Bleeding in late pregnancy

1. BLEEDING IN LATE PREGNANCY
Prepared By
Samar Zidan Ali
(B. Sc. In nursing)
Prepared by
Samar Zidan
(B. Sc. In nursing)
2020

2. • Introduction
• Definition of Antepartum Hemorrhage
• Incidence of Antepartum Hemorrhage
• Causes of Antepartum Hemorrhage
• Complications of Antepartum Hemorrhage
• Comparison between Placenta Previa and
Abruptio Placenta.
0utlions

3. 3)Vasa praevia2) Abruptio Placenta
(Accidental Hemorrhage)
1)Placenta Previa
 Definition
 Types
 Incidence
 Risk factors
 Diagnosis
 Management
 Nursing -
Management
 Definition
 Incidence
 Causes
 Types of abruption
 Degrees of Separation
 Diagnosis
 Management
 Prevention
 Complications of
Abruptio placenta
 Nursing Management
 Definition
 Incidence
 Causes of placenta
praevia
 Degrees
 Diagnosis
 Management of
Placenta Praevia
 Complications of
Placenta Praevia
 Nursing Management

4. Introduction
Bleeding in late pregnancy also known as
antepartum hemorrhage, is a serious
complication of pregnancy occurring
within the third trimester. It is associated
with significant maternal and
Common.mortalityandmorbidityfetal
causes of antepartum hemorrhage
placentaland,previaplacentalare
causesrare,abruption
.ruptureuterineandvasapreviainclude

5. It is bleeding from the genital tract after 20wks
of pregnancy (fetal viability) or during labor
before delivery of fetus.
Definition
Incidence
It accounts for almost 1/3 maternal deaths in Egypt

6. Non obstetricObstetric
Local cause in
the genital tract
as carcinoma of
cervix.
FetalMaternal
Vasa previaExtra
placental
hemorrhage
Placental site
hemorrhage
Ruptured
uterus
Cervical or
vaginal tears
Placenta
previa
Abruptio
placenta
(accidental
Hemorrhage)
Causes

7.  Hemorrhagic shock.
 Acute renal failure.
 Disseminated intravascular coagulation (DIC)
Increased risk for postpartum hemorrhage.
 Severe anemia.
Maternal Risks:
 Prematurity and birth asphyxia.
 Intrauterine fetal death.
Fetal Risks:
Complications of antepartum
Hemorrhage

8. Placenta previa

9. Placenta previa is defined as placental implantation in
the lower uterine segment, with either complete or
partial obstruction of the cervical os.
Definition
Incidence
 1 in 200 – 250 pregnancies.
 It is more common in multiparas and in twin pregnancy
due to the large size of the placenta.

10. The cause of placenta praevia is often unknown
but these are some of the factors that put
women more at risk:
• advanced maternal age (>35 years),
• infertility treatment,
• multiparity,
• multiple gestations
• previous placenta previa
• pervious uterine surgery or cesarean delivery
• Uterine fibroid
Causes of placenta praevia

11. Minor Major
Low lying placenta
"PP Lateralis"
Marginal PP
"PP marginalis"
Partial PP
"Incomplete PP
Centralis"
Total PP
"Complete PP
Centralis"
Grade 1 Grade 2 Grade 3 Grade 4
Placenta is implanted
in LUS  Placental
edge does not actually
reach the internal os
The edge is at
the margin of
the internal os.
Internal os is
partially
covered by the
placenta
Internal os is
covered
completely by
the placenta.
Degrees

12. You can usually expect
to birth vaginally with
this type
Types II, III and IV are associated with a risk of heavy
bleeding in labour as the cervix dilates and, therefore
caesarean birth is usually recommended.
Degrees
Grade 1 Grade 2 Grade 3 Grade 4

13. • Stretching of the lower uterine segment normally occurs
during pregnancy and labor the placenta is not elastic and
cannot stretch and this leads to separation of the placenta
from the lower uterine segment and bleeding, so bleeding is
inevitable or unavoidable.
• In case of placenta previa centralis bleeding may occur
early in pregnancy and is usually severe because a great part
of the placenta is attached to the lower uterine segment.
The Mechanism of Bleeding

14. Symptoms
Signs
Investigations
Diagnosis
General examination
Abdominal examination
Vaginal examination
Laboratory
Ultrasound
Causeless, painless and recurrent
bright-red vaginal bleeding; usually near
the end of 2nd trimester or after.

15. Signs
• General examination:
• The general condition of the patient depends upon the
amount of blood loss.
• acute severe blood loss: hemorrhagic shock
• chronic blood loss: anaemia
• Abdominal examination:
• Fundal level equal to period of amenorrhoea, relaxed
and not tender.
• Palpable the foetal parts and Audible fetal heat
sound(FHS)
• Malpresentations, are more common as well as non-
engagement of the head. This is because the lower
uterine segment is occupied by the placenta.

16. • Vaginal examination:
No vaginal examination is done during Expectant treatment
except:
 After 37 weeks when the fetus is nearly mature.
 If labor starts.
 If there is attack of sever bleeding.
 with the following precautions:
• In the operating room,
• under general anaesthesia,
• Available blood transfusion
• When active treatment is indicated1-Artificial Rupture of the
membranes, Caesarean Section
Signs

17. 1- Laboratory
• Hematocrit or complete blood count
• Blood type and Rh
• Coagulation tests
2-Ultrasound
• it’s the most useful test to confirm diagnosis
• Full bladder can create false appearance of anterior
previa
• MRI(Magnetic resonance imaging)
• Test for fetal maturity and fetal well being
Investigations

18. Management of placenta praevia depends on:
• The amount of bleeding
• The condition of mother and fetus
• The degree of the placenta
• The duration of pregnancy
Management of Placenta Praevia

19. – Look to the amount of bleeding;
• If the bleeding is severe, continue antishock measures and
do immediate caesarean section .
• If the bleeding is slight, look to the gestational age;
– If completed 37 weeks or more, pregnancy is terminated by
induction of labour or caesarean section
– If less than 37 weeks , conservative treatment is indicated till the
end of 37 weeks
– Conservative treatment:
• The patient is kept hospitalized with bed rest and
observation till delivery.
• Anaemia should be corrected if present.
• Observation of foetal wellbeing.
:labourIf the patient is not in

20. – Vaginal examination is done under the previously
mentioned precautions.
– Vaginal delivery is allowed in the following conditions:
• Placenta praevia is lateralis or marginalis anterior,
• bleeding is slight,
• cephalic presentation,
• partially dilated cervix to allow amniotomy
:labourIf the patient is in

21. cont.,
Caesarean section is indicated in:
• Placenta praevia centralis
• Placenta praevia marginalis
• Severe bleeding.
• malpresentation.
• Other obstetric indications as cord prolapse and elderly
primigravida.
N.B. Although upper segment C.S. is sometimes advocated to
be away from the placenta, lower segment C.S. is
preferable because:
• It allows better control of bleeding from the placental site.
• It leaves a stronger scar can resist subsequent vaginal
delivery.

22. FoetalMaternal
Prematurity
 Asphyxia.
Congenital
Malformatio
ns (2%).
Abortion.
Preterm labour.
Antepartum haemorrhage
Malpresentation and non-
engagement.
During
:pregnancy
Complications of Placenta Praevia

23. Maternal
 Lacerations of lower uterine segment due
to increased
 vascularity.
 Premature rupture of membranes.
 Cord prolapse.
 Prolonged labor.
 Placenta accreta due to deficient decidual
reaction in the lower segment allows deep
penetration of chorionic villi.
:labourDuring

24. Maternal
 Anemic uterus  atony.
 Soft cervix  tear.
 Retained placenta.
Postpartum hemorrhage:
Puerperal sepsis.
Maternal shock and maternal death
Complications of Placenta Praevia

25. Abruptio Placenta (Accidental

26. Placental abruption,, also known as abruptio placentae,
It is antepartum hemorrhage due to premature
separation of the normal situated placenta.
Definition
Incidence
This condition occurs in about 1% of all pregnancies

27. 1. Idiopathic: in most cases the cause is unknown.
2. Maternal hypertension Pregnancy-induced
hypertension..
3. Trauma as blow on the abdomen direct trauma.
4. Traction of the placenta by short cord.
5. Thrombosis of uterine or ovarian veins.
Etiology:

28. 6. Sudden reduction of the size of the uterus after
rupture of membrane.
7. Premature rupture of membrane.
8. The presence of ant phospholipid antibodies.
9. The presence of uterine fibroid benth the placenta
10. Previous history of placenta abruption.
Etiology:

29. 3.Combined or mixed
type:
2.Concealed
abruption
1.Revealed
abruption
some blood is
retained inside the
uterus and some is
expelled through the
cervix.
Blood collects
behind the
placenta, with no
evidence of vaginal
bleeding.
the blood appears
externally as vaginal
bleeding
Types of abruption

30. CriteriaGrade
No symptoms of separation were apparent from maternal or fetal
signs; the diagnosis that a slight separation did occur is made after
birth, when the placenta is examined and a segment of the placenta
shows a recent adherent clot on the maternal surface.
0
Minimal separation, but enough to cause vaginal bleeding and
changes in the maternal vital signs; however, no fetal distress or
hemorrhagic shock occurs.
1
Moderate separation; there is evidence of fetal distress; the uterus
is tense and painful on palpation.
2
Extreme separation; without immediate interventions, maternal
shock and fetal death will result
3
Degrees of Separation:

31. Diagnosis:
Symptoms
Signs
General examination
Abdominal examination
Vaginal examination
•concealed hemorrhage
•Revealed Hemorrhage
•Combined accidental hemorrhage

32. There is a sudden onset of
severe abdominal pain; there
may be a history of trauma or
pre-eclampsia
Symptoms
1)concealed
hemorrhage

33. General Examination
a) Signs of shock and internal hemorrhage as rapid pulse and
subnormal temperature, the blood pressure is low .
b) Signs of pre-eclampsia in the form of edema and proteinuria
are usually present.
Signs

34. Abdominal examination
c) The uterus is larger than the period of amenorrhea and it gradually
increases in size.
d) The uterus is very tender and hard in consistency.
e) The fetal parts are not felt due to abdominal rigidity.
f) The fetal heart sounds are absent and if present it shows marked fetal
distress.
Vaginal Examination
There is no vaginal bleeding
Signs

35. The patient complains of
vaginal bleeding, there may be
a history of trauma or pre-
eclampsia.
Symptoms
2)Revealed
Hemorrhage

36. General Examination
a) The general condition of the patient is related
to the amount of blood loss.
b) Signs of pre-eclampsia are usually present.
Vaginal Examination:
There are no characteristic signs
Signs

37. • The blood is partially revealed and partly concealed.
• Signs and symptoms depend on the amount of blood
loss and whether it is more revealed or concealed.
3)Combined accidental
hemorrhage

38. Management depends on the severity of
bleeding and the age.
• Intravenous fluids, generally lactated Ringer’s solution,
are given to prevent or reverse hypovolemia
• Laboratory tests to evaluate client’s status and the
clotting mechanism are ordered: platelet count,
fibrinogen level, fibrin split products, thrombin time,
prothrombin time, partial thromboplastin time, and
bleeding time.
• Also, a type and cross-match for three to four units of
blood or packed cells is requested

39. • If the mother is Rh negative, she is checked for Rh
sensitization. An indwelling urinary catheter is inserted. If
separation is small and the pregnancy near term,
induction of labor and vaginal delivery may be possible. If
labor is not progressing, a cesarean birth is performed. If
separation is moderate or severe, a cesarean birth is
performed as soon as possible.
Management depends on the severity of
bleeding and the age.

40. • The incidence of placental abruption may be decreased by
cessation of tobacco, cocaine, or amphetamine use, and
appropriate care for hypertensive disorders of pregnancy.
• One trial demonstrated a reduction in the incidence of abruption
with intrapartum treatment of preeclampsia using magnesium
sulfate
• Adequate contraceptive instructions should be given, Preventing
therapeutic abortions and closely spaced pregnancies.
• Hypertensive disorder of pregnancy should be monitored closely for
an Abruptio placenta
PREVENTION

41. B)For the baby, placental
abruption can lead to:
A) Maternal
 Fetal distress
 Premature birth
 Stillbirth
1. Shock (hemorrhagic and
neurogenic)
2. Acute renal failure
3. D I C
4. Postpartum hemorrhage
5. Sheehan syndrome due to
necrosis of anterior lobe of the
pituitary gland
6. Ruptured uterus
Complications of Abruptio placenta:

42. Comparison between Placenta Previa and
Abruptio Placenta:
Abrubtio PlacentaPlacenta Previaitems
 Sudden onset of
bleeding & pain.
 History of trauma or
preeclampsia.
 Painless, causeless,
recurrent.
1- Bleeding
 Related to the amount of
blood lost in the revealed
type only.
 Preeclampsia may be
present.
 Related to the amount of
blood loss because all the
blood is revealed.
2- General exam.
 In the mixed type uterus
is very tender & hard.
 FHS are absent or there
is fetal distress.
 ± Malpresentation3- Abdominal
Examination

43. Abrubtio PlacentaPlacenta Previaitems
 Blood is dark brown.
 No fullness.
 Placenta is not felt in
the lower segment.
 Not done.
 Vaginal bleeding is
bright red.
4- Vaginal exam.
(with certain
precautions)
 Placenta is in the
upper segment.
 Placenta is in the lower
segment
5- U/S
 High risk; due to poor
Contractility of the uterus
following an abruption.
 High risk ;due to low
Placement of the placenta
there is limited uterine
contraction.
6- Risk for post
partum
hemorrhage
Comparison between Placenta Previa and
Abruptio Placenta:

44. Vasa praevia

46. Vasa praevia describes fetal vessels coursing
through the membranes over the internal
cervical os and below the fetal presenting part,
unprotected by placental tissue or the umbilical
cord.
• 1:2500
Definition
Incidence

47. Vasa praevia type 2Vasa Previa type 1
 fetal vessels running
between lobes of a placenta
with one or more accessory
lobes
 This can be secondary to
avelamentous cord insertion
in a single or bilobed
placenta
Types:

48. • Bilobed placenta
• Invitro fertilization
• Low lying placenta
• Multiple pregnancy
• Succenturiate lobe
• Velamentous insertion of the cord
Risk factors;

49. • In the antenatal period, in the absence of vaginal bleeding,
there is no method to diagnose vasa praevia clinically.
• In the intrapartum period, in the absence of vaginal
bleeding, vasa praevia can occasionally be diagnosed
clinically by palpation of fetal vessels in the membranes at
the time of vaginal examination.
• This can be confirmed by direct visualization using an
amnioscope.
Diagnosis:

50. • In the presence of vaginal bleeding, especially
associated with membrane rupture and fetal
compromise, delivery should not be delayed to try
and diagnose vasa praevia.
• Vasa praevia can be accurately diagnosed with colour
Doppler ultrasound, often utilizing the transvaginal
route.
Diagnosis:

51. • In cases of suspected vasa Previa , transvaginal colour
Doppler ultrasonography should be carried out to
confirm the diagnosis.
• An antenatal diagnosis requires elective caesarean
section
• If the diagnosis of vasa previa is strongly suspected in
the presence of fetal compromise in labour, or if
haemorrhage is significant, emergency caesarean
section (category I) is required, early notification of
neonatal team, followed by neonatal resuscitation
including volume replacement with O negative blood
Management

52. Nursing Management
Placenta previa

53. Subjective Data
• The client describes painless bleeding.
Objective Data
• Vaginal bleeding may range from spotting to profuse bleeding.
The uterus remains soft and relaxes fully between
contractions if labor begins. FHR generally remains stable
unless bleeding is profuse and maternal shock occurs.
Assessment

54. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
Deficient Fluid
Volume related
to blood loss
The woman
will maintain
perfusion to
placenta and
vital organs.
*Observe, report, and record
blood loss (count and/or weigh
pads). *Monitor client’s vital
signs, FHR, I&O, and laboratory
reports. *Maintain comfortable
environment to prevent
diaphoresis.
*Inspect skin for pallor,
cyanosis, clamminess, and
coldness. *Encourage client to
maintain fluid intake
Evaluation: Evaluate each outcome to determine how it has
been met by the client

55. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
Impaired Gas
Exchange,
Fetal related to
decreased
maternal blood
volume and
hypotension
FHR will
remain
within
normal limits
-Monitor FHR, baseline
variability, and decelerations.
-Observe amniotic fluid for
meconium.
-Instruct womanto lie on left side
position to promote placental
perfusion.
-Administer IV fluids to mother
to promote placental perfusion.
Evaluation: Evaluate each outcome to determine how it has
been met by the client

56. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
related toFear
outcome of
pregnancy due
to bleeding.
Woman will
be able to
discuss her
concerns
with the
health care
providers.
 Assess fetal heart sounds so the
mother would be aware of the
health of her baby.
 Allow the mother to vent out
her feelings to lessen her
emotional stress.
 Assess any bleeding or spotting
that might occur to give
adequate measures.
 Answer the mother’s questions
honestly to establish a trusting
environment.
 Include the mother in the
planning of the care plan for
both the mother and the baby.

57. Nursing Management
Abruptio Placenta

58. • Nursing Management
Monitor the client’s bleeding, pain, vital signs, FHR, and fetal
activity. Administer blood products or blood as ordered. Provide
oxygen as ordered. If a cesarean delivery is to be performed,
prepare the client for surgery. Maintain the client on bed rest.
Accurately record I&O and insert indwelling urinary catheter as
ordered. Have client lie on her side (left preferred) but not on her
back.

59. Subjective Data :
• The client may describe moderate to severe pain in the
abdomen. Fetal movement may become hyperactive and then
may cease.
Objective Data :
• Vaginal bleeding is assessed. External fetal monitor will show
uteroplacental insufficiency, baseline changes, late
decelerations, and reduced variability. The contraction pattern
will change and the resting tone will increase. Vital signs show
indications of shock.
Assessment

60. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
-Hypovolemic
Shock Causing
Inadequate Organ
Blood Flow and
Tissue Oxygenation
Secondary To The
Hemorrhage
Hypovolemic
shock will be
minimized or
managed as
measured by
stable vital signs,
urinary output of
30ml/ hr or
greater ,normal
peripheral pulse
,normal motor
function ,and
orientation to
person ,place ,and
time
1. Monitor blood pressure, pulse, and
respiration at frequent intervals.
2. Assess peripheral pulse.
3. Observe for indicators of decreased
cerebral perfusion, such as restlessness or
confusion.
4. Observe for signs of shock.
5. Monitor urinary output hourly or as
indicated by severity.
6. If signs of shock develop, place patient in
modified trendelenburg position (only
elevate the leg s) to increase blood return
without contributing to respiratory
impairment and administer oxygen at 8 to
10 L/min by mask.
7. Restoration of circulating volume by
placement of two large-bore IVs
8. Report first signs of shock or vital signs
changes to physician

61. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
-Risk For
Impaired Gas
Exchange, Fetal
related to altered
uteroplacenta
oxygen transfer
due to placental
separation
The fetus will
have a normal
baseline FHR,
variability with
no
decelerations.
-Observe external fetal monitor for
decelerations, decreased baseline
variability, and FHR. Provide oxygen to
mother via mask. Have mother lie on
left side.
-Notify physician if a baseline or
periodic FHR change is noted or if
there is a nonreactive NSTs or
biophysical profile of 6 or less.
-Once delivery is imminent, notify the
intensive care nursery of a possible
high risk infant.

62. NURSING
DIAGNOSES
PLANNING/
OUTCOMES
NURSING INTERVENTIONS
-Anxiety related to
vaginal bleeding
and possible fetal
loss
The client will
be able to
verbalize
feelings about
bleeding and
possible loss of
pregnancy
-Explain pathophysiology of bleeding
and status of fetus.
Encourage client and family to talk
about their feelings.
-Allow them some privacy to grieve.
-Contact minister, priest, or rabbi as
requested by the client.
Evaluation: Evaluate each outcome to determine how it has been met
by the client

63. Nursing Management
Vasa praevia

64. • Nursing Management
1. Identify, and assist with treatment of, the disorder.
• Monitor fetal heart rate and status during labor.
• Assist with diagnosis of the condition.
• Anticipate and assist with emergency cesarean birth.
2. Provide physical and emotional support.
3. Provide client and family education. Explain
emergency procedures to the client and family.

65. Reference
 Belleza M, May 17, 2016: Placenta Previa Nursing Care Plan and
Management. aveilable at: https://nurseslabs.com › placenta-previa
 Cotton DB, Read JA, Paul RH, Quilligan EJ. The conservative
aggressive management of placenta previa. Am J Obstet Gynecol.
2011 ;137(6):687.
 Foundations of Maternal & Pediatric Nursing, Third Edition Lois
White, Gena Duncan, and Wendy Baumle, RN, MSN, Printed in the
United States of America, 2011,pp45-50.

66. Reference
 Maternal-fetal medicine: Principle and practice. 7th ed.
Philadelphia, PA: Elsevier Saunders, 2015, p. 732–42).
 -Ramadan S, 2018: Bleeding in late pregnancy.aveilable
at:www.slideshare.com.
 Silver RM. Abnormal placentation: placenta previa, vasa previa, and
placenta accreta. Obstet Gynecol. 2015;126(3):654–68.
 Tikkanen M. Placental abruption: epidemiology, risk factors and
consequences. Acta Obstet Gynecol Scand. 2011;90(2):140–9.