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Hemorrhage in late pregnancy


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Hemorrhage in late pregnancy

  1. 1. Hemorrhage in late pregnancy Presentation by Prativa Dhakal M.Sc. Nursing Maternal health nursing Batch 2011
  2. 2. Contents • Antepartum Hemorrhage • Causes of Antepartum hemorrhage • Definition of Placenta Previa • Incidence • Etiology • Pathological anatomy • Types of placenta Previa 12/13/2013 • Clinical Features • Conformation of diagnosis • Complications • Prognosis • Management • Nursing Management • Research Evidence • References 2
  3. 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 12/13/2013 3
  4. 4. Causes of Antepartum Hemorrhage Presenting symptoms and Probable other symptoms and signs Symptoms and signs sometimes present diagnosis typically present Bleeding after 22nd weeks Shock Abruptio placenta gestation Tense/tender uterus Intermittent or constant Decreased/absent fetal movement abdominal pain Fetal distress or absent fetal heart sounds Bleeding (intra abdominal and/or vaginal) Severe abdominal pain (may decrease after rupture) 12/13/2013 Shock Abdominal distention/free fluid Abnormal uterine contour tender abdomen Easily palpable fetal parts Absent fetal movements and fetal heart sounds Rapid maternal pulse Ruptured uterus 4
  5. 5. Causes of antepartum hemorrhage cont… Presenting symptoms Symptoms and signs sometimes present Probable diagnosis and other symptoms and signs typically present Bleeding after 22 weeks gestation 12/13/2013 Shock Bleeding may be precipitated by intercourse Relaxed uterus Fetal presentation not in pelvis/lower Uterine pole feels empty Normal fetal condition Placental previa 5
  6. 6. Causes of antepartum hemorrhage A.P.H. Placental bleeding (70%) Placenta previa (35%) and Abruptio placenta (35%) 12/13/2013 Unexplained (25%) Or Intermediate Extra placental causes (5%) Local cervico-vaginal lesions: Cervical polyp Carcinoma cervix Varicose vein Local trauma 6
  7. 7. Placenta previa • When placenta is implanted partially or completely over the lower uterine segment it is called placenta previa. 12/13/2013 7
  8. 8. Incidence of Placenta Previa United States: • 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%. 12/13/2013 8
  9. 9. Etiology • Dropping down theory • Persistence of chorionic activity in the decidua capsularis and its subsequent development into capsular placenta • Defective decidua • Big surface area of the placenta 12/13/2013 9
  10. 10. Predisposing factors • Multiparity • 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 12/13/2013 10
  11. 11. Pathological anatomy Placenta: • Placenta may be large and thin. • Tongue shaped extension from the main placental mass. • Extensive areas of degeneration with infarction and calcification may be evident. • Morbidly adherent placenta due to poor decidua formation in the lower segment. 12/13/2013 11
  12. 12. Pathological anatomy cont… Umbilical cord: • Cord may be attached to the margin or onto the membranes. • 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. 12/13/2013 12
  13. 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 12/13/2013 13
  14. 14. 12/13/2013 14
  15. 15. 12/13/2013 15
  16. 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. 12/13/2013 16
  17. 17. Clinical features Symptoms: • Painless, apparently hemorrhage causeless and recurrent • Hemorrhage from the implantation site in the lower uterine segment may continue after placental delivery. Signs: • General condition and anemia are proportionate to the visible blood loss. 12/13/2013 17
  18. 18. Clinical features cont… Abdominal examination – 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 twin pregnancy. – 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. 12/13/2013 18
  19. 19. Clinical features cont… Vulval inspection • Only inspection has to be done to note the amount, character of blood. • Blood is bright red in colour. Vaginal examination • Must not be done outside the operation theater in the hospital. 12/13/2013 19
  20. 20. Confirmation of diagnosis Localization of placenta • Sonography: Transabdominal ultrasound (TAS) • Transvaginal ultrasound (TVS) • Transperineal ultrasound • Colour Doppler flow study Clinical • By internal examination (Double setup examination) • Direct visualization during caesarean section • Examination of the placenta following vaginal delivery 12/13/2013 20
  21. 21. Complications Maternal During Labour: During pregnancy: • APH with varying degrees of shock • Malpresentation • Premature labour 12/13/2013 • • • • • Early rupture of membrane Cord prolapse Slow dilatation of cervix Intrapartum hemorrhage Increased incidence of operative interference • PPH • Retained placenta 21
  22. 22. Complications cont… Puerperium • Sepsis is increased due to – Increased operative interference – Placental site near to vagina and anemia – Subinvolution – Embolism 12/13/2013 Fetal • Low birth weight • Asphyxia • Intrauterine death • Birth injuries • Congenital malformation 22
  23. 23. Prognosis Maternal • 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 interference Fetal • Perinatal mortality ranges from 10-25%. • The causes of death are prematurity, asphyxia and congenital malformation. 12/13/2013 23
  24. 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% 12/13/2013 24
  25. 25. Prevention • 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 ignored • Family planning and limitation of births reduce the incidence. 12/13/2013 25
  26. 26. Management At home: • 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 the uterus. • Vaginal examination must not be done. 12/13/2013 26
  27. 27. Treatment 1. Immediate attention: Quickly assess • Amount of blood loss: General condition, pallor, pulse rate and blood pressure. • 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 sonographic examination. 12/13/2013 27
  28. 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 caesarean section • 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. 12/13/2013 28
  29. 29. Treatment cont… Conduct of expectant treatment: • Bed rest with bathroom facilities • Investigations: Hemoglobin estimation, blood grouping and urine for protein • 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. 12/13/2013 29
  30. 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. 12/13/2013 30
  31. 31. Treatment cont… Active interference: • 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. 12/13/2013 31
  32. 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 pelvis etc. 12/13/2013 32
  33. 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 12/13/2013 33
  34. 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 status. • Assess fetal status with continuous fetal monitoring. 12/13/2013 34
  35. 35. Nursing Diagnoses • Ineffective Tissue Perfusion, Placental, related excessive bleeding causing fetal compromise to • 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 12/13/2013 35
  36. 36. 12/13/2013 36
  37. 37. Definition • It is one form of antepartum hemorrhage where bleeding occurs due to premature separation of normally situated placenta. 12/13/2013 37
  38. 38. Pathology • Initiated by hemorrhage into the decidua basalis. • The decidua then splits, leaving a thin layer adhered to the myometrium. • 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 pathways. 12/13/2013 38
  39. 39. Pathology cont… • Early stage: May be no clinical symptoms, and separation is discovered upon examination of the freshly delivered placenta. – There is a circumscribed depression on the placenta's maternal surface. – 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. 12/13/2013 39
  40. 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. 12/13/2013 40
  41. 41. Varieties of abruptio placenta • Concealed Hemorrhage • Revealed • Mixed 12/13/2013 41
  42. 42. 12/13/2013 42
  43. 43. Revealed Mixed Concealed 12/13/2013 43
  44. 44. Risk factors • Increased age, poor socioeconomic condition and parity • Preeclampsia • Chronic hypertension • Preterm ruptured membranes • Folic acid deficiency • Short cord 12/13/2013 • • • • • • • • Multifetal gestation Low birth weight Hydramnios Cigarette smoking Thrombophilias Cocaine use Prior abruption Uterine leiomyoma 44
  45. 45. Abruptio placenta cont… Couvelaire uterus • 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 laparotomy. 12/13/2013 45
  46. 46. Abruptio placenta cont… • These myometrial hemorrhages seldom interfere with myometrial contraction to cause atony, and they are not an indication for hysterectomy. 12/13/2013 46
  47. 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. 12/13/2013 47
  48. 48. Abruptio placenta cont… Blood coagulopathy: • 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 dimer. 12/13/2013 48
  49. 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. 12/13/2013 49
  50. 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. 12/13/2013 50
  51. 51. Clinical features Depends upon • Degree of separation of placenta • Speed at which separation occurs and • Amount of blood concealed inside the uterine cavity. 12/13/2013 51
  52. 52. The clinical features of the revealed and mixed variety are given below: Revealed Symptoms: Mixed 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 bleeding moderate) slight) or blood stained serous discharge. General Proportionate to visible blood Shock is pronounced which is out condition loss, shock is usually absent of proportion with the visible blood loss. Pallor Related with visible blood loss Pallor is usually severe and out of proportion to visible blood loss. 12/13/2013 52
  53. 53. The clinical features of the revealed and mixed variety are given below: Revealed Mixed Features of May be absent preeclampsia Frequent association preexisting or appear. either Uterine height Proportionate to POG Disproportionately enlarged and globular. Uterine feel Normal feel with localized Uterus is tense, tender and rigid tenderness, contractions frequent and local amplitude Fetal parts Can be identified easily Difficult to make out FHS Usually present Usually absent Urine output Normal Usually diminished 12/13/2013 53
  54. 54. The clinical features of the revealed and mixed variety are given below: Revealed Mixed Laboratory Blood Hb% Low value proportionate Markedly lower, out of proportion to to blood loss blood loss Coagulation profile Usually unchanged Variable changes : Clotting time increased (>6 min) Fibrinogen level low (<150mg/dl) Platelet count low Increased PTT Increased FDP and D dimer Urine for protein May be absent Usually present Confusion diagnosis With acute obstetrical gynecological surgical complication 12/13/2013 in With placenta previa. 54
  55. 55. Abruptio placenta cont… Sheehan Syndrome • 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 insufficiency. • Exact pathogenesis is not well understood but such endocrine abnormalities develop infrequently in women who hemorrhage severely. • Varying degrees of anterior pituitary necrosis and impaired secretion of one or more trophic hormones (in some cases) • Diagnosis: MRI 12/13/2013 55
  56. 56. Distinguishing features of placenta previa and abruptio placenta Placenta previa Clinical features Nature of bleeding Character bleeding of Painless, apparently causeless and recurrent Bleeding is always revealed Bright red Abruptio placenta Painful, often attributed to preeclampsia or trauma and continuous Revealed, concealed or usually mixed Dark coloured Proportionate to visible blood General condition loss Out of proportion to the and anemia visible blood loss in concealed or mixed variety Features of pre- Not relevant eclampsia Present in one-third cases 12/13/2013 56
  57. 57. Distinguishing features contd… Placenta previa Abd. examination Height of uterus Feel of uterus Malpresentation FHS Placentography Abruptio placenta Proportionate height 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 present Usually absent specially in concealed type Placenta in lower segment Placenta in upper segment Vaginal examination Placenta is felt on lower Placenta is not felt on lower segment segment. Blood clots should not be confused with placenta. 12/13/2013 57
  58. 58. Management • 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. 12/13/2013 58
  59. 59. Prevention • Prevention, early diagnosis and effective therapy of preeclampsia and other hypertensive disorders of pregnancy. • Needle puncture during amniocentesis should be under ultrasound guidance. • 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. 12/13/2013 59
  60. 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 Preliminaries • Blood for Hemoglobin and hematocrit estimation, coagulation profile, ABO and Rh grouping and urine for detection of protein. • RL solution drip started with wide bore cannula and arrangement for blood transfusion. • Close monitoring of maternal and fetal condition. 12/13/2013 60
  61. 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 oxytocin. 12/13/2013 61
  62. 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. 12/13/2013 62
  63. 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 maintained. 12/13/2013 63
  64. 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 fetal distress. 12/13/2013 64
  65. 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 unknown outcome 12/13/2013 65
  66. 66. 12/13/2013 66
  67. 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 hydatidiform mole. 12/13/2013 67
  68. 68. Classification of rupture uterus Uterine rupture typically is classified as either: • Complete • Incomplete 12/13/2013 68
  69. 69. Causes 1. Spontaneous 2. Scar rupture 3. Iatrogenic 12/13/2013 69
  70. 70. Causes cont… Spontaneous 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. 12/13/2013 70
  71. 71. Causes cont… Scar rupture • 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. 12/13/2013 71
  72. 72. Causes cont… Iatrogenic or traumatic: During pregnancy: – – – – 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 During labour: – Internal podalic version, Destructive operation – Manual removal of placenta – Application of forceps or breech extraction through incompletely dilated cervix – Injudicious administration of oxytocin for augmentation of labour. 12/13/2013 72
  73. 73. Dehiscence and scar rupture Dehiscence: – Disruption of part of scar and not the entire length – Fetal membranes remain intact and – Bleeding is almost nil or minimal Rupture includes: – Disruption of the entire length of scar – Rupture of membranes with varying amount of bleeding from the margins or from its extension. 12/13/2013 73
  74. 74. Diagnosis During pregnancy 1. Scar rupture Classical or hysterotomy • Dull abdominal pain all over the area with slight vaginal bleeding. • Tenderness on uterine palpation. • FHS may be irregular or absent. • Sooner or later the rupture becomes complete. 12/13/2013 74
  75. 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. 12/13/2013 75
  76. 76. Diagnosis cont… 3. Rupture following fall, blow or external version or use of oxytocics: • History of such accident followed by acute pain abdomen and slight vaginal bleeding. • Rapid pulse and tender uterus, confirmation is done by laparotomy. 12/13/2013 76
  77. 77. Diagnosis cont… During labour 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. 12/13/2013 77
  78. 78. Diagnosis of spontaneous obstructive rupture cont… Premonitory phase: • 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. 12/13/2013 78
  79. 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. 12/13/2013 79
  80. 80. Phase of rupture in spontaneous obstructive rupture • Sense of something giving way at height of uterine contraction. • Constant pain is changed to dull aching pain with cessation of uterine contraction. • 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. 12/13/2013 80
  81. 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 of contractions. • Presence of shock, evidences of internal hemorrhage, tenderness over the uterus and varying amount of vaginal bleeding. 12/13/2013 81
  82. 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 delivery • Exploration of uterus to feel the rent confirms the diagnosis. • Shortening of cord immediately following a difficult vaginal delivery • Placenta being extruded out into abdominal cavity, through the rent in the uterus. 12/13/2013 82
  83. 83. Prevention • At risk mothers likely to rupture should have mandatory hospital delivery. There are – Contracted pelvis – Previous history of caesarean section, hysterotomy or myomectomy – Uncorrected transverse lie – Multiparity with pendulous abdomen – Grand multiparity – Known case of hydrocephalous • General anesthesia should not be used to give undue force in external version 12/13/2013 83
  84. 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 labour. 12/13/2013 84
  85. 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 personnel. • Manual removal in morbid adherent placenta should be done by senior person. 12/13/2013 85
  86. 86. Treatment 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 simultaneously. • Any of the following procedures may be adopted following laparotomy – Hysterectomy – Repair – Repair and sterilization 12/13/2013 86
  87. 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 situation. 12/13/2013 87
  88. 88. Nursing Diagnoses • Deficient Fluid Volume related to active fluid loss from hemorrhage • Ineffective Tissue Perfusion, Maternal Vital Organ and Fetal, related to hypovolemia • Fear related to surgical outcome for fetus and mother 12/13/2013 88
  89. 89. References 1. Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition. Philadelphia: Churchill livingstone elsevier; 2009 2. Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New central book agency;2004 3. Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family. Sixth edition. Philadelphia: Lippincott Williams & Wilkins; 2010. 4. Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United states of America: Mcgraw Hill companies; 2010. 5. Placenta Previa. Internet [Updated on 5th June 2012, Cited on 21st October 2013] Available form: 6. Nettina SM, Mills EJ. Lippincott manual of nursing practice. 8th edition. Baltimore: Lippincott Williams and Wilkins; 2006 12/13/2013 89