Video lectures on YouTube Channel name Lecture by Abhilasha verma

1. ANTE PARTUM HAEMORRHAGE
(APH)
PRESENTED BY
MRS. ABHILASHA VERMA

2. DEFINITION
“ It is defined as bleeding from or into genital tract after stage of
viability but before birth of baby”
 According to WHO viability = 20 weeks, 500 gm weight, body
length 25 cm.
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3. CAUSES AND TYPES OF APH
APH
Placental
Bleeding(70%
)
Placenta
Previa
(35%)
Placenta Abruptia
(35%)
Unexplaine
d
(25%)
Extra
Placental
Bleeding
5%
Local cervico-
vaginal Lesion
Cervix Polyp
Carcinoma
cervix
Varicose Vein Local trauma
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4. PLACENTA PREVIA
DEFINITION
“Placenta is implanted partially and completely over lower uterine
segment over and adjacent to internal os is called placenta
previa”
or
“Bleeding occur because changes which normally takes place in
the lower segment before and during labour cause placental
separation from it before delivery, is known as placenta previa.”
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5. INCIDENCE
• 1
3rd cases of APH are due to placenta previa.
• 1 in 200 pregnancies
• 80% ( Multiparous woman)
• Age > 35 years
• Multiple pregnancy
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6. ETIOLOGY
• Exact cause unknown
• Poor decidual reaction of upper segment, fertilized egg
Lower segment
• Big surface area of placenta
• Defective decidua
• Others – Multi parity, previous CS, Uterus scar, smoking during
pregnancy.
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7. CAUSE OF BLEEDING
• As placental growth slow down in later months, lower segment
progressively dilate, in elastic placenta shed off leads to
opening up of utero-placental vessels and leads to bleeding.
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8. TYPES OF PLACENTA PREVIA
Based on degree of placenta extension to lower segment.
Type I
Lateral /
Low lying
Type II
Marginal
Type III
Incomplete
or Partial
Type IV
Central
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9. TYPES OF PLACENTA PREVIA
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10. TYPE- I “LATERAL OR LOW LYING PLACENTA
PREVIA”
• Major part of placenta attached to the upper segment and only
lower margin reaches on to lower segment but not up to OS.
• Low risk of ante partum haemorrhage.
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11. TYPE II “ MARGINAL PLACENTA PREVIA”
• Placental edges reaches to the margins of internal Os but
doesn’t cover it.
• Depending upon position it is of two types Type II
Anterior
Type II Posterior
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12. TYPE III “INCOMPLETE OR PARTIAL PLACENTA
PREVIA”
• Placenta covers internal Os when internal Os is closed but only
partially covers it when it is fully dilated.
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13. TYPE IV “ COMPLETE OR CENTRAL PLACENTA
PREVIA”
• Placenta completely covers internal Os all time even after it is
fully dilated.
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14. CLINICAL MENIFESTATIONS OR SIGN /
SYMPTOMS
• Anaemia and visible blood loss.
• Abdominal Examination-
Soft , relaxed uterus, no tenderness.
Floating head
Stallworthy sign ( Posterior placenta) Slow FHR on pressing head down
into pelvis soon after recover promptly when pressure released.
Vaginal bleeding ( Classical sign) painless, causeless, sudden onset (
usually during end of 1st trimester or during second trimester)
FHR easily heared , fetal parts easily palpated.
Mal-presentations are common ( Transverse/ Breech)
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15. DIAGNOSIS- USG confirm placental location
COMPLICATION “ MATERNAL”
During pregnancy During labour During puerparium
APH with shock Early ROM Sepsis
Malpresentation Cord prolapse Subinvolution
Premature labor Slow dilation of cervix Embolism
Death due to
haemorrhage
Intra Partum
haemorrhege
PPH
Retained Products
Trauma to cervix and
lower segment
FETAL COMPLICATION
Low Birth weight
Asphyxia
IUFD
Birth Injury
Maternal and fetal morbidity and
mortality
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16. MANAGEMENT OF PLACENTA PREVIA
GENERAL MEASURES
Prevention measures-
• Adequate antenatal care to improve
health and anaemia correction.
• Antenatal diagnosis of low lying
placenta at 20 week USG.
• Warning haemorrhage should not be
ignored.
At Home-
• Immediately put to bed.
• Inspection of clothing soaked in
blood.
• Quick and gentle examination.
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 HOSPITAL TRANSFER
• Arrangement made to shift
patient to equipped hospital
having facilities of blood
transfusion, emergency CS,
NICU, etc.
• Start IV RL< continue during
transport.
• Arrange blood donors.
Admission To Hospital-
Specific management
done.
Management depends
upon-
Amount of bleeding.
Condition of mother
and fetus.
Placenta location.

17. Management Of Placenta Previa
IMMEDIATE ATTENTION
Assessment of case:
Amount of blood loss.
FHR auscultation.
Abdominal examination to
note tenderness.
Inspection of vulva for active
bleeding.
Blood sample taken- Hb,
grouping and cross
matching
FORMULATION OF LINE
OF TREATMENT
Expectant Management
Definitive management
Scheme of management
of Placenta previa
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18. EXPECTANT MANAGEMENT
• Johnson and Macafee protocol 1945
Indication-
• GA> 37 week
• Bleeding <500 ml
• Patient not in labor
• Mother and fetus aren’t in emergency.
Measures-
 Complete bed rest with bathroom and toilet facilities.
 Inspection of vulvar pads
 Investigations
 Fetal surveillance USG every 2-3 weeks
 Supplementary hematinics
 Avoid straining at stool ( Mild laxatives)
 Minimal ambulation when bleeding stops.
 Correction of maternal blood loss.
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DEFINITIVE
MANAGEMENT
Indication-
Bleeding at 37 weeks or
more
Patient in labor.
Continue active bleeding(
Moderate)
Measures-
C S delivery = Placenta
edges 2 cm from internal
os
NVD = Placenta edges 3 cm

19. SCHEME OF MANAGEMENT
OF PLACENTA PREVIA
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20. DOUBLE SET UP EXAMINATION PLACENTA PREVIA
Two team approaches are used in double set up .. That is one
team is ready for NVD and 2nd team ready to perform CS if
necessary.
Rarely performed in operating room
Palpation of placental edges and fetal head with set up of
immediate CS.
High risk of intra operative blood loss because obstetrician
may cut into placenta during uterine incision.
Increased risk of placenta accreta
CS delivery under regional anaesthesia if-
Complete PP
Fetal head not engage
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21. ABHILASHA VERMA 21

22. ABRUPTIO PLACENTAE
DEFINITION
“It is the form of ante partum hemorrhage (APH) where bleeding occurs
due to premature separation of normally situated placenta.”
Bleeding is almost always maternal but placenta tear may cause fetal
bleeding.
INCIDENCE
1 : 200 Pregnancies
15-20% perinatal mortality
2-5 % maternal mortality
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23. ETIOLOGY
Exact cause is unknown in most cases.
High birth order pregnancies.
Advancing maternal age.
Poor socio-economic condition.
Malnutrition and cigarette smoking ( Vaso spasm)
Short cord (Mechanical Pulling)
Trauma:
Needle injury
Accident
Ex. Cephalic version. Continue……………….
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24. Sudden uterine compression
 PROM and delivery of 1st twin baby.
Supine hypotension syndrome –
 Passive engorgement of uterine and placental blood vessels result in
rupture and extravasation of blood.
Poor placentation.
Folic acid deficiency.
Abnormal implantation and septum
Torsion of uterus.
Placental anomalies. ( Circumvallate placenta)
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25. ABHILASHA VERMA 25
Types
of
Abrupti
o
placent
a
Conceale
d
Revealed
Mixed

26. REVEALED ABRUPTIO
PLACENTA
• Most common type.
• Following placental
separation blood released
and effused sooner or later
escapes under placental
margins and make its own
way between membrane and
uterine wall down to internal
os of cervix, where pass
through vagina.
CONCEALED ABRUPTION
PLACENTA
• Blood collects behind
separated placenta and/or
collects in between membrane
and decidua.
• Collected blood is prevented
from coming out of cervix by
presenting part.
• Blood isn’t visible outside (
Rare case)
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MIXED ABRUPTIO PLACENTA
It is quite uncommon, some part of blood collected inside ( Concealed)
and some part of blood is expelled out ( Revealed). There may be one
variety dominate over another.

27. ABRUPTIO PLACENTA
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28. CONCEALED & REVEALED ABRUPTIO
PLACENTA
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29. CLINICAL FEATURES OF AP
Parameters Revealed Concealed ( mixed)
Symptoms Abdominal discomfort,
pain followed by slight
vaginal bleeding
Acute intense abdominal
pain followed by vaginal
bleeding, continue pain
Character of bleeding Dark color bleeding Dark color bleeding, blood
stained serous drainage
General condition Propionate to visible blood
loss, shock usually absent
Shock, out of
proportionate to visible
blood loss.
Pallor Related with visible blood
loss
Severe, out of
proportionate severe
pallor
Features of pre-eclampsia Absent Frequently present
Uterine height Acc. To GA Enlarged and more
globular then GA
Fetal parts Easily identified Difficult to find
FHS Usually present Usually absent
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30. INVESTIGATIONS
ABHILASHA VERMA
30
Parameters Revealed Concealed
Blood Hb% Low values
proportionate to
visible blood loss
Lower values out of
proportionate to
visible blood loss
Coagulation profile Usually unchanged Clotting time increase
Low platelet count
Low fibrinogen count
Urine protein Absent Present

31. DIFFERENTIAL DIAGNOSIS
Revealed type confused with placenta previa.
Concealed or mixed type confused with-
• Ruptured uterus
• Rectus sheath hematoma
• Intestinal or appendicular perforation
• Twisted ovarian tumor
• Volvulus
• Tonic uterine contraction
ABHILASHA VERMA 31

32. CLINICAL GRADING OR DEGREE OF ABRUPTIO PLACENTA
1) Grade – 0
• Absent c/m
• Diagnosis made after inspection of placenta following delivery.
2) Grade – 1 (40%)
• Slight vaginal bleeding
• Irritable, tender uterus may be minimum or absent
• FHS good
• Maternal BP and fibrinogen unaffected
3) Grade- 2 (45%)
• Mild to moderate vaginal bleeding
• Uterine tenderness always
• Increase maternal Bp and pulse
• Decrease fibrinogen level
• Absent shock
• Fetal distress and shock
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Grade –3 (15%)
Bleeding moderate to severe
Marked uterine tenderness
Shock present
Fetal death is rule
Coagulation defect
Anemia present

33. MANAGEMENT OF PLACENTA
ABRUPTION
USG guided
safe needle
puncture
aminocentes
is
Early
detection
Avoid
trauma
Folic acid
administration
Avoid
supine
hypotensio
n
syndrome
Avoid sudden
decompression
of uterus
ABHILASHA VERMA 33
PREVENTIVE
MEASURE

34. TREATMENT
ABHILASHA VERMA
34
Assessment of case -
• Amount of blood loss
• Maturity of fetus
• Type and degree of
separation.
• Labor status
Emergency measures –
• Blood sent for Hb,
hematocrit estimation,
coagulation profile, ABO ,
Rh, urine protein
estimation.
• Blood donors arrange.
Definitive treatment
(Immediate delivery)
 Patient in labor-
• Accelerate labor by low
rupture of membrane
• Oxytocin drip
• Vaginal delivery
 Patient not in labor-
• Induction of labor
• CS

35. SCHEME OF MANAGEMENT OF ABRUPTIO
PLACENTA
ABHILASHA VERMA 35

36. PREVIOUS YEARS QUESTIONS
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37. 1. Placenta previa and Abruptia are examples of:
a) APH RIMS & R SAIFAI UP 2013
b) PPH
c) Eclampsia
d) Vesicular mole
Answer (a)
2. A woman is 37 weeks pregnant and she is bleeding profusely with
no pain is suggestive of: Safdarjung Hos. Delhi
Nursing Officer 2018
a) Ante partum hemorrhage
b) Unavoidable hemorrhage
c) Accidental hemorrhage
d) Concealed hemorrhage
Answer (a)
ABHILASHA VERMA 37

38. 3. Ante partum hemorrhage (APH) is associated with all of the
following except:
a) Post partum hemorrhage (PGI Rohtak Staff Nurse 2017)
b) Anemia
c) Increased perinatal mortality
d) Post term pregnancy
Answer (d)
4. Vaginal bleeding after 28th weeks of pregnancy which is sudden
onset, painless, causeless and recurrent is known as:
a) Abortion (RUHS M.Sc. Nursing Entrance
2018)
b) Abruptio Placentae
c) Placenta previa
d) Vasa previa
Answer (c)
ABHILASHA VERMA 38

39. 5. What is the color of blood in placenta previa?
a) Bright red UPPSC, UP STAFF NURSE NURSE 2017
b) Brick red
c) Brown Red
d) None Of these
Answer (a)
6. A client arrives at the hospital at 38 weeks gestation with profuse
vaginal bleeding. She states that it occurred suddenly without any
contractions. Which condition may the client be experiencing that
require immediate notification of the health care provider?
a) Placenta previa BHU NURSING OFFICER SEP. 2019
b) Concealed abruption
c) Placenta accrete
d) Ruptured uterus
Answer (a)
ABHILASHA VERMA
39

40. 7. Sign and symptoms of the placenta previa include:
a) Sharpe abdominal pain RUHS M.Sc.Nursing entrance 2014
b) Early rupture of membrane Jhalawar Med. College Staff Nurse 2010
c) Increased low back pain
d) Painless vaginal bleeding
Answer (d)
8. Placenta Previa is characterized by all of following EXCEPT:
a) Painless bleeding RUHS M.Sc. Nursing Exam 2017
b) Present in 1st trimester
c) Causeless bleeding
d) Recurrent bleeding
Answer (b)
ABHILASHA VERMA 40

41. 9. Following risk is associated with placenta previa:
a) Disseminated Intra vascular coagulation ( DIC) IGNOU Post B.sc
Nursing 2012
b) Chronic hypertension RUHS Post B.Sc. Nursing Entrance
2017
c) APH
d) Infection
Answer (c)
10. Possibility of common complications after delivery into a
mother suffering with placenta previa:
a) Infertility ESIC Staff Nurse Bhiwari 2019
b) Uterine atonicity
c) Hemorrhage
d) Amenorrhoea
Answer (c)
ABHILASHA VERMA 41

42. 11. Maternal complication during labor labor in placenta previa:
a) Early ROM RAK M.Sc. Nursing Entrance 2014
b) Asphyxia
c) Low birth weight babies
d) Birth injuries
Answer (a)
12. An occurrence in which umbilical cord vessels pass through
placental membranes and lie across the cervical os is termed as:
a) Abruptio placenta AIIMS Raipur Staff Nurse Aug
2019
b) Placenta previa
c) Placenta accrete
d) Vasa previa
Answer (d)
ABHILASHA VERMA 42

43. 13. Management during minor placenta previa:
a) Blood transfusion AIIMS BHOPAL Nursing Officer
May 2018
b) Complete rest
c) Caesarean section
d) Drug therapy
Answer (b)
14. Mother is diagnosed with partial placenta previa. The nurse
tells the client that the usual treatment for partial placenta previa
is-
a) Bed rest BCCL Staff Nurse 2015
b) Administration of platelets
c) Immediate caesarean section
d) Induction of labor with oxytocin
Answer (a)
ABHILASHA VERMA 43

44. 15. Definitive treatment of placenta previa are:
a) Bed rest RAK M.Sc. Nursing entrance 2018
b) Supplementary hematinic
c) Use tocolytic
d) Caesarean section
Answer (d)
16.A multigravida 32 years old lady, admitted at 10 weeks with
bleeding per vagina, which of the action the nurse should first
to do first:
a) Perform a per vaginal examination ESIC Staff Nurse Delhi
2012
b) Provide perineal pads
c) Take consent for Caesarean section
d) Check FHR and BP
Answer (b)
ABHILASHA VERMA 44

45. 17. A client with painless vaginal bleeding has just been
diagnosed as having placenta previa. Which of following
procedure usually performed to diagnose placenta previa:
a) Aminocentesis ESIC Staff Nurse Kolkata & Banglore 2012
b) Digital or speculum examination
c) External fetal monitoring
d) Ultrasound
Answer (d)
18. In caring for a client diagnosed with placenta previa, the
nurse should avoid which of the following:
a) Inspecting the perineum BPS GOVT. MED. COLL. KHANPUR,
HARYANA
b) Performing ultrasound
c) Performing a pelvic examination
d) All of above
Answer (c)
ABHILASHA VERMA 45

46. 19. The nurse gently performs leopold’s maneuvers on a client
with a suspected placenta previa and expects to find the:
a) Fetal head firmly engaged RAK M.Sc Nursing Entrance
2009
b) Fetal presenting part high and floating
c) Fetal small parts difficult to palpate
d) Uterus hard and tetanically contracted
Answer (b)
20.If a vaginal examination is to be performed on a client with
possible placenta previa, the nurse must be prepared for
immediate:
a) Forceps delivery RAK M.Sc. Nursing entrance
2010
b) Induction of labor
c) Caesarean section
d) X ray examination
Answer (c)
ABHILASHA VERMA 46

47. 21. When the placenta covers the internal os partially when
closed but does not entirely do so when dilated ia known as:
a) Marginal placenta previa RAK M.Sc.Nursing entrance 2016
b) Low-lying placenta previa
c) Central placenta previa
d) Incomplete placenta previa
Answer (d)
22. Which of following considered as dangerous placenta previa-
a) Type I Posterior SSB DD & DNH Nursing officer Feb
2018
b) Type II Anterior RUHS M.Sc. Nursing Entrance
2018
c) Type II Posterior RAK M.Sc. Nursing Entrance 2014
d) Type I Anterior
Answer (c)
ABHILASHA VERMA 47

48. 23. Abruptio placenta means premature separation of-
a) Normally situated placenta NPCIL Staff Nurse June 2019
b) Abnormal placenta
c) Abnormally situated placenta
d) Fetal membrane
Answer (a)
24 Accidental hemorrhage is also known as:
a) Vasa previa NVS (Navodaya) Staff Nurse Sep. 2019
b) Placenta previa
c) Abruptio placentae
d) Circumvallete placenta
Answer (c)
ABHILASHA VERMA 48

49. 25. The condition “Abruptio placentae’ refers to-
a) Abortion NVS Staff Nurse Jan 2018
b) Ante partum hemorrhage
c) PPH
d) Low lying placenta
Answer (b)
26. Incidence of abruptio placentae occur in:
a) Third trimester GMCH Mewat Haryana 2014
b) Second trimester
c) First trimester
d) None of these
Answer (a)
ABHILASHA VERMA 49

50. 27. Premature separation of normally implanted placenta during
the second half of pregnancy, usually with severe hemorrhage is
known as:
a) Placenta previa DSSSB Staff Nurse 2013
b) Ectopic pregnancy BSF Staff Nurse 2014 SI
c) Incompetent cervix
d) Abruption placentae
Answer (d)
28. The most common pathological cause of late pregnancy
bleeding:
a) Placenta previa IGNOU Post B.Sc. Nursing 2016
b) Gestational hypertension
c) Fetal distress
d) Abruptio placentae
Answer (d)
ABHILASHA VERMA 50

51. 29. Couvelaire uterus condition associated with-
a) Post term placenta RAK M.Sc. Nursing Entrance 2014
b) Revealed abruptio placenta
c) Concealed abruptio placenta
d) Placenta previa
Answer (c)
30. Couvelaire uterus is seen in-
a) Placenta previa PGI Rohtak Staff Nurse 2015
b) PIH
c) Accedental hemorrhage
d) PPH
Answer (c)
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52.  It is pathological entity in
association of severe
form of concealed
abruptio placentae.
There is massive
intravasation of blood
into uterine musculature
up to serous coat.
( Only laparotomy can
diagnose this condition)
52

53. 31. Following are the causes of separation of a normally situated
placenta, EXCEPT:
a) Sudden uterine decompressionAIIMS Raipur Staff nurse 2017
b) Defective decidua
c) Supine hypotension syndrome
d) Thrombophlebitis
Answer (b)
32.Which of following is termed as fetal blood vessels lying over the
internal os, in front of presenting part-
a) Vasa previa RRB Staff Nurse 2019
b) Cord presentation RUHS M.Sc. Nursing Entrance 2019
c) Cord prolapse
d) Occult cord prolapse
Answer (a)
ABHILASHA VERMA 53

54. 33. Among following, event during pregnancy that require
immediate attention by the physician:
a) Back ache AIIMS Bhopal Nursing Nursing Officer May 2018
b) Bleeding per vvagina
c) Dependent edema
d) Frequency of micturition
Answer (b)
ABHILASHA VERMA 54

55. THANK YOU
ABHILASHA VERMA 55