seminar on aph

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Name of the student teacher : Miss. B. Karuna kumari

Course & Class : M.Sc Nursing, 1st

year

Subject : Obstetrical & Gynecological nursing

Topic : Antepartum Hemorrhage

Group : Pear group

Date : 24.10.2011

Time : 8am – 10am

Duration : 2hours

Venue : M.Sc Nursing 1st

year Class Room

Method of teaching : Lecture cum Discussion

Av Aids : Black board - meaning of placenta praevia and

Abruptio placenta

-incidence of antepartum

hemorrhage

Power point – etiology of abruption placenta and

- Complications of placenta

praevia and abruptio placenta

- Nursing diagnosis for APH

Chart - Schematic management of



Placenta previa ,abruption

placenta

Hand out - Research studies related to

Antepartum hemorrhage

Model - Types of placenta praevia and

abruptio placenta

HOD : Mrs. Rafath Razia madam, Professor

Guided by : Mrs. B. Valli Madam, Asst. Professor

Govt. College of Nursing



OBJECTIVES

STUDENT TEACHER OBJECTIVES

- Develop skills in teaching or explanation of the topic

- Understand the organisation of topic

- Develop skills in controlling the group

- Develop skills in using different types of AV aids

BEHAVIOURAL OBJECTIVES General objective: by the end of the session, students will be able to gain in depth

knowledge about antepartum hemorrhage and its management.

Specific objectives :

At the end of the session the group will be able to :

- Define antepartum haemorrhage

- Understand the causes of antepartum haemorrhage

- Classify the antepartum hemorrhage

- Define the abruptio placenta

- List the etiology of abruptio placenta

- Expain the effects of abruptio placenta

- Enumerate the clinical features of abruptio placenta

- Describe the treatment of abruptio placenta

- Discuss about the nursing care of abruptio placenta

- Define the placenta praevia

- List the etiology of placenta praevia



- Explain the effects of placenta praevia

- List the types of placenta praevia

- Explain the clinical features of placenta praevia

- Describe treatment of placenta praevia

- Discuss the nursing management of placenta praevia

- Expain the levels of prevention of antepartum hemorrhage

- Discuss the differences between placenta praevia and abruptio placenta

- Discuss about research studies and case scenario related to antepartum

hemorrhage



ANTEPARTUM HEMORRHAGE

INTRODUCTION

Antepartum bleeding or hemorrhage is bleeding from vagina

that takes place after 24th

week of gestation. It occurs 2-5% of all cases. In the

absence of pregnancy, uterus receives 1% of the heart‟s output. This increases

dramatically to approximately about 20% of out put in the third trimester. As such

uterine bleeding which can occur due to various causes can be substantial during

pregnancy, leading to profound blood loss and hemodynamic instability. It is one

of the most significant cause of maternal death during the third trimester. Severeantepartum hemorrhage causes causes still birth and neonatal death and also if

bleeding is severe, it may accompany by shock. Disseminated intravascular

coagulopathy. And the mother may die or will be left with permanent illness.

DEFINITION

Antepartum hemorrhage is defined as bleeding from or into the genital tract after

28th week of pregnancy but before birth of the baby.

- Dutta

Antepartum hemorrhage is also called prepartum hemorrhage, is bleeding from the

vagina during pregnancy from 20-24 weeks of gestation.

- Encyclopedia

INCIDENCE

Antepartum hemorrhage affects 3-5% of all pregnancies. It is 3 times more

common in multiparous than in primiparous women.



According to confidential enquiry into maternal and child health (

CEMACH) ( 2005), the mortality rate due to obstetric hemorrhage was 0.66 per

1,00,000 maternities.

ETIOLOGY

The antepartum hemorrhage is mainly caused by following

1. Placental bleeding (75%) : which includes abruption placenta (35%) and

placenta praevia (35%)

2. Unexplained cause is about 25% or its indeterminate ( excluding placental

bleeding and local lesions

3. Extra placental causes (5%)

Local cervico vaginal lesions:

Cervical polp

Carcinoma of cervix

Varicose veins

Local trauma

CLASSIFICATION OF ANTEPARTUM HEMORRHAGE

Antepartum hemorrhage is classified according to the site of placenta.

1. Accidental hemorrhage or abruption placenta is bleeding from the

premature separation of the placenta situated in the upper uterine segment

2. Antepartum hemorrhage due to placenta praevia or unavoidable antepartum

hemorrhage is bleeding from a placenta situated partially or wholly in the

lower uterine segment

3. Unclassified antepartum hemorrhage in which group of patients. There is

neither evidence of placenta praevia nor of accidental hemorrhage. The



cause of bleeding may not determined even after the delivery. Usually such

bleeding may be due to incidental findings such as cervical erosion, vascular

ulcerated polyps and rarely carcinoma of cervix.

ABRUPTIO PLACENTA

INTRODUCTION

Placental abruption (also known as abruptio placentae) is

a complication of pregnancy, wherein the placental lining has separated from

the uterus of the mother. It is the most common pathological cause of late

pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks

of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a

fetal mortality rate of 20 – 40% depending on the degree of separation. Placental

abruption is also a significant contributor to maternal mortality.

The heart rate of the fetus can be associated with the severity

DEFINITION

It is one form of antepartum hemorrhage where the bleeding occurs

due to premature separation of normally situated placenta.

- Dutta

Abruption placenta or premature separation of placenta or ablation placentae

or placental abruption is a premature separation of normally implanted

placenta from the uterus after 20 week of gestation

The term abruption means to tear apart and term accidental implies

separation as a result of trauma but does not occur spontaneously.

http://en.wikipedia.org/wiki/Complication_of_pregnancy

http://en.wikipedia.org/wiki/Placenta

http://en.wikipedia.org/wiki/Uterus

http://en.wikipedia.org/wiki/Mother

http://en.wikipedia.org/wiki/Pregnancy

http://en.wikipedia.org/wiki/Pregnancy

http://en.wikipedia.org/wiki/Mother



http://en.wikipedia.org/wiki/Complication_of_pregnancy



INCIDENCE

Abruption placenta occurs in 0.4 to 1.5% of all pregnancies, incidence

peaks at 24 to 26 weeks of gestation

ETIOLOGY

The exact cause of a placental abruption may be remains abscure

( unknown).

Direct causes are rare. But include

Hypertension in pregnancy is the most important predisposing factor,pre eclampsia, gestational hypertension and essential hypertension, all are

associated with abruptio placenta.

The mechanism of the placental separation in pre eclampsia is spasm of

vessels in the utero placental bed ( decidual spiral artery) leads to anoxic

endothelial dmage leads to rupture of vessels or extravasation of blood

in the deciduas basalis ( retro placental hematoma)

Trauma traumatic separation of the placenta usually leads to its

marginal separation with escape of blood outside. The trauma may be

due to

a) Attempted external cephalic version specially under anesthesia using

great force

b) Road traffic accidents or blow on the abdomen

c) Needle puncture at aminocentesis

Sudden uterine decompression :- sudden decompression of the uterus

to diminished surface area of the uterus adjacent to the placental



attachment and results in separation of placenta. This may occur in

following:

a) Delivery of the first baby of twins

b) Sudden escape of liquor amnii in hydraminos and

c) Premature rupture of membranes

Short cord, either relative or absolute, can bring about placental

separation during labour by mechanical pull.

Supine hypotension syndrome:- In this condition which occurs in

pregnancy ther is passive. Engorgement of the uterine and placental

vessels resulting in rupture and extravasation of the blood. Sick placenta:- Poor placentation evidenced by abnormal uterine artery

Doppler wave forms is associated with placental abruption.

Folic acid deficiency:-deficiency of folic acid without evidence of overt

megaloblastic erythropoiesis has been blamed to cause of separation of

placenta.

Torsion of the uterus:leads to increased venous pressure and rupture of

the veins with separationof the placenta.

Cocaine abuse: is associated with increased risk of treatment

hypertension and placental abruption.

Thrombophilias: Inherited or acquired have been associated with

increased risk of placental infarcts or abruption.

Risk factors:-

The prevalenceis more with

a) High birth order pregnancies is gravida 5 and above – three times more

common than in first birth



b) Advancing age of the mother

c) Poor socio economic condition

d) Malnutrition

e) Smoking and alcohol abuse (drinking more than 14 alcohol drinks/week in

pregnancy)

f) A tendency of recurrence in subsequent pregnancies is ten fold

g) Diabetes

h) Uterine fibroids

i) Poly hydraminos

j)

Chorio amnionitis/vasculitisk) Blood cloting disorders

CLASSIFICATION:

I. The most common classification of abruption placenta according to type

and severity is 3types-

1. Revealed : -

Following separation of the placenta, the blood insinuates

downwards between the membranes and decidua. Ultimately the blood comes out

of the cervical canal to be visible externally. This is the commonest type.

2. Concealed : -

The blood collects behind the separated placenta or collected in

between the membranes and decidua. The collected blood is prevented from

coming out of the cervix by the presenting part, which passes on the lower

segment. At times, the blood may percodates into the amniotic sac after rupturing

the membranes. In any of the circumstances blood is not visible outside. This type

is rare.



3. Mixed : -

In this type, some part of the blood collects inside ( concealed) and a

part is expelled ( revealed) usually one variety predominates over the other. This

type is quite common

II. DEGREES

Abruption placenta is also divided into three degrees

1. Mild Abruptio placenta

In this condition the placenta separates from centre of the placenta

2. Moderate abruption placenta

In this placenta passess between fetal membranes and uterine wall

and escapes vaginally . it can develop abruptly. It can progress from mild to

extensive separation with external hemorrhage.

3.

Severe abruption placenta

Here almost total separation leads to possible fetal cardiac distress

III. PAGE ‘S CLASSIFICATION

Page‟s classified abruptio placenta into four grades

Grade 0 : clinically unrecognized before delivery and diagnosis made after

examination of placenta

Grade 1 : These show external bleeding only or mild tetany but no evidence of

maternal shock.



Grade 2 : There is uterine tetany usually with uterine tenderness possible with

external bleeding, fetal distress or death but with no evidence of shock

Grade 3 : There is maternal shock or coagulation defects with uterine tetany or

intrauterine death of fetus.

Grade 0 and 1 is revealed hemorrhage, and grade II is concealed and

grade II & III is mixed type

CLINICAL TYPES

Class 0: asymptomatic. Diagnosis is made retrospectively by finding an

organized blood clot or a depressed area on a delivered placenta.

Class 1: mild and represents approximately 48% of all cases. Characteristics

include the following:

No vaginal bleeding to mild vaginal bleeding

Slightly tender uterus

Normal maternal BP and heart rate

No coagulopathy

No fetal distress

Class 2: moderate and represents approximately 27% of all cases.

Characteristics include the following:

No vaginal bleeding to moderate vaginal bleeding

Moderate-to-severe uterine tenderness with possible tetanic contractions

Maternal tachycardia with orthostatic changes in BP and heart rate

Fetal distress

Hypofibrinogenemia (i.e., 50 – 250 mg/dL)

http://en.wikipedia.org/wiki/Coagulopathy

http://en.wikipedia.org/wiki/Fetal_distress

http://en.wikipedia.org/wiki/Fetal_distress

http://en.wikipedia.org/wiki/Coagulopathy



Class 3: severe and represents approximately 24% of all cases. Characteristics

include the following:

No vaginal bleeding to heavy vaginal bleeding

Very painful tetanic uterus

Maternal shock

Hypofibrinogenemia (i.e., <150 mg/dL)

Coagulopathy

Fetal death

When bleeding is entirely concealed the blood may collect in any

one of the following situations

Behind the placenta as a large retroplacental clot.

Between the membranes and uterine wall separating the membranes from

uterine wall

It may collect behind the presenting part

The blood may occasionally extravasate into the uterine musculature,

tearing and injuring the tissues badly. The extravasated blood may be

visible as bluish ecchymosis scattered throught the uterine musculature.

Because of disorganization of uterine musculature the uterus loses its

tone and distends easily with blood. This is called apoplexy of

( couvelaire uterus). These patients also have fibrinogen deficiency due

to failure of blood clotting mechanism

http://en.wikipedia.org/wiki/Hypofibrinogenemia

http://en.wikipedia.org/wiki/Hypofibrinogenemia



PATHOPHYSIOLOGY

Predisposing factors

Trauma

Pregnancy

Hypertension

Use of drugs like cocaine

Smoking

At placental bed contain distended blood vessels

Ruptured blood vessels and causing separation

Partial separation complete separation

Detached peripheral detached central

portion portion massive vaginal bleeding

mild to moderate mild to moderate ( concealed )

vaginal bleeding concealed bleeding DIC maternal fetal death

blood at peripheral shock death

portion decreased platelet

decreased fibrinogen

increased fibrin

progressive separation fluid enters into

fetal distress muscle fibres



PATHOLOGICAL CHANGES

Premature placental separation is initiated by hemorrhage into the

deciduas basalis. This produces following pathological changes

Degeneration and necrosis the decidual basalis as well as placenta

adjacent to it

Rupture of basal plate thus communicating hematoma with in tervillous

space

Evidences of retroplacental hematoma by depression at maternal surface

and areas of infarction

Formation of a big hematoma

Failure to contract and compress the turn bleeding points

Absence of rhythmic uterine contractions

Couvelaire uterus

It‟s a pathological entity first delivered by couvelaire and is met

within association with severe form of concealed abruption placenta . there is

massive intravasation of blood into uterine musculature upto serous coat. It can

diagnosed on laprotomy.

Features : dark pot wine colour, patchy or diffuse, sub peritoneal petechial

hemorrhage , free blood in peritoneum and broad ligament.



Changes in Other Organs:

Fibrin note in the hepatic sinusoids Acute cortical necrosis or acute tubular necrosis

Intrarenal vasospasm

Shock, proteinuria due to renal anoxia

Proteinuria due to preeclampsia

Overt hypo fibrino genemia

Blood coagulopathy is due to excess consumption of plasma fibrinogen due

to disseminated intravascular coagulopathy and retro placental bleeding

CLINICAL FEATURES:

The clinical features depend on degree of separation of placenta, speed at which

separation occurs and amount of blood concealed inside the uterine cavity.

Revealed Mixed, Concealed

features predominant

Symptoms

Character of bleeding

Abdominal discomfort or

pain followed by vaginal

bleeding (slight)

Continuous dark colour

The client seized with

acute intense pain on

abdomen followed by

slight vaginal bleeding,

pain continuous.

Continuous, dark colour

or blood stained serous

discharge



General Condition

Pallor

Features of

preeclampsia

Uterine height

Uterine Feel

Fetal parts

Fetal heart sounds

Proportionately blood

loss, shock is absent

Related with visible blood

loss

May be absent

Proportionate to the

period of gestation.

Localised tenderness,

contractions frequent and

local amplitude

Can be identified easily.

Usually present.

Normal

Shock is pronounced,

which is out of

proportionate to the

visible blood loss

Pallor is usually severe

and out of proportionate

to visible blood loss

Either pre-existing or

appear for first time.

May be disproportionately

enlarged and globular.

Uterus is tense, tender and

rigid.

Difficult to make out.

Usually absent.

Usually diminished



Urine out put

INVESTIGATIONS:

Ultra sonography : Retro placental mass could be seen in 20-25 % of cases

LABORATORY

Blood: HB %

Coagulation profile

Urine for protein

Confusion diagnosis

Low value proportionate

to the blood loss

Usually unchanged

May be absent

With placenta praevia

Withheld vaginal

Makedly lower out of

proportionate to blood

loss

- Clotting time

increases more than

6 min.

- Low fibrinogen

level less than 150

mg/dl.

-

Low platelet count- Increased partial

thromboplastin

time and fibrin

degradation

products

Usually present

With Acute obstetrical-

gynocological surgical



examination. complication.

DIFFERENTIAL DIAGNOSIS:

Placenta praevia

Rupture uterus

Rectus Sheath hematoma

Apendicular or interstinal perforation

Twisted ovarian tumor

Volvulus

Acute hydramnios

Tonic uterine contractions

PROGNOSIS:

The prognosis of mother & baby depends on the clinical types (revealed,

concealed, mixed), degree of placental separation, the interval between separation

of placenta and delivery of baby and efficacy of treatment. Bleeding in placental

obruption is almost always maternal. Fetal bleeding is only observed with

traumatic variety of placental abruption.

COMPLICATIONS:

1. Maternal

a. In revealed type-maternal risk is proportionate to visible blood loss.

Maternal death is rare.

b. In concealed type –



- Hemorrhage leads to intra peritoneal or braod ligament hematoma

- Shock due to release of thromboplastin in maternal circulation

- Blood coagulation disorders for example disseminated intravascular

coagulopathy

- Oliguria and anuria due to hypovolemia

- Post partum hemorrhage due to atony of uterus

- Puerperal sepsis

- Ischemic pituitary necrosis

- Sheehan‟s syndrome

2.

Fetal Prematurity

Anoxia

Fetal death in revealed ( 25-30%) and in concealed type (50-100%)

MANAGEMENT

Treatment at home

Arrangement should be made to shift the patient to an equipped maternity

unit as early as possible

In the hospital

1. In revealed type:

Assess the case for amount of blood loss, maturity of fetus whether the client isin labour or not

Preliminaries



1. Blood is sent for haemoglobin, coagulation profile, ABO and Rh typing and

also test for detection of protein

2. Ringer lactate drip is started with a wide bored cannula and arrangement for

blood transfusion is to be made

3. Close m9onitoring of fetal and maternal condition

Definitive Treatment:

The patient is in labour:

The labour is accelerated by low rupture of membranes to escape of liquor

amnii and to increase uterine tone which allows separated placenta to be

compressed between fetal bulk and uterine wall, oxytocin drip may be started to

accelerate labour.

The patient is not in labour:

Pregnancy 37 weeks or more ;

Induction of labour is done by low rupture of membrane with or without

oxytocin or

Caesarean section is preformed if there is appearance of fetal distress, when

amniotomy fails and associated with complicating factors.

Pregnancy less than 37 weeks;

a. Bleeding moderate to severe and continuing low rupture of membrane is

effective, oxytocin dripp may be added. And rarely caesarean section is

performed



b. Bleeding slight or slopped means patient put on conservative treatment,

close observation of mother and carefull fetal monitoring with continuous

tocograph.

II. Mixed or Concealed type:

A. Preacautions:

1. Rapid management is critical

2. Fetal death occurs in upto 30% within 2hr.

3. Don‟t delay the management for ultrasound conformation.

a. Ultrasound is unreliable for diagnosis.

b. Placental abruption is clinical diagnosis.

B. Indications:

1. Brisk bleeding.

2. Unstable vital signs.

3. Fetal distress

4. Grade II and III placental abruption.

C. Immediate interventions:

1. Oxygen

2. Trendelenberg position

3. Obtain immediate intravenous access.

a. Two large bore IV (16-18 gauze)

b. Initiate isotonic crystalloid bolus – normal saline, ringer lactate.

4. Blood transfusion atleast one litre minimum in concealed type to prevent

complications.

5. Call for immediate obstetric and neonatal support.

6. Delivery within 20 min if there is fetal distress.



7. Caesarean section unless iminant vaginal delivary by induction. If the

cervix is unfavourable early caesarean section is performed. If the

progress of labour is delayed (6-8 hr). Late caesarean section is

performed especially in case of couvelerie uterus.

8. Anti D game globulin if maternal blood is Rh negative.

D. Monitoring:

1. Orthostatic blood pressure and pulse

2. Monitor intake & output.

3. Maintain urine output over 30 cc/hr.

4.

Monitor HB or hematocrit q 1-2hr- Maintain HB more than 10 g/dl or heamatocrit more than 30%.

- In fusion of packed RBC as needed.

5. Monitor Coagulation studies

- Transfusion of fresh frozen plasma as needed

- Platelet transfusion as needed

NURSING MANAGEMENT:

Nursing Diagnosis:

Impaired gas exchange to fetus related to insufficient oxygen supply

secondary to premature separation of placenta

Pain related to concealed bleeding secondary to premature separation of

placenta.

Risk for fluid volume deficit related to bleeding.

Powerlessness related to disease condition.

Fear related to perceived threat to fetal survival.

Nursing Interventions:



- Monitor maternal vital signs

- Monitor fetal heart rate

- Monitor uterine contractions and vaginal bleeding

- Vaginal delivary depends on degree and timing of separation of placenta in

labour

- Caeserean delivery indicated for moderate to severe placental separation.

- Evaluate maternal laboratory values

- Replace fluid and electrolyte and if required transfuse blood

- Provide emotional support assess the client condition and determine the

extent of bleeding frequently- Check fundal height every 30 min. As if the level of fundal height increases

suspects abruptio placenta.

- Count the no. Of pads that the client uses, weighing them as necessary to

measure amount of blood loss.

- Maintain IO chart

- Encourage woman to verbalise her feelings

- Keep all equipments ready for caesarean delivery.

- Council the client and help her by developing effective coping stratergies.



PLACENTA PRAEVIA

INTRODUCTION

Placenta praevia (placenta previa AE) is

an obstetric complication in which the placenta is attached to the uterine wall close

to or covering the cervix. It can sometimes occur in the later part of the first

trimester, but usually during the second or third. It is a leading cause of antepartum

haemorrhage (vaginal bleeding). It affects approximately 0.5% of all labours.

Placenta praevia is hypothesized

to be related to abnormal vascularisation of

the endometrium caused by scarring or atrophy from previous trauma, surgery, or

infection.

In the last trimester of pregnancy the isthmus of the uterus unfolds and

forms the lower segment. In a normal pregnancy the placenta does not overlie it, so

there is no bleeding. If the placenta does overlie the lower segment, as is the case

with placenta praevia, it may shear off and a small section may bleed.

DEFINITION:

When the placenta is implanted partially or completely over the lower

uterine segment is called Placenta Praevia.

The term praevia denoted the position of placenta in relation to the internal

os.

INCIDENCE:

About 1/3 of antepartum hemorrhage belongs to placenta praevia. The

incidence of placenta praevia ranges from 0.5 to 1 % among hospital

deliveries.

http://en.wikipedia.org/wiki/American_English

http://en.wikipedia.org/wiki/Obstetrics


http://en.wikipedia.org/wiki/Uterine

http://en.wikipedia.org/wiki/Cervix

http://en.wikipedia.org/wiki/Antepartum_haemorrhage


http://en.wikipedia.org/wiki/Vagina

http://en.wikipedia.org/wiki/Childbirth

http://en.wikipedia.org/wiki/Blood_vessel

http://en.wikipedia.org/wiki/Endometrium

http://en.wikipedia.org/wiki/Atrophy

http://en.wikipedia.org/wiki/Uterine_isthmus



http://en.wikipedia.org/wiki/Uterine_isthmus

http://en.wikipedia.org/wiki/Atrophy

http://en.wikipedia.org/wiki/Endometrium

http://en.wikipedia.org/wiki/Blood_vessel

http://en.wikipedia.org/wiki/Childbirth

http://en.wikipedia.org/wiki/Vagina



http://en.wikipedia.org/wiki/Cervix

http://en.wikipedia.org/wiki/Uterine


http://en.wikipedia.org/wiki/Obstetrics

http://en.wikipedia.org/wiki/American_English



- In 80% of cases it is found in multi parous women.

- The incidence also increases beyond the age 35,

- with high birth order pregnancies and

- In multiple pregnancy.

- Increased family planning acceptance and limitation of births lowers

incidence of placenta praevia.

ETIOLOGY:

The Exact cause is unknown. The following theories are postulated.

Dropping down theory:

According to this theory fertilized ovum drops down from upper uterine

segment to lower uterine segment and gets implanted there itself due to poor

decidual reaction.

Persistant chorionic activity:

Persistent chirionic activity in deciduas capsularis and its development into

capsular placenta comes in contact with deciduas vera of lower uterine

segment. That inturn leads to placenta praevia

Increased surface area of placenta

The surface area of the placenta as big as in case of multiple pregnancy. Then

placenta encroach into lower uterine segment

Defect in decidua

Due to defect in the deciduas chorionic villi unable to get nourishment. So

for nourishment it spreads over wide area of uterine wall which further leads

to encroachment of placenta onto lower uterine segment.



Predisposing factors of placenta

The main predisposing factors of placenta praevia includes

Frequent smoking leads to hypertrophoid placenta Multiparity and increased maternal age increases the incidence of placenta

praevia

Abnormality of shape and size of the placenta that is big size placenta and

succenturiate placenta

History of praevious caesarean section, scar in uterus due to hysterectomy

and myomectomy

TYPES OR DEGREES OF PLACENTA PRAEVIA

Depending on the degree of extension of placenta to the lower uterine

segment, it is divided into four types

1. Type I ( low lying)

The major part of the placenta is attached to the upper segment and only the

lower margin encroaches onto the lower segment but not upto the os

2. Type II ( Marginal )

The placenta reaches the margin of the internal os but does not cover it

3. Type III (incomplete or partial) the placenta covers the internal os

partially ( covers the internal os when it closed but it does not entirely do sowhen fully dilated

4. Type IV ( complete or central or total )

The placenta completely covers the internal os even after it is fully dilated



For clinical purpose the types of placenta praevia graded into two

types . that are

1. Mild degree

As per above classification the type I and II anterior comes under first category

2. Major degree

Type II posterior, type III and type IV are considered as major degree

Type II posterior considered as dangerous placenta praevia because of curved

birth canal the major thickness of placenta lies on sacraln promontory whichcompress placenta, cord and prevents engagement of fetal head

PATHOPHYSIOLOGY

As the placental growth slows down in later months

The lower uterine segment progressively dilates

The inelastic placenta is shared off the wall of lower uterine segment

Opening up of uteroplacental vessels leads to episodes of bleeding

However the separation of placenta provoked by trauma including vaginal

examination, coital act, external version

Inevitable bleeding



PATHOLOGICAL ANATOMY

Placenta:

The placenta may be large or thin. There is often tongue shaped extensionfrom the main placenta mass. Extensive areas of degeneration with infarction,

calcification may be evident. The placenta may be morbidly attached due to

poor decidual reaction

Umbilical cord:

The cord may be attached to the margin or into membranes. The insertion of

the cord may be closed to the internal os gives rise to vasa praevia . which may

rupture along with rupture of membranes

Lower uterine segment

Due to increased vascularity the lower uterine segment and the cervix

become soft and more friable

CLINICAL FEATURES

The most characteristic feature is painless and apparentaly sudden onset,

causeless and recurrent vaginal bleeding. In about 1/3 of the cases there is a

history of warning hemorrhage usually slight

Symptoms

- Vaginal bleeding

- Sudden onset

- Painless bleeding

- Recurrent

- Unrelated activity



Signs

- Size of the uterus according to the period of gestation

- Uterus feels relaxed, soft, elastic and tenderness

- Malpresentation

- Floating head

- Presence of fetal heart rate in mild cases

DIAGNOSIS

History collection

Abdominal examination : The presenting part felt like soft boggy through

the brim in case of major degree

Vulval inspection : Is done to note the colour and amount of bleeding

Vaginal examination must be not be done

Placentography usually performed to detect localisation of placenta and the

relationship between margin of placenta in relation to the internal os

Colour Doppler flow study to note the venous flow in the hyperechoic areas

Magnetic resonance image to see the quality of placental image excellence

Double set up of examination ( vaginal examination) is done to by keeping

everything ready for caesarean section in operation theatre

Differential diagnosis

- Abruption placenta

- Vasa praevia

- Local cervical lesion

- Circumvallate placenta



COMPLICATIONS

1. Maternal

a. During pregnancy

- Antepartum hemorrhage

- Malpresentation

- Premature labour

b. During labour

- Early rupture of membranes

- Cord prolapsed

- Slow dilatation

- Intrapartum hemorrhage

- Increased operative deliveries

- Post partum hemorrhage

- Retained placenta

c. Puerperium

- 15

th

day of puerperium may be incidence of sepsis2. Fetal

- Low birth weight baby

- Asphyxia

- Intrauterine death

- Birth injuries

- Congenital malformation

PROGNOSIS

Due to increased maternal death are reduced by early diagnosis, prompt

treatment and use of antibiotics



TREATMENT

At home

Patient immediately put on bed Assess the blood loss

Quick but gentle abdominal examination should be done

Vaginal examination must not be done

Transfer client to hospital

Immediate attention

Assess the amount of blood loss

Blood samples are taken for grouping

Start IV normal saline

Gentle abdomen and inspection of vulva

Expectant treatment

- Availability of blood for transfusion

- Facilities for cesearean section for 24 hours

- Bed rest to reduce fatigue

- Investigation for typing and grouping

- Supplemental hematinics to maintain blood volumwe

- A gentle speculum examination done once bleeding stops

- If the mother is in more than 37 weeks termination of pregnancy is done

- Steroid therapy given for maturity of placenta

Definitive treatment



Definitive treatment should be instituted soosn after hospitalization or following

expected treatment resolves into:

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 the operation theatre keeping

everything ready for caesarean section

Contra indications for vaginal examination :

- Patient in exsanguinated state

- Diagnosed cases of major degree placenta praevia

- Associated with complicating factors like elderly primi, malpresentation etc

a. Low rupture of memebranes:

Induce the labour by low rupture of membranes using long kocher‟s forceos

in lesser degree of placenta praevia. The finger in inserted to exclude the

cord prolapsed . amniotomy helps to initiation of labour and there byencourages descent of the head. This inturn presses on the separated placenta

and controls the bleeding. Oxytocin drip may be started . if amniotomy fails

to stop bleeding and initiation of labour caesarean section is performed.

Precautions during vaginal delivery

All possible steps taken to restore blood volume

Methergin 2.5mg should be given intramuscularly.

Proper examination of cervix following delivery

Checking the baby‟s haemoglobin level

Indications for Caesarean Section:



1. Major degree placenta praevia

2. Lesser degree placenta praevia where amniotomy fails.

3. Complicating factors associated with lesser degree of placenta praevia.

2. Caesarean section without internal examination in conditions where the

vaginal examination is contraindicated .

Alternative therapies to treat placenta previa –

Generally low placenta becomes alright on its own. But incase, you want to

have a natural childbirth or a home birth, it is best to ensure that the problem

has been resolved. Here are some ways through which can help yourself. Low

placenta finds its cure by three techniques.

• The first and most prevalent method to treat low placenta is rest. Doctors all

over the world suggest complete bed rest to pregnant women suffering from

placenta previa. In case of bleeding one is advised to put two pillows under

one‟s legs, knees onwards. Doctors also suggest women to restrict their movements to the minimum, getting up only to eat and visit the toilet. Often

eating well and resting allows the baby to grow as the months proceed and the

baby itself pushes the placenta away from the cervix while fixing its head.

• Acupuncture is another method, quite prevalent in china, to help cure

placenta previa. The acupuncture practitioners have key puncture points where

they insert needles to help the placenta move away from the opening of the

uterus. Du 20 is one such point, located at the top of the head, known to cure

this problem.

• Traditional Chinese medicines also have a cure for placenta previa.

However, the herbs used are generally not disclosed by the practitioners. They



although pay visits at your home also to help those how can not get up from

their bed or travel. Nettles are one herb known to help during excessive

bleeding or spotting during pregnancy. It is a rich source of Vit-K.

Certain things to be kept in mind –

• Vaginal examinations are not done on women suffering from low placenta

during pregnancy.

• In case of low placenta problem, avoid intercourse completely during the

course of your pregnancy.• Exerting exercise or movement should be completely avoided.

• Any kind of bleeding to spotting should not be overlooked and should be

brought to the doctor‟s notice immediately.

NURSING MANAGEMENT:

Nursing Diagnosis:

Decreased cardiac output related to excessive blood loss

Fluid volume deficit related to severe blood loss

Altered peripheral tissue perfusion related to hypovolemia

Risk for injury related to decreased placental perfusion.

Anxiety & fear related to treatment regimen.

Altered family process related to hospitalization.

Anticipatory grieving related to actual or perceived threat to self, pregnancy

or infant.



Expected outcomes of Care:

Expected outcomes for the woman experiencing palcenta praevia may include the

following. The woman will;

Verbalise understanding of her condition and its management.

Identify and use available support systems.

Demonstrate compliance with prescribed activity limitations.

Develop no complications related to bleeding.

Carry the pregnancy to term or near term.

Give birth to a healthy new born.

Plan of care and interventions:

Assess for amount of bleeding, fetal condition

Encourage mother for adequate rest

Closely monitor the woman

Weigh the pads to know the amount of bleeding one gram represents the one

ml of blood.

Ultra sonography done for every 2-3 weeks.

Monitor fetal conditions by cardio tocograph.

No vaginal or rectal examinations are performed.

Place the woman on pelvic rest.

Assess for signs of hypovolemic shock.

Make referral if necessary.

If the mother is in term and persistant bleeding delivery by caesarean section

is indicated.

Vaginal birth can be attempted for woman with minimal bleeding.



Monitor vital signs frequently.

Assess for signs of fetal hypoxia by continuous monitoring.

Observe fundus contractions after delivery

Provide emotional support for client and her family.

Allow the mother to express her feelings.

Then provide spiritual support.

Educate the woman about home management including bedrest, watching

for spotting or bleeding, close followup with health care provider.

Advice the mother to lie on left lateral position.

Provide and teach perineal hygiene to decrease the risk of infection.

PREVENTION

The prevention mainly aims at :

- Elimination of known factors that likely to cause antepartum hemorrhage

- Correction of anemia during antenatal period so that patient can withstand

blood loss

- Prompt detection and institution of therapyto minimise grave complications

likely to arise out of antepartum hemorrhage like shock, blood coagulation

disorders and renal failure

Primordial prevention

Adequate antenatal care to improve the health status of women

Correction of anemia to withstand for blood loss

Family planning and limitation of births reduce the incidence of antepartum

hemorrhage

Routine administration of folic acid from the early pregnancy



Avoid drinking, smoking, or using recreational drugs during pregnancy

Recognizing and managing conditions in the mother such as diabetes and

high blood pressure also decrease the risk of placental abruption

Primary prevention

Prevention, early detection and effective therapy of pre eclampsia and other

hypertensive disorders during pregnancy

Avoidance of trauma specially forceful external cephalic version under

anesthesia

Avoid supine hypotesion syndrome the patient is adviced to lie in the leftlateral position in the later months of pregnancy

Needle puncture during amniocentesis should be under the ultrasound

guidance

Significance of “warning hemorrhage” should not be ignored or

underestimated

Antenatal diagnosis of low lying placenta at 20 weeks with routine

ultrasound needs repeat ultrasound examination at 34 weeks to conform the

diagnosis.

Secondary prevention

Hospitalization

Amniocentesis is preferable for artificial rupture of membranes

Avoid sudden decompression of of the uterus in acute or chronic hydramnios

Administer Intravenous fuids with a large bore needle

Avoid vaginal examination



Either induction of labour or caesarean section performed based on period of

gestation and severity of disease condition

Maintainence of normal fluid volume

Teriary prevention

Immediate Hospitalization

Resuscitation

Blood transfusion

Caesarean section irrespective of gestational age

Differences between placenta praevia abruption placenta

Placenta Praevia Abruptio Placenta

Clinical Features:

Nature of Bleeding

Character of Blood:

General condition and

anemia

a. Painless,

apparentlycauseless,

recurrent.

b. Bleeding always

revealed

Bright red

Proportionate to visible

blood loss

a. Painful, often

attributed topreeclampsia or

trauma.

b. Revealed,

concealed and

mixed

Dark coloured.

Out of proportionate

to visible blood loss

in concealed type.



Features of preeclampsia

Abdominal examination

Height of the uterus

Feel of uterus

Mal presentation

Fetal heart sounds

Placentography.

Vaginal examination.

Not relevant

Proportionate height.

Soft and relaxed.

Common

Usually present.

Placenta in lower

segment.

Placenta felt at lower

uterine segment

Present in 1/3 of

cases.

May be

disproportionately

enlarged in concealed

type.

May be tensed, tender,

and rigid.

Unrelated

Usually absent.

Placenta in upper

segment.

Placenta not felt at lower

uterine segment but there

is presence of blood

clots.



RESEARCH STUDIES

Fouzia sheikh,fcps.

2. Sabreena abbas khokhar,mbbs

3. Pushpa sirichand,mcps, dgo, fcps

4. Raheela bilal shaikh,mbbs

1. “A study of antepartum hemorrhage:mat ernal and p erinatal outcome

OBJECTIVE: To determine the maternal and perinatal complications in patients

presented

with antepartum hemorrhage (APH) at a tertiary care hospital so that a preventive

strategy can be made to optimize fetomaternal outcome.

METHODOLOGY: This prospective descriptive study was conducted from

September

2007 to august 2008 at Department of Gynaecology and Obstetrics unit II, Liaquat

University Hospital, Hyderabad, Sindh, Pakistan. A total of 195 diagnosed cases of

antepartum hemorrhage were included in the study after obtaining informed

consent.

RESULTS: The incidence of APH was 5.4%. maternal and perinatal morbidity

was very high with increased rates of caeserian section ( 57.1% ), postpartum

hemorrhage ( 19%),



need of blood transfusion ( 77.4% ), shock ( 6.66% ), peripartum hysterectomy (

1%), preterm delivery ( 79.16% ) and maternal and perinatal mortality ( 3% and

49.7% respectively ).

CONCLUSION:

It was concluded that APH does stand out as a serious condition

with manifestation of significant maternal and perinatal morbidity and mortality.

These complications can be reduced by provision of antenatal care to every woman

at their doorsteps and provision of family planning services to reduce family size

hence complications Journal of obstetrics and gynaecology the journal of the

Institute of Obstetrics and Gynaecology (2000)

2. Comparision study of maternal and neonatal outcome with placenta

praevia and antepartum hemorrhage.

We set out to assess the maternal and neonatal outcomes of

women with placenta praevia and antepartum haemorrhage (APH) between 1991

and 1997, compared with woman with a diagnosed placenta praevia who did not

bleed.

The demographic data, maternal and perinatal outcomes of 159

women with antepartum haemorrhage were compared with 93 women without

antepartum haemorrhage in a retrospective study. Women with antepartum

haemorrhage had the diagnosis of placenta praevia confirmed at an earliergestation. More women with antepartum haemorrhage received antenatal steroids

and tocolytic agents, and had emergency caesarean sections. The majority of

women with bleeding had an emergency caesarean section for antepartum

haemorrhage and more delivered early because of fetal distress.



There were more preterm deliveries in women with antepartum

haemorrhage. The mean birth weight was 2.69 kg in the women with antepartum

haemorrhage and 3.06 kg in those without. More infants in the bleeding group had

a low Apgar score at the first minute, respiratory distress syndrome, and admission

to special baby care and neonatal intensive care unit. It is concluded that there is an

increased risk of premature delivery in women with antepartum haemorrhage and

placenta praevia. Aggressive management, tocolysis and cervical cerclage should

be explored further to improve the perinatal outcome. Women without antepartum

haemorrhage can be managed on an outpatient basis.

SUMMARY:

So far we have discussed about antepartum hemorrhage and its etiology and

classification. Then placental abruption its definition, etiology, types, effects on

mother and fetus, clinical features, prevention and medical and nursing

management. Then we also dealt about placenta praevia its definition etiology,

varieties clinical features and its management.

CONCLTION:

Antepartum hemorrhage is bleeding from genital tract after 28 weeks of

pregnancy and before delivery. It is quiet common and most dangerous, acute

condtion during pregnancy. And it is one of the leading causes of maternal

mortablity and morbidity. So as a mid wife we should know about antepartum

hemorrhage and its management to provide adequate and intime care for mother

with antepartum hemorrhage to deliver healthy baby from healthy mother.



BIBLIOGRAPHY

Books :

1. Boback teals (1995) „maternity nursing‟ ( 4thedition) Philadelphia , Mosby

publications ; page no 364-368

2. D.C dutta (2006) „Text book of obstetrics‟ (6th

edition) new Delhi, new

central book agency ; page no. 243-261

3. Myles (1992) „Text book of midwives‟ (11thedition) Calcutta, Longman

groups pvt ltd ; page no.

4. Annama Jacob (2002) „Text book of comprehensive midwifery‟ (2nd

edition)

new Delhi , jaypee brothers pvt ltd ; page no. 115-119

5. B.T Basavanthappa (2005) “Text book of reproductive and midwifery

health” (1st

edition) new delhi, jaypee brothers medical publishers pvt ltd:

page no :520-530

6. Neelam kumara (2007) “maternity Nursing” (1st

edition), banglore, page no:

328-338

Journals

1. Journal of nurse midwifery (2004) jan-feb (44),vol.1 page no. 6

2. Journal of nursing research and midwifery (2006) November, vol 18, page

no. 20-22

3. An international journal of obstetrics and gynecology

4. (2007) vol. 109, march ; page no. 44-56



5. International journal of nursing studies (2008) vol. 54, September ; page

no. 535-538

Web site

1. http:// www.medicinet.com

2. http:// www.medplus.com

3. http:// www.wilkipedia.com

http://www.medicinet.com/



http://www.medplus.com/



http://www.wilkipedia.com/








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