186 BIRTH 28:3 September 2001

Waiting For Something to Happen: Hospitalization withPlacenta Previa

Anne Katz, RN, PhD

ABSTRACT: Background: Placenta previa occurs in approximately 1 of every 200 preg-nancies. No research examining women’s experiences of this condition has been published.The objective of this study was to describe the experience of women hospitalized withplacenta previa. Methods: A descriptive study was conducted using a convenience sampleof 10 pregnant women who had been hospitalized with placenta previa. Women wererecruited from a tertiary care hospital and participated in two semistructured interviewsduring the pregnancy and one after the baby’s birth while in hospital. They were admittedto hospital from 28 weeks’ gestation and remained in hospital until delivery, generally at36 weeks’ gestation. Transcripts of the interviews were analyzed using content analysis todescribe their experience. Results: Six themes were identified from the descriptions of theexperience as related by the participants. They encompassed the experience from the firstsymptoms to feelings about the experience after the baby was born. Conclusions: Womenwith placenta previa experience significant stressors while in hospital. Health caregiversshould be aware of the loss of control and isolation these women feel and be mindful ofthe potential for sequelae in the postpartum period. (BIRTH 28:3 September 2001)

Placenta previa occurs in approximately 1 of every indication that anything abnormal had occurred in thepregnancy. In other instances the woman may consult200 pregnancies (1). It is a condition in which the

placenta implants in the lower part of the uterus, and with her caregiver after experiencing an episode ofpainless vaginal bleeding. Admission to the hospitalas the pregnancy progresses the risk of bleeding is

significant and may result in the death of the woman, is usually immediate, with little time for the womanto prepare herself or her family for a prolonged hospitalher fetus, or both. In addition, placenta previa increases

the risk of the placenta becoming embedded in the stay.In many countries, such as Canada, the usual man-wall of the uterus and not separating after the delivery,

which can cause massive bleeding. agement for these women is complete bed rest in hospi-tal with or without bathroom privileges. If bleeding isNo studies have been published about how women

experience placenta previa. The condition is unusual not present, women may be able to mobilize in awheelchair on the antepartum floor (2). Home care forin that women often have no symptoms and may be

diagnosed on routine ultrasound examination with no these women is more common in the United Statesbut may not be available in all areas.

The medical literature contains articles describingthe diagnosis and management of placenta previa, but

Anne Katz is Assistant Professor in the Faculty of Nursing at the does not mention the experience of women with thisUniversity of Manitoba and the coordinator of the Campus Health

condition. Nursing studies have been conducted thatResource Centre, Winnipeg, Manitoba, Canada.explored the physical and psychosocial effects of bed

Address correspondence to Dr. Anne Katz, Faculty of Nursing, 405 rest in pregnancy for other complications of pregnancyHelen Glass Centre for Nursing, University of Manitoba, Winnipeg,

(3–9). These investigations described symptoms ofManitoba R3T 2N2, Canada.dysphoria, stress and anxiety, boredom, depression,

This study was supported by a grant from the Manitoba Association feelings of being imprisoned, loneliness, and worriesof Registered Nurses, Winnipeg, Manitoba, Canada.

about the status of their families. Concerns about emo-tional changes, health and body image, adapting toq 2001 Blackwell Science, Inc.

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unfamiliar hospital routines, having to take on the in the typed transcripts. Tapes and transcripts werestored in a safe place according to standard researchdependent role, loss of control, uncertainty related to

length of hospital stay, symptoms, the nature of the protocols. The transcripts were read and then codedusing a data management software program, QSRcause of the problem necessitating admission, and con-

cern for the baby’s health were also described. The NU*DIST (SCOLARI, Sage Publications Software).The codes were reviewed, refined, and then groupedcurrent study describes the experiences of 10 women

who were hospitalized with placenta previa. into themes generated from the coded transcripts.Validity of the findings was obtained through the

processes of fittingness and auditability. Fittingness isMethodsa term used by Guba and Lincoln (10) to describe the‘‘fit’’ of research findings into contexts separate fromTen women were recruited from among patients whothe study. Research findings are said to fit when othershad been admitted with placenta previa to the antepar-who read the findings find them meaningful in termstum ward of a tertiary care hospital in a western Cana-of their own experiences. The fittingness of this studydian city. The purpose of the study was explained inwas assessed by discussing the findings with two healtha letter that the unit manager gave to the women shortlycare professionals who worked in prenatal care andafter admission. After having time to consider the invi-who had experience in dealing with women hospital-tation to participate in the study, they were asked byized with placenta previa. These objective profession-the unit manager if they wished to be part of theals stated that in their experience, women who werestudy. Those who agreed to participate were asked byhospitalized with placenta previa described similar ex-a research associate to sign consent to participate andperiences. Findings are said to be auditable when othersa date and time for the first interview was set. Thecan follow the process, in this case the process ofwomen were interviewed soon after admission andtranscript review and coding and then generation ofagain before the baby was born. Interviews were con-themes used by the researcher to arrive at the findings.ducted in the rooms of the women at a time when

the women’s roommates were not present. ParticipantsStudy Samplewere interviewed again in their homes approximately

4 to 6 weeks after delivery. Interviews followed aThe women were admitted to hospital at between 28semistructured format (Table 1), and were conductedand 33 weeks’ gestation, except for a woman who wasfrom April 1998 until February 1999. Approval foradmitted with bleeding at 25 weeks. All were marriedthe study was granted by a university ethics reviewand 6 had children at home. Nine women were em-board.ployed at the time of their admission. The womenInterviews were taped and transcribed verbatim.were Caucasian and had a minimum of high schoolThe women were assured that identifying informationeducation. Of interest is that 4 women had conceivedwould be removed from the tapes and would not appearthrough in vitro fertilization. All except 1 woman re-mained in hospital until delivery; the placenta of an-other was found on ultrasound examination to haveTable 1. Semistructured Interviewmoved away from the cervical os and she was dis-

Before delivery charged home to await labor.What has the experience of having placenta previa meant

to you?ResultsWhat were your feelings when you were diagnosed?

How were you told and who told you?How do you feel about being in hospital? Six themes were identified from the descriptions of

Impact on home and work life the experience, as related by the women who wereEffects on emotional well-being

interviewed. They encompassed the woman’s experi-How do you view this pregnancy?ence from the first symptoms to feelings about theHow do you cope with the day-to-day happenings of being

in the hospital? experience after the baby was born. The first theme,Coping mechanisms, sources of support ‘‘Warning signs,’’ describes any symptoms theseDiversions women experienced. The second theme, ‘‘Getting the

What do you think will happen in the next number of weeks?news,’’ details how the diagnosis was made and ex-Preparation for deliveryplained to the women. The third theme, ‘‘AcceptingHopes and dreams for the baby

After delivery the reality,’’ describes the ways in which these womenHow did the delivery proceed? dealt with the diagnosis and meaning of hospitalizationLooking back, what thoughts do you have about the whole and responded to hospital life. ‘‘Leaving the family,’’

experience?the fourth theme, highlights these women’s feelings

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os.’’ He said I would have to talk to my doctor about it.about being absent from husbands and children. ‘‘En-And then I realized it could mean hospitalization and thatduring’’ the experience, the fifth theme, relates to com-I would need a cesarean section.

ing to terms with bed rest, meals, noise, and roommates.The sixth theme, ‘‘Having the baby,’’ details the experi-

Accepting the Realityence of amniocentesis and going home.

The women initially struggled with the need for beingWarning Signsin hospital, particularly for those who had no bleeding.One woman looked for a rationalization for the admis-For 6 women the diagnosis of their condition came assion, ‘‘It’s actually reassuring knowing that if anythinga shock. Most were asymptomatic, and for the 4 whodoes happen you are here and it will be taken care ofhad some bleeding it was described as minimaland you don’t have to worry.’’ However, at times aspotting:different but equally compelling logic was used. She

I had a little bit of spotting, which went on for two days. . . . stated that at times she wished she would have theI called the doctor’s office and they said that considering baby, even if it was premature, ‘‘It’s just the fact ofthat I was in the second trimester it could mean different getting out of here, of having to stay so long. Some-things so they suggested that I go for an ultrasound.

times I wish it would just happen and then I feel badand guilty for thinking that.’’However, another woman described bleeding during

After being in hospital for a short while, the womenthe night and her response:met others on the unit and began to informally support

I woke at 6 a.m. and I thought I had peed the bed. I bolted one another. At times during the study up to 3 womenout of bed and there was blood and a liquidy clot in the with placenta previa stayed on the unit. The nursessheets. I didn’t panic because I couldn’t panic. . . . I had encouraged those who could ambulate to visit thoseto think . . . call the hospital, get someone here to stay with

on strict bed rest, and often introduced the women tomy daughter. Then I felt the baby move. . . .each other. This socializing made the days go by fasterand provided comparisons for personal experiences.Getting the NewsAs 1 woman stated, ‘‘I’ve realized that I’m not as badoff as I thought and I’m not the only one in thisFor the 6 women who did not experience any bleeding,position.’’the diagnosis resulted from a routine ultrasound scan

in the second trimester. They described feeling wellLeaving the Familyduring the pregnancy and expressed disbelief that

something could be wrong:Hospitalization meant separation from family and

I was feeling good. (When they told me) I was really sur- friends, and this was particularly hard for women withprised and I thought I would go home and get some things.

young children at home. Some had to scramble for. . . But they said) you’re not doing that, you could runlong-term childcare, relying on parents to fill the gapinto problems on the highway. I couldn’t believe there was

a problem because I feel so good. until a more permanent solution could be found. Know-ing that their families were surviving without them

Another woman described waiting for the results of was bittersweet for some women, ‘‘They’re doing goodthe ultrasound and her feelings when she realized that without me . . . I don’t know if I like that very much.’’she had to remain in hospital for the duration of her Others worried continuously about their husbands whopregnancy: were having to take care of the house, the children,

the pets, and themselves:We thought we could go home that night . . . and we got

‘‘My husband is at home and he has to run fromthe results and they said that it (the cervical os) was totallywork and pick up the kids and do this and do thatcovered and I had to stay for at least four to six weeks and

after that everything kind of went downhill for a couple of . . .buy groceries and he just seems so worn out. Anddays. he still comes here every night.’’ Eventually all the

women found some level of comfort despite the hard-The process of diagnosing the condition was frustrating ship of being away from home. Daily life in hospitalfor these women, who realized that something was was stressful, however, as described in the next theme.wrong from the reactions of the person doing the ultra-sound. They then had to wait for some time so that Enduringthe radiologist could confirm the diagnosis:

The major challenge for most of the women on admis-He said, ‘‘Well, you see here on the ultrasound, you havesome strong vascular activity which seems to be over the sion was getting used to a bed rest regimen and the

189BIRTH 28:3 September 2001

and the sound carries. I get up and shut the door and someonesubsequent restriction on freedom of movement. Al-else will come in and they leave it open again.though in time all the women were allowed to move

about the floor freely, the initial restriction seemedStaff talking in the hallway was also a source of un-daunting:wanted noise, and the women described the feeling of

It was a bit stressful that first week. . . . I was thinking being constantly on display as people walking downthat the only space I could move in was the bed, the wash- the hall would glance into the rooms.room and two doors down to the shower. I was thinking that Most of these women were in hospital for betweenis the only space I could move in for the rest of the time

3 and 8 weeks, and their unhappiness with the daily. . . what am I going to do?routine was evident. The admission was time limited,however, and at 36 weeks’ gestation, most women hadOne woman feared for her physical conditioningamniocentesis and were scheduled for delivery.after weeks of inactivity and recognized that she might

experience problems after the baby was born:Having the Baby

I’m also quite nervous about losing muscle tone and beingcompletely weak when this is over because when everything After weeks of being in hospital, the final few daysis said and done, you go home and you have a child to look seemed extremely long to many women. One womanafter.

described how part of her hoped that she would gointo labor spontaneously so that it would be over: ‘‘I

The daily activities of the hospital were a source feel bad for thinking I wish it would just be over andof frustration for most of the women. In this particular I know that he (the baby) should stay in me longerhospital, shared accommodations are the rule and hav- but. . . .’’ Most women were scheduled for amnio-ing a series of roommates was an ongoing source of centesis at 36 weeks’ gestation, and this was a sourcestress for these women. The most common problem of anxiety for many. One woman thought that theassociated with sharing a room was disturbed sleep; procedure was ‘‘too risky,’’ either because the needleroommates were frequently admitted in the middle of could hit the baby or start labor. The women werethe night and were visited by medical and nursing staff eager to talk to other patients who had undergone thefrequently in the first few hours of their admission. procedure to hear about their experience, and theySome roommates were seen as not respectful and used would then use the information to prepare themselves.the telephone in the middle of the night or left the Despite information from medical and nursing staff,bedside light on, which was disruptive. On occasion, it appeared that first-hand experience of the procedurehowever, having a roommate provided support and from another woman was needed.companionship: ‘‘We’re two women with the same Nine of the women spent an uncomplicated timecondition and going through the same thing and having in the hospital and delivered their babies by plannedthe same feelings.’’ cesarean section at 36 or 37 weeks’ gestation. Eight

The monotony of the meal schedule was cited as a babies did well after delivery, but 2 were admitted tomajor frustration for women who remained in hospital the neonatal intensive care unit for treatment. Thisfor more than 4 weeks. Meals were seen as a way to posed a dilemma for a mother who was ready forbreak the boredom of the day; however, the quality discharge within a few days but would have to leaveand quantity of the food was a source of annoyance the hospital without her baby. Her words poignantlyto many. One woman described her feelings: describe her feelings:

Some of the portions you get are not very big and whileI don’t want to go home . . . that’s all I could think about

some of it tasted good, if I would have served it to mywhen I was pregnant, just getting home, but then once I had

cockatoo, the bird would starve. I can’t even choke thehim and he had to be in the nursery . . . going home is the

potatoes down.furthest thing from my mind now.

The noise of the hospital was also a source of many Eventually the long and frustrating wait was over, andcomplaints. Although some women managed to nego- these women could go home with their babies and puttiate with staff to leave them sleeping until at least the experience behind them.breakfast time, many were awoken each morning bystaff replenishing water bottles and cleaning the wash- Discussion and Conclusionsroom at an early hour. One woman expressed her frus-tration as follows: This study confirmed the results of previous nursing

studies of patients undergoing bed rest with respect toAt six or six thirty there’s medication for my roommate andthen they leave the door open and things start moving outside feelings of boredom and imprisonment, anxiety about

190 BIRTH 28:3 September 2001

family, and worries about physical changes. As in other women when possible. Women should also be toldabout organizations that provide telephone and web-studies, participants reported issues with control and

the need to adapt to hospital routine. Whereas some based support such as Sidelines (Tel 714-487-2265) orthe Pregnancy Bed Rest Web site (www.son.wisc.edu/women, particularly those who had not experienced

any bleeding, felt uncertain about the need to be in ~son/bedrest/index.html).Opportunities for distraction should be included inhospital, most expressed the belief that if something

were to happen, being in the hospital was the safest the care plan, and may include watching educationaland recreational movies and doing arts and crafts,place for both themselves and their baby. This, too,

corroborated other findings. which women in this study found to be an enjoyableway to pass the time. Reading also may be a source ofPlacenta previa is unusual among the complications

of pregnancy in that it is a condition often with no distraction, and some hospitals have a patient lendinglibrary with a mobile book cart that is brought to thesymptoms. Most women have no knowledge of the

condition and are surprised by the urgency with which units on a weekly basis. Some women may be able tocontinue working while in hospital by using laptopthey are admitted to hospital and placed on a bed rest

regimen. They are often frightened by the warnings computers and modems to connect them to their work-place. Unless specifically contraindicated for medicalthat staff give them, and at the same time, are frustrated

by the need to remain on bed rest when they feel well. reasons, this opportunity may alleviate the financialburden of early maternity leave and lessen boredomConcerns about family and home appeared to be

exacerbated by the long period of inactivity and a lack for the woman while in hospital.Attention should be paid to the coping mechanismsof privacy coupled with the demands of time on the part

of spouses, leaving these women feeling disconnected of these women in the immediate postpartum periodas well as after discharge. The inactivity during thefrom loved ones. In this study the women did not dwell

on the health of the fetus to any degree; they seemed weeks of hospitalization coupled with the sequelae ofcesarean section place these women at significant riskconfident that the outcome would be satisfactory and

seemed more concerned with their own feelings. of exhaustion and postpartum depression.

Implications for EducationImplications for Practice

These women seemed to have little information aboutOne of the major concerns for these women was adapt-ing to the hospital routine and the difficulties they the condition of placenta previa and associated proce-

dures such as amniocentesis. Some women were frus-experienced in sharing a room with a succession ofother women. If at all possible, these women should trated about the long-term plan for care, as articulated

by their primary care physicians. Information wasbe assigned to a private room; otherwise roommatesshould be placed in the same room only as a last resort. sought from various members of the care team and

was not always consistent, causing confusion at times.Encouraging these women to decorate the room withpersonal possessions may help them to feel more com- Hospital staff may assist these women by providing

information related to the condition and making surefortable and may facilitate a sense of ease with thesurroundings. that what is passed on is congruent with information

from the primary care provider and other medical andEvery effort should be made to accommodate per-sonal preferences related to daily routine. Women nursing staff. Regular team meetings are important to

ensure consistency in the information given to theseshould be allowed to sleep as late as possible, andarrangements should be made to have breakfast deliv- women.

It is important to educate medical, nursing, andered at a time that fits in with their morning schedule.Having access to a refrigerator and microwave will midwifery students about the impact that hospitaliza-

tion has on women. Affected women experience signif-allow these women to eat their meals and snacks attimes that meet their needs rather than those of the icant life changes for the time they are in hospital, and

students should be alert to the potential complications,institution. Families should be encouraged to bring inmeals and to share them with the pregnant woman, both physical and emotional, that they may experience.preferably in a private lounge area dedicated for theuse of long-stay patients. Implications for Research

The women in this study found mutual support help-ful for decreasing their loneliness and sharing informa- No research has been published that describes the expe-

riences of women with placenta previa and their fami-tion and experiences. This should be promoted bynursing staff and can be further encouraged by offering lies during and after the hospital stay. The effect of a

lengthy separation from spouses and children deservesprenatal classes for small groups of hospitalized

191BIRTH 28:3 September 2001

investigation. It would also be important to identify the special needs of these women for privacy and somecontrol in their daily lives while in the hospital.issues in the postpartum period for these women and

their families.ReferencesThe consequences of separation from family,

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