1. Hemorrhage in late
Maternal health nursing
• Antepartum Hemorrhage
• Causes of Antepartum
• Definition of Placenta
• Pathological anatomy
• Types of placenta Previa
• Clinical Features
• Conformation of
• Nursing Management
• Research Evidence
3. Antepartum hemorrhage
• It is defined as bleeding from or into the genital tract after
the 28th week /22nd week of pregnancy but before the
birth of baby.
• Placenta previa
• Abruptio placenta
• Rupture of uterus
4. Causes of Antepartum Hemorrhage
Presenting symptoms and
other symptoms and signs Symptoms and signs sometimes present
Bleeding after 22nd weeks
Intermittent or constant
Decreased/absent fetal movement
Fetal distress or absent fetal heart sounds
Bleeding (intra abdominal
Severe abdominal pain
Abdominal distention/free fluid
Abnormal uterine contour
Easily palpable fetal parts
Absent fetal movements and fetal heart
Rapid maternal pulse
5. Causes of antepartum hemorrhage cont…
symptoms Symptoms and signs sometimes present Probable
and other symptoms and
signs typically present
Bleeding after 22 weeks
Bleeding may be precipitated by
Fetal presentation not in pelvis/lower
Uterine pole feels empty
Normal fetal condition
6. Causes of antepartum hemorrhage
Placenta previa (35%)
Extra placental causes (5%)
Local cervico-vaginal lesions:
7. Placenta previa
• When placenta is implanted partially or completely over
the lower uterine segment it is called placenta previa.
8. Incidence of Placenta Previa
• 0.3-0.5% of all pregnancies.
• Risks increase 1.5- to 5-fold with a history of cesarean delivery.
• Meta analysis: Rate of placenta previa increases with a rate of
1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries,
and as high as 3.7% after 5 cesarean deliveries.
• Of all placenta previas, the frequency of complete placenta
previa ranges from 20-45%, partial placenta previa accounts
for approximately 30%, and marginal placenta previa accounts
for the remaining 25-50%.
• Dropping down theory
• Persistence of chorionic activity in the decidua
capsularis and its subsequent development into
• Defective decidua
• Big surface area of the placenta
10. Predisposing factors
• Increased maternal age (> 35 years)
• History of previous caesarean section or any other scar in
the uterus (myomectomy or hysterotomy)
• Placental size and abnormality
• Smoking-causes placental hypertrophy or compensate
carbonmonoxide induced hypoxemia
11. Pathological anatomy
• Placenta may be large and thin.
• Tongue shaped extension from the main placental
• Extensive areas of degeneration with infarction and
calcification may be evident.
• Morbidly adherent placenta due to poor decidua
formation in the lower segment.
12. Pathological anatomy cont…
• Cord may be attached to the margin or onto the
• Insertion of cord may be close to the internal os or the
fetal vessels may run across the internal os in
velamentous insertion giving rise to vasa previa
Lower uterine segment:
• Lower uterine segment and the cervix becomes soft
and more friable.
13. Types/degree of placenta previa
• Low-lying placenta (Type I)
• Marginal placenta previa (Type II)
• Partial or incomplete placenta previa (Type III )
• Total or central placenta previa (Type IV)
• Vasa previa
16. Cause of bleeding
• As the placental growth slows down in later months and the
lower segment progressively dilates, inelastic placenta is
sheared off the wall of lower segment.
• This leads to opening up of utero-placental vessels and
leads to an episode of bleeding.
• As it is a physiological phenomena which leads to the
separation of placenta, the bleeding is said to be inevitable.
• The separation of the placenta may be provoked by trauma
including vaginal examination, coital act, external version or
during high rupture of membranes.
17. Clinical features
• Painless, apparently
• Hemorrhage from the implantation site in the lower
uterine segment may continue after placental delivery.
• General condition and anemia are proportionate to
the visible blood loss.
18. Clinical features cont…
– Size of uterus is proportionate to POG.
– Uterus feels relaxed, soft and elastic.
– Persistence of malpresentation like breech or transverse or
unstable lie is more frequent. There is also frequency of
– Head is free floating in contrast to POG.
– FHS is usually present, unless there is major separation of
the placenta with the patient in exsanguinated condition.
19. Clinical features cont…
• Only inspection has to be done to note the amount,
character of blood.
• Blood is bright red in colour.
• Must not be done outside the operation theater in the
20. Confirmation of diagnosis
Localization of placenta
• Sonography: Transabdominal ultrasound (TAS)
• Transvaginal ultrasound (TVS)
• Transperineal ultrasound
• Colour Doppler flow study
• By internal examination (Double setup examination)
• Direct visualization during caesarean section
• Examination of the placenta following vaginal delivery
degrees of shock
• Premature labour
Early rupture of membrane
Slow dilatation of cervix
Increased incidence of
• Retained placenta
22. Complications cont…
• Sepsis is increased due to
– Placental site near to
vagina and anemia
• Low birth weight
• Intrauterine death
• Birth injuries
• Substantial reduction of maternal deaths in placenta
previa throughout globe.
• Ultimate cause of death are hemorrhage and shock.
• Morbidity is raised due to hemorrhage and operative
• Perinatal mortality ranges from 10-25%.
• The causes of death are prematurity, asphyxia and
24. Prognosis cont…
• Maternal mortality rate ranges from 2-3%.
• Maternal mortality is 0.03% in the United States.
• Neonatal mortality associated with placenta previa is as
high as 1.2%
• Adequate antenatal care to improve the health status of
women and correction of anemia
• Antenatal diagnosis of low lying placenta at 20 weeks with
routine ultrasound needs repeat ultrasound examination
at 34 weeks to confirm diagnosis.
• Significance of warning hemorrhage should not be
• Family planning and limitation of births reduce the
• The patient is immediately put in bed.
• To assess the blood loss
• Inspection of clothing soaked with blood
• To note the pulse, blood pressure and degree of anemia
• Quick but gentle abdominal examination to mark height of
uterus, to auscultate the FHS and to note any tenderness on
• Vaginal examination must not be done.
1. Immediate attention: Quickly assess
• Amount of blood loss: General condition, pallor, pulse rate and
• Blood samples: Cross matching, group and hemoglobin.
• An infusion of normal saline is started and blood transfusion
• Gentle abdominal palpation: Uterine tenderness and auscultation
to note the fetal heart rate.
• Inspection of vulva to note the presence of any active bleeding.
Confirmation of diagnosis: History, physical examination and
28. Treatment cont…
2. Formulation of line of treatment
• Depends upon the duration of pregnancy, fetal and maternal status
and extent of the hemorrhage.
a. Expectant treatment
• Vital prerequisites: Availability of blood for transfusion, facilities for
• Selection of cases:
– Mother is in good health status (Hemoglobin ≥ 10 gm%,
hematocrit > 30%),
– Duration of pregnancy is <37 weeks,
– Active vaginal bleeding is absent,
– Fetal well being is assured.
29. Treatment cont…
Conduct of expectant treatment:
• Bed rest with bathroom facilities
• Investigations: Hemoglobin estimation, blood grouping and urine
• Periodic inspection of the vulval pads and fetal surveillance with
USG at interval of 2-3 weeks
• Supplementary hematinics if the patient is anemic.
• When patient is allowed out of bed a gentle speculum examination
is made to exclude local cervical and vaginal lesions for bleeding.
30. Treatment cont…
Termination of the expectant treatment: Expectant treatment is
carried upto 37 weeks of pregnancy.
• Premature termination may have to be done in conditions, such as
– Recurrence of brisk hemorrhage and which is continuing
– The fetus is dead
– The fetus is found congenitally malformed on investigation
• Steriod therapy: If the duration of pregnancy is less than 34 weeks.
31. Treatment cont…
• Bleeding occurs at or after 37 weeks of pregnancy.
• Patient is in labour
• Patient is in exsanguinated state on admission
• Bleeding is continuing and of moderate degree
• Baby is dead of known to be congenitally deformed.
32. Definitive treatment
1. Vaginal examination in operation theatre followed by low rupture
of membranes or Caesarean section.
2. Caesarean section without internal examination
1. Vaginal examination: Double setup examination should be done in
operation theatre keeping everything ready for caesarean section.
• Contraindications of vaginal examination are:
– Patient is in exsanguinated state
– Major degree of placenta previa
– Associated complicating factors: Malpresentation, elderly
primigravida, history of previous caesarean section, contracted
33. Definitive treatment cont…
a. Low rupture of membrane: Done in lesser degree of placenta
previa (Type I and Type II anterior).
b. Caesarean section: The indication are:
– Severe degree of placenta
– Lesser degree of placenta previa where amniotomy fails to stop
bleeding or fetal distress appears.
– Complicating factors associated with lesser degrees of placenta
previa where vaginal delivery is unsafe.
– Caesarean section without internal examination
34. Nursing Assessment
• Determine the amount and type of bleeding; also, review any
history of bleeding throughout this pregnancy.
• Inquire as to the presence or absence of pain in association
with the bleeding.
• Record maternal and fetal vital signs.
• Palpate for the presence of uterine contractions.
• Evaluate laboratory data on hemoglobin and hematocrit
• Assess fetal status with continuous fetal monitoring.
35. Nursing Diagnoses
• Ineffective Tissue Perfusion, Placental, related
excessive bleeding causing fetal compromise
• Deficient Fluid Volume related to excessive bleeding
• Risk for Infection related to excessive blood loss and open
vessels near cervix
• Anxiety related to excessive bleeding, procedures, and
possible maternal-fetal complications
• It is one form of antepartum hemorrhage where bleeding
occurs due to premature separation of normally situated
• Initiated by hemorrhage into the decidua basalis.
• The decidua then splits, leaving a thin layer adhered to the
• Consequently, the process in its earliest stages consists of the
development of a decidual hematoma that leads to
separation, compression, and ultimate destruction of the
placenta adjacent to it.
• Inflammation—infection—may be a contributor to causal
39. Pathology cont…
• Early stage: May be no clinical symptoms, and separation
is discovered upon examination of the freshly delivered
– There is a circumscribed depression on the placenta's maternal
– Usually measures a few centimeters in diameter and is covered
by dark, clotted blood.
• In some instances, a decidual spiral artery ruptures to
cause a retroplacental hematoma, which as it expands,
disrupts more vessels to separate more placenta.
40. Pathology cont…
• The area of separation rapidly becomes more extensive
and reaches the margin of the placenta.
• Because the uterus is still distended by the products of
conception, it is unable to contract sufficiently to
compress the torn vessels that supply the placental site.
• The escaping blood may dissect the membranes from the
uterine wall and eventually appear externally or may be
completely retained within the uterus.
45. Abruptio placenta cont…
• Widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa.
• Such effusions of blood are also occasionally seen
beneath the tubal serosa, between the leaves of the
broad ligaments, in the substance of the ovaries, and free
in the peritoneal cavity.
• Incidence is unknown, can be demonstrated only at
46. Abruptio placenta cont…
• These myometrial hemorrhages seldom interfere with
myometrial contraction to cause atony, and they are not
an indication for hysterectomy.
47. Abruptio placenta cont…
Changes in other organs
• Liver: fibrin knots in the hepatic sinusoids
• Kidney: Acute cortical necrosis or acute tubular necrosis
• Shock proteinuria: is due to renal anoxia which usually
disappears two days after delivery.
48. Abruptio placenta cont…
• It is due to excess consumption of plasma fibrinogen due
to DIC and retroplacental bleeding.
• There is overt hypofibrinogenemia (<150mg/dl) and
elevated levels of fibrin degradation products and D
49. Clinical classification
Depending upon the degree of placental abruption and its
clinical effects, the cases are graded as follows:
• Grade 0: Clinical feature may be absent.
• Grade 1: External bleeding is slight. Uterus is irritable;
tenderness may or may not be present. Shock is absent.
FHS is good.
50. Clinical classification cont…
• Grade 2: External bleeding is mild to moderate. Uterine
tenderness is always present. Shock is absent. Fetal
distress or even fetal death occurs.
• Grade 3: Bleeding is moderate to severe or may be
concealed. Uterine tenderness is marked. Shock is
pronounced. Fetal death is the rule. Associated
coagulation defect or anuria is present.
51. Clinical features
• Degree of separation of placenta
• Speed at which separation occurs and
• Amount of blood concealed inside the uterine cavity.
52. The clinical features of the revealed and mixed variety are given below:
Abdominal discomfort or pain Active intense pain abdomen
followed by vaginal bleeding
followed by slight vaginal bleeding.
The pain becomes continuous.
Character of Continuous dark colour (slight to Continuous dark colour (usually
slight) or blood stained serous
Proportionate to visible blood Shock is pronounced which is out
loss, shock is usually absent
of proportion with the visible
Related with visible blood loss
Pallor is usually severe and out of
proportion to visible blood loss.
53. The clinical features of the revealed and mixed variety are given below:
of May be absent
preexisting or appear.
Uterine height Proportionate to POG
Disproportionately enlarged and
localized Uterus is tense, tender and rigid
tenderness, contractions frequent
and local amplitude
Can be identified easily
Difficult to make out
54. The clinical features of the revealed and mixed variety are given below:
Low value proportionate Markedly lower, out of proportion to
to blood loss
Variable changes :
Clotting time increased (>6 min)
Fibrinogen level low (<150mg/dl)
Platelet count low
Increased FDP and D dimer
Urine for protein May be absent
With acute obstetrical gynecological
in With placenta previa.
55. Abruptio placenta cont…
• Severe intrapartum or early postpartum hemorrhage rarely is
followed by pituitary failure.
• Characterized by failure of lactation, amenorrhea, breast atrophy,
loss of pubic and axillary hair, hypothyroidism, and adrenal cortical
• Exact pathogenesis is not well understood but such endocrine
abnormalities develop infrequently in women who hemorrhage
• Varying degrees of anterior pituitary necrosis and impaired
secretion of one or more trophic hormones (in some cases)
• Diagnosis: MRI
56. Distinguishing features of placenta previa and abruptio placenta
Nature of bleeding
causeless and recurrent
Bleeding is always revealed
Painful, often attributed to
preeclampsia or trauma
Revealed, concealed or
Proportionate to visible blood
General condition loss
Out of proportion to the
visible blood loss in concealed
or mixed variety
Features of pre- Not relevant
Present in one-third cases
57. Distinguishing features contd…
Height of uterus
Feel of uterus
May be disproportionately
enlarged in concealed type
Soft and relaxed
May be tense, tender and rigid
Malpresentation is common. Head may be engaged
The head is high floating
Usually absent specially in
Placenta in lower segment
Placenta in upper segment
Vaginal examination Placenta is felt on lower Placenta is not felt on lower
segment. Blood clots should not
be confused with placenta.
• Depending on gestational age and status of mother and fetus.
• With a fetus of viable age, and if vaginal delivery is not
imminent, then emergency cesarean delivery is chosen.
• Resuscitation and acute management, with massive external
bleeding, intensive resuscitation with blood plus crystalloid
and prompt delivery to control hemorrhage are lifesaving for
the mother and hopefully, for the fetus.
• If the diagnosis is uncertain and the fetus is alive but without
evidence of compromise, then close observation can be
practiced in facilities capable of immediate intervention.
• Prevention, early diagnosis and effective therapy of
preeclampsia and other hypertensive disorders of pregnancy.
• Needle puncture during amniocentesis should be under
• Avoidance of trauma specially forceful external cephalic
version under anesthesia
• To avoid sudden decompression of the uterus
• To avoid supine hypotension
• Routine administration of folic acid from early pregnancy.
60. In the hospital
1. Revealed type: assessment is to be done as regards:
– Amount of blood loss
– Maturity of fetus
– Whether the patient is in labour or not
• Blood for Hemoglobin and hematocrit estimation, coagulation
profile, ABO and Rh grouping and urine for detection of
• RL solution drip started with wide bore cannula and
arrangement for blood transfusion.
• Close monitoring of maternal and fetal condition.
61. Management cont…
Patient is in labour
• Labour is accelerated by low rupture of membranes.
• Oxytocin drip is started to accelerate labour.
The patient is not in labour:
• Pregnancy 37 weeks or more: induction of labour is to be
done by low rupture of membrane with or without
62. Management cont…
• Pregnancy less than 37 weeks:
– Bleeding moderate to severe and continuing—low
rupture of membrane, administration of oxytocin drip
– Bleeding slight or has stopped—the patient is put on
conservative management, close observation of the
mother and careful monitoring is essential.
63. Management cont…
2. Mixed or concealed type
Principles of management of concealed type are:
• To correct hypovolemia and to restore blood loss. Normal
saline or hemaccel infusion is started
• To bring about effective uterine contraction and termination
of the abruption process.
• To observe blood coagulation profiles at two hourly interval.
• Close monitoring of maternal and fetal condition is
64. Management cont…
• Vaginal delivery
• Caesarean section:
– Early: Unfavourable cervix where speedy vaginal delivery is not
possible and there is good prospect of fetal survival.
– Late: If inspite of amniotomy and oxytocin, the progress of
labour is delayed (6-8 hours) and instead, the general condition
gradually deteriorates with appearance of complicating factors
like oliguria or falling fibrinogen level or there is evidence of
65. Nursing Diagnoses
• Ineffective Tissue Perfusion: Placental related to excessive
bleeding, hypotension, and decreased cardiac output,
causing fetal compromise
• Deficient Fluid Volume related to excessive bleeding
• Fear related to excessive bleeding, procedures, and
67. Rupture of uterus
• Dissolution in the continuity of uterine wall any time
beyond 28 weeks of pregnancy is called rupture of uterus.
• Injury to the wall of uterus in early months of pregnancy
is called perforation either instrumental or perforating
68. Classification of rupture uterus
Uterine rupture typically is classified as either:
70. Causes cont…
1. During pregnancy: previous dilatation and curettage operation or
MRP, grand multiparity, congenital malformation of the uterus of
bicornuate variety, in couvelaire uterus.
• Usually complete, involves the upper segment and usually occurs in
later months of pregnancy.
2. During labour:
• Obstructive rupture: involves lower segment and usually extends
through one lateral side of the uterus to the upper segment.
• Non-obstructive rupture: Grand multiparae , rupture usually occurs
in early labour, usually involves fundal area and is complete.
71. Causes cont…
• Incidence of lower uterine segment scar rupture is about 1-2%,
Classical: 5-10 times higher.
• During pregnancy: Classical or hysterotomy scar is likely to give way
during later months of pregnancy. Lower segment scar rarely
ruptures during pregnancy.
• During labour: The classical or hysterotomy scar is more vulnerable
to rupture during labour.
72. Causes cont…
Iatrogenic or traumatic:
Injudicious administration of oxytocin
Use of prostaglandins for induction of abortion or labour.
Forcible external version specially under general anesthesia
Fall or blow on the abdomen
– Internal podalic version, Destructive operation
– Manual removal of placenta
– Application of forceps or breech extraction through incompletely
– Injudicious administration of oxytocin for augmentation of labour.
73. Dehiscence and scar rupture
– Disruption of part of scar and not the entire length
– Fetal membranes remain intact and
– Bleeding is almost nil or minimal
– Disruption of the entire length of scar
– Rupture of membranes with varying amount of bleeding from
the margins or from its extension.
1. Scar rupture
Classical or hysterotomy
• Dull abdominal pain all over the area with slight vaginal
• Tenderness on uterine palpation.
• FHS may be irregular or absent.
• Sooner or later the rupture becomes complete.
75. Diagnosis cont…
2. Spontaneous rupture in uninjured uterus:
• Confined to the high parous women.
• Acute onset but sometimes insidious.
• Acute type: Patient has acute pain abdomen with fainting
attacks and may collapse.
• Presence of features of shock, acute tenderness on
abdominal examination, palpation of superficial fetal
parts, if the rupture is complete and absence of FHS.
76. Diagnosis cont…
3. Rupture following fall, blow or external version or use of
• History of such accident followed by acute pain abdomen
and slight vaginal bleeding.
• Rapid pulse and tender uterus, confirmation is done by
77. Diagnosis cont…
1. Scar rupture:
• Classical or hysterotomy scar rupture: Features are same as
those occur during pregnancy. The onset is usually acute.
• Lower segment scar rupture (silent rupture): The onset is
insidious, no classical feature of lower segment scar rupture,
confirmation is by laparotomy.
2. Spontaneous or obstructive rupture: Has distinct premonitory
phase prior to rupture.
78. Diagnosis of spontaneous obstructive rupture cont…
• Multipara in labour with features of obstruction.
• Pain becomes severe in an attempt to overcome the
obstruction and come to quick intervals.
• Gradually the pains become continuous and mainly
confined to the suprapubic region.
• Patient is exhausted and dehydrated.
79. Diagnosis of spontaneous obstructive rupture cont…
• Pulse rate and temperature rise.
• Distended tender lower segment.
• Bandl’s ring may be visible
• Fetal distress or FHS absent.
• Presenting part is found jammed in the pelvis and the
vagina becomes dry and oedematous.
80. Phase of rupture in spontaneous obstructive rupture
• Sense of something giving way at height of uterine
• Constant pain is changed to dull aching pain with cessation of
• Features of exhaustion and shock.
• Abdominal examination: Superficial fetal parts, absence of
FHS, absence of uterine contour and two separate swellings,
one contracted uterus and the other fetal ovoid.
• Vaginal examination: Recession of presenting part and varying
degrees of bleeding.
81. Diagnosis cont…
3. Spontaneous non-obstructive rupture:
• Rare and confined to high parous women.
• Height of uterine contraction is suddenly seized with an
agonizing bursting pain followed by a relief with cessation
• Presence of shock, evidences of internal hemorrhage,
tenderness over the uterus and varying amount of vaginal
82. Diagnosis cont…
4. Rupture following manipulative or instrumental delivery
• Sudden deterioration of general condition of patient with
varying amount of vaginal bleeding following manipulative
• Exploration of uterus to feel the rent confirms the diagnosis.
• Shortening of cord immediately following a difficult vaginal
• Placenta being extruded out into abdominal cavity, through
the rent in the uterus.
• At risk mothers likely to rupture should have mandatory
hospital delivery. There are
– Contracted pelvis
– Previous history of caesarean section, hysterotomy or
– Uncorrected transverse lie
– Multiparity with pendulous abdomen
– Grand multiparity
– Known case of hydrocephalous
• General anesthesia should not be used to give undue force in
84. Prevention cont…
• Undue delay in the progress of labour in a multipara with
previous uneventful delivery should be viewed with concern
and cause should be sought for.
• Judicious selection of cases with previous history of caesarean
section for vaginal delivery.
• Judicious selection of cases and careful watch are mandatory
during oxytocin infusion either for induction or acceleration of
85. Prevention cont…
• Internal podalic version in singleton fetus should never be
done in obstructed labour.
• Attempted forceps delivery or breech extraction through
incompletely dilated cervix should be avoided.
• Destructive vaginal operations should be performed by skilled
• Manual removal in morbid adherent placenta should be done
by senior person.
Resuscitation and laparotomy
• Depending upon the state of clinical condition, either
resuscitation is to be done followed by laparotomy or in acute
conditions, resuscitation and laparotomy are to be done
• Any of the following procedures may be adopted following
– Repair and sterilization
87. Nursing Assessment
• Continuously evaluate maternal vital signs; especially note an
increase in the rate and depth of respirations, an increase in
pulse, or a drop in BP indicating status change.
• Observe for signs and symptoms of impending rupture (ie, lack
of cervical dilatation, tetanic uterine contractions,
restlessness, anxiety, severe abdominal pain, fetal bradycardia,
or late or variable decelerations of the FHR).
• Assess fetal status by continuous monitoring.
• Speak with family, and evaluate their understanding of the
88. Nursing Diagnoses
• Deficient Fluid Volume related to active fluid loss from
• Ineffective Tissue Perfusion, Maternal Vital Organ and
Fetal, related to hypovolemia
• Fear related to surgical outcome for fetus and mother
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