour 2
n=149
Hour 3
n=136
Hour 4
n=49
Hour 5
n=22
Hour 6
n=12
20
(13,4%)
19
(12,8%)
10
(7,4%)
8
5
4
0
(16,3%)
(22,7%)
(33,3%)
127
(85,2%)
95
(63,8%)
54
(39,7%)
13
(26,5%)
2
1
1-3
(9,1%)
(8,3%)
1
32
(21,4%)
68
(50,0%)
27
(55,2%)
14
(63,7%)
6
4-6
(0,7%)
(50,1%)
1
3
4
1
1
1
7-9
(0,7%)
(2,0%)
(2,9%)
(2,0%)
(4,5%)
(8,3%)
Pain level was assessed 1 hour after surgery and once an hour. The results indicated
that in the first hour, the effect of anesthetic drugs caused less pain in pregnant women,
and the later hours, pain level increased mainly on average.
Table 7. Results of resuscitation care of women after surgery
and related factors
Results
n
Percentage
Resuscitation time:
- In 3 hours
82
67
55,0
45,0
- ≥ 3 hours
Complications
- No
- Yes and mild
- Yes and heavy
125
17
7
83,9
11,4
4,7
Results of resuscitation
- Good
82
67
55,0
45,0
- Not good
55% of women had resuscitation before 3 hours; 45% had resuscitation from over
3 hours, of which 11 women (7.4%) had resuscitation more than 6 hours. The average
resuscitation time was 3 hours and 52 minutes. Women were consciousness as early
as after 2 hours and 20 minutes and women had the longest resuscitation time of 18
hours. Most women had no complications (83.9%); 17 women had mild complications and
4.7% (7 women) had serious complications, in which 3 cases of re-surgery for hemostasis
suture, 3 cases of uterine hemostasis balloon and 1 placenta accreta woman with very
servere bleeding before surgery, surgery resulting injured bladder, a total of 2000ml of
blood transfusion and blood products. After surgery, blood clotting disorder, the recovery
time was 10.5 hours. 14 women with complications of varying degrees had resuscitation
time of more than 6 hours.
The results of general resuscitation included 82 women with well resuscitation
(resuscitation time ≤ 3 hours and no complications) reaching 55%; 67 women had not
good resuscitation (resuscitation time was over 3 hours with or without complications),
accounting for 45%
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Table 8. Factors related to the resuscitation results
Good
Not good
Factors
Not yet
OR, 95%CI
p
resuscitation resuscitation
44
38
70
12
38
44
70
13
54
44
23
20
47
27
History of
cesarean
section
4,8
(2,28-10,12)
<0,01
Had
No
3,05
(1,38-6,74)
Comorbidities
Surgical type
<0,01
<0,05
Had
Planned
Emergency
2,02
(0,97-4,25)
No placenta
accreta
8,6
Placenta previa
<0,01
<0,01
(3,72 – 20,63)
With placenta
12
68
14
40
16
51
accreta
<500ml
≥ 500ml
The amount of
15,4
(6,43-37,51)
blood lost
The results showed that the good resuscitation results were more common in women
who had not had cesarean section before; no comorbidities; planned surgery; placenta
previa without placenta accreta and low and average blood loss before and during surgery
(less than 500ml).
4. DISCUSSION
4.1. General characteristics and
pregnant history of women who had a
cesarean section due to placenta previa.
that the participants were at high risk in the
age group over 35. Especially in the study
there was a 19-year-old woman who was
in very young age, which was not found in
literature. Therefore, the results showed
that the placenta previa was always a
serious situation, the intervention should
considerate to preserve the uterus for very
young women.
The study results showed that the
average age of the participants was 32.5 ±
4.9 years, of which mainly the age group
from 22 to 35 years old, accounting for
71.1%. This study result was similar to that
of Pham Van Do (2018) while the pregnant
woman’s age was about 20-45 years old
[2]. Nguyen Trung Kien (2019) showed
that the proportion of women over 35 years
old participating in the study accounted
for 30.9% [5], it was similar to the study of
28.2%. The previous study results indicated
Theresearchresultsindicatedthat11.4%
of women were thin; 12.1% of women were
overweight and 23.5% had other medical
problems before getting pregnant. Most of
the other studies [3], [4], [5] did not mention
these two characteristics of pregnant
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RESEARCH ARTICLE
women, however, the research conducted dangerous for the fetus and women.
to find out more of these 2 information. The
The rate of women with anemia before
further studies should conduct to examine
giving birth in the study was lower than that
the effects of body status and comorbidities
of the Le Thi Giang with anemia up to 60.5%
to the postoperative recovery.
[3]. From this result, it showed that anemia
The research results indicated that the
majority of study participants had ever been
pregnant, from the 3rd time up, accounting
for the highest percentage of 40.9%; 2
times (26.8%) and one pregnancy (18.8%).
The research results were different from
those recorded in the study of Le Thi Giang
(2015) with the highest percentage of
participants who had ever been pregnant
once (67.4%) [3]. The group of participants
who had never had a cesarean section
before accounted for the highest proportion
(38.3%), and ranked second was the group
who had a cesarean section twice (32.9%).
Particiapnts with 3 times of cesarean section
3 times or more accounted for a low rate
(4%). Regarding the group of particiapnts
who had never had a cesarean section,
the research results were higher than the
research results of Nguyen Lien Phuong
(8.3%) [7].
status of pregnant women was a problem of
concern because it may affect the outcome
of the intervention and the resuscitation
status after the surgery.
Results of placenta previa ultrasound of
the particiants showed that the majority of
women had the complete placenta previa
(85.2%). This result was consistent with
research results of some authors Pham
Van Do (59.1%) and Pham Thi Linh (98%)
[2], [6].
Regarding the handling of the placenta
previa cases, the results showed that
94 women underwent cesarean section
and uterine preservation, accounting
for 63.1% and 55 women with cesarean
section and hysterectomy, accounting
for 36.9%. Among the women who had a
hysterectomy, one woman had to have a
complete hysterectomy due to excessive
bleeding, severe blood loss (this woman
had to transfuse 13 units of blood). She was
tvery short gestational age of 17th week.
4.2.
Clinical
and
subclinical
characteristics of women with cesarean
section due to placenta previa
About blood loss, 43.6% of pregnant
women had very servere bleeding (over
500ml). With such blood loss, 75 women had
to transfuse blood and the average amount
of transfusion was 3.11 ± 2.6 units of blood.
Especially, there were women who had to
transfuse up to 13 units of blood, which
was the case of emergency surgery due to
placenta previa with placenta accreta. In the
3-unit blood transfusion surgery, 15 hours
after surgery, the patient had to re-operate
due to monitoring bleeding in the abdomen,
continued extremly blood loss and
According to the research results, the rate
of women with vaginal bleeding accounts for
49%. The research results were consistent
with research results of Le Thi Giang (55.2)
[3]. The results were lower than that of
Nguyen Trung Kien (67.9%) [5]. Most of
the participants at the National Hospital for
Obstetrics and Gynecology were appointed
by doctors to stay in the hospital at full
term, to take care of the overall health of
the woman and fetus according to medical
orders to detect and report to the doctor for
early and timely intervention while there were
signs of bleeding and labor to avoid vaginal continued infusion of 10 units. Our results
bleeding, servere bleeding, which would be were similar to those published by Le Hoai
Journal of Nursing Science - Vol. 04 - No. 01
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RESEARCH ARTICLE
Chuong showed that out of a total of 500 a relationship between previous cesarean
cases of placenta previa, hysterectomy was section, placenta characteristics, level of
42 cases, accounting for 8.4%. According
to Hoang Van Yen (2010), research on the
management of bleeding during and after
cesarean section at the National Hospital for
Obstetrics and Gynecology in 2008-2009,
uterine artery constriction was selected in
86.9% of cases [8].
blood loss and resuscitation time after
cesarean section. The higher number of
previous cesarean sections made the longer
the resuscitation time after caesarean
section.
The following-up and detecting the
heavy status after cesarean sections
due to placenta previa is the task of
the resuscitation therapist to track vital
signs, monitor bleeding in the wound,
bleeding in abdomen, signs of uterine
contraction, monitoring postpartum fluid,
monitoring transmission. Therefore, in the
recsuscitation care, nurses should plan fully
and properly intervention for the risk women
with previous cesarean sections, placenta
previa, placenta accreta blood lost before
and during surgery and comorbidities.
Regarding the results of regressive
care and related factors: In the study, we
analyzed and showed that women who
had had a caesarean section; women
with comorbidities; women who have both
a striker and a toothpaste and those who
have surgery in an emergency situation;
women who lost a lot of blood before,
during surgery had worse recovery
results than women with advantages: no
history of cesarean section, no associated
disease, planned surgery and little blood
loss. or medium. Our research results are
consistent with research results of some
other authors [9], [10]. These authors
indicated that there was an association
between cesarean section history, forward
placenta characteristics, degree of blood
loss, and time of resuscitation after
cesarean section. The more women who
have had a caesarean section before, the
longer the time had consciousness and
recovered from a cesarean section due to
the placenta.
5. CONCLUSION AND RECOMMENDATION
Conclusion:
Characteristics of research participants
results indicated that the women were
average age 32.5 ± 4.9 years; 40.9% of
pregnant women had pregnant ≥ 3 times;
61.7% of women had ever had a C-section;
while admitted to hospital, 49% of pregnant
women had vaginal bleeding; 57% of
women had uterine contractions and 89.9%
had an open cervix; 85.2% of women had
complete placenta previa (85.2%) and
34.9% of women had placenta accreta;
36.9% of women had a hysterectomy and
50.3% had a blood transfusion, the average
amount of transfusion was 3.11 ± 2.6 units
of blood.
The resuscitation results and related
factors indicated that the women with
cesarean section, comorbidities, placenta
previa with placenta accreta and emergency
surgery; blood lost before and during
surgery had worse resuscitation results
than the women without previous cesarean
section, comorbidities, placenta previa with
placenta accreta and emergency surgery.
Results of the research were consistent
with the results of some other authors [9],
[10]. This author pointed out that there was
Most women had better progress after
surgery in terms of mental health, breathing,
circulation,painsensationstatus.Theresults
of good resuscitation care accounted for
55%. The rate of good resuscitation results
was higher among women who had not
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Journal of Nursing Science - Vol. 04 - No. 01
RESEARCH ARTICLE
previously had C-section; no comorbidities;
planned surgery; no placenta previa, no
placenta accreta and not much blood loss
6. Pham Thi Linh (2019). Research on
placenta accreta on women with a history
of cesarean section at the National Hosptal
for Obstetrics and Gynecology for 5 years
of 2014 to 2018. Master’s thesis, Hanoi
Medical University. [In VietNamese]
Recommendation: Providing care of
women after cesarean section due to pla-
centa previa, the nurses should pay atten-
tion to women who had a history of previous
cesarean section, with comorbid diseases,
emergency surgery; placenta previa, pla-
centa accreta and extremly loss of blood
before and during surgery.
7. Nguyen Lien Phuong, Tran Danh
Cuong, Vu Ba Quyet (2018). Research
on the diagnosis and management of
placenta accreta at the National Hosptal for
Obstetrics and Gynecology in 2017. Journal
of Obstetrics and Gynecology, volume 16
(01), 05-2018, p. 87 – 91 [In VietNamese]
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