Name of students : Miss.

Sonali moreshwar dikondwar

Venue :pooja nursing college bhandara

Date :

Group : 4th year BSc

Topic : antepartum hemorrage

Method of teaching : Demonstration method

Audio visual aids : chart, board, bulletin board ,leaflet

Previous knowledge : The students have somewhat previous knowledge regarding the
APH
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1 2 min Definition of
Definition Lecture cum board . able to define
APH discussion APH
• Antepartum haemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring
from 22 weeks
(>500g) of pregnancy and prior to the birth of
the baby.

• complicates 3—5% of pregnancies

• leading cause of perinatal and maternal mortality
worldwide.
• Up to one-fifth of very preterm babies are born in
association with APH
• Most of the time unpredictable.
Severity
NO consistent definitions of the severity of APH.
It is recognised that the amount of blood lost is
often underestimated
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Lecture cum .
The amount of blood coming from the discussion
introitus may not represent the total
blood lost (for example in a
concealed placental abruption).

It is important to assess for signs of clinical

shock. The presence of fetal
Student will
compromise or fetal demise is an able to tell

Enlist terminology
important indicator of volume chart terminologeis
2 5 Min depletion.
of APH
Different terminologies used:
• Spotting — staining, streaking or blood spotting
noted on underwear or sanitary protection

• Minor haemorrhage — blood loss less than 50 ml

that has settled
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• Major haemorrhage — blood loss of 50—

1000 ml, with no signs of clinical shock

• Massive haemorrhage — blood loss greater

than 1000 ml and/or signs of clinical shock.

• Recurrent APH - > one episode

RCOG Guidelines
3 5 min Enlist causes of Lecture cum Bulletin Students will
APH Etiology discussion board able to tell
etiology
• Placenta praevia
• Abruptio placenta
• Vasa praevia
• Excessive show
• Local causes ( bleeding from cervix, vagina and
vulva )
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a 5 min Describe
Placenta Praevia (PP) Lecture cum chart Students will
placenta praevia discussion able to tell
• Implantation of placenta over or near the internal placenta
praevia
os of cervix.
• Confirm diagnosis of PP can be done at 28 weeks
when LUS forming.

Leading cause of vaginal bleeding in the 2nd and 3rd

trimester.

Risk Factors of Placenta Praevia

Previous placenta praevia (4-8%)
Previous caesarean sections ( risktwith t numbers
Of c-section)
Previous termination Of pregnancy
Multiparity
Advanced maternal age (>40 years)
Multiple pregnancy
Smoking
Deficient endometrium due to presence
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b 5 min Describe Lecture cum board Students will

abruptio placenta Abruptio Placenta (AP) discussion able to tell
abruptio
• Separation of normally located placenta after 22 placenta

weeks of gestation ( > 500g) and prior to

delivery of fetus.

Risk factors :
• Previous history of AP
• Maternal hypertension
• Advanced maternal age
• Trauma ( domestic violence, accident, fall)
• Smoking/alcohol/cocaine
• Short umbilical cord
• Sudden decompression of uterus (
PROM/delivery of 1st twins
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Lecture cum chart
Obstetrics Emergency discussion
Diaqnosed CLINICALLY :
• Painful vaginal bleeding -80%
• Tense and tender abdomen/back pain (70%)
• Fetal distress( 60%)
• Abnormal uterine contractions (hypertonic and
high frequency)
• Preterm labour ( 25%)
• Fetal death ( 15%)
Ultrasound is NOT USEFUL to diagnose AP.
• Retroplacental clots (hyperechoic) easily missed
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c 5 min Describe vasa Vasa Praevia (VP) Lecture cum chart Students will
praevia discussion able to tell
• Rupture of fetal vessels that run in membrane vasa praevia

below fetal presenting part which is

unsupported by placenta/ umbilical cord.

• Predisposinq Factors:
-Velamentous insertion of the umbilical cord
-Accesory placental lobes
-Multiple gestations

Diagnosis of VP
• Antenatal diagnosis —reduced perinatal
mortality and morbidity.
• Painless vaginal bleeding at the time of
spontaneous rupture of membrane or post
amniotomy
• Fetal bradycardia
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• Fetal shock or death can occur rapidly at the Lecture cum

discussion
time of diagnosis due to blood loss constitutes a
major bulk of blood volume is fetus ( 3kg fetus-
300mI)
Hence, ALWAYS check the fetal heart after rupture
of membrane or amniotomy
• Definitive diagnosis by inspecting the placenta
and fetal membrane after delivery.
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4 5 min Enlist complication COMPLICATION OF APH Lecture cum Bulletin Students will
of APH discussion board able to tell
complication
Maternal shock of APH

Renal tubular necrosis

Consumptive coagulopathy
Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion Small for gestational
age and fetal growth restriction
Prematurity (iatrogenic and spontaneous)
Fetal death
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5 10min Describe clinical

Clinical assessment in APH Lecture cum leaflet . able to tell
assessment of discussion clinical
APH • First and foremost *Mother and fetal well being assessment

(mother is the priority)

• establish whether urgent intervention is required

to manage maternal or fetal compromise.

• Assess the extent of vaginal bleeding,

cardiovascular condition of the mother

• Assess fetal wellbeing.

Full History

Should be taken after the mother is stable.

• associated pain with the haemorrhage?
Continuous pain : Placental abruption.
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Lecture cum
• If the APH is associated with spontaneous or discussion
iatrogenic rupture of the fetal membranes :
ruptured vasa praevla
• Previous cervical smear history possibility of Ca
cervix. Symptomatic pregnant women usually
present with APH (mostly postcoltal) or vaginal
discharge.
Examination
• General.• PULSE & BP (a MUST!)
• Abdomen:
• The tense, tender or 'woody' feel to the uterus
indicates a significant abruption.
Painless bleeding, high fetal presenting part —
Placenta praevia
soft, non-tender uterus may suggest a lower genital
tract cause or bleeding from placenta or vasa
praevia
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Examination Lecture cum

discussion
Speculum
-identify cervical dilatation or visualise a lower
genital tract cause.

Diqital vaqinal examination

Should NOT be done until Placenta Praevia has
been excluded by USG.

Investigations
FBC

• Coagulation profile
• Blood Grouping and GSH.
• Ultrasound- TRO PPI IUD • D-dimer : AP
• colour doppler TVS — VP
• In all women who are RhD-negative, a Kleihauer
test should be performed to quantify FMH to
gauge the dose of anti-D lg required.
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6 1 5 min Describe MANAGEMENT Lecture cum chart . able to tell

management discussion management

• WHEN to admit?
• Based on individual assessment
-Discharqe after reassurance and
counsellinq Women presenting with
spotting who are no longer bleeding
and where placenta praevia has
been Excluded.
However, a woman with spotting +
previous IUD due to placenta
abruption, an admission would be
appropriate.
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Lecture cum
• All women with APH heavier than spotting and discussion
women with ongoing bleeding should remain in
hospital at least until the bleeding has stopped.
• If preterm delivery is anticipated, a single course
of antenatal corticosteroids ( dexamethasone
12mg 12 hourly ,2 doses) to women between 24
and 34 weeks 6 days of gestation.
• Tocolytics should NOT be given unless for VERY
preterm women who need time to transfer to
hospital with NICIJ.

For very preterm ( 24-26 weeks)

-conservative management if mother is stable .
-Delivery of fetus — life threatening
At these gestations, experienced neonatologists
should be involved in the counselling of the
woman and her partner
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For Placenta Praevia Lecture cum

discussion
• Conservative — MaCafee's regime
premature < 37 weeks;mother haemodynamically
stable,no active bleeding, fetus stable)
-advise bed rest, keep pad chart, vital signs
monitoring , Ultrasound, steroids, GSH,
Daily CTG and biophysical profile, fetal
movement count.

• Plan for delivery ( >37 weeks)

Crossmatch 4 units of blood.
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Lecture cum
For Abruptio placenta,(obs discussion
emergency)
• ICU admission : Close monitoring and
resuscitation! ABC ( high flow 02, aggressive
fluid resuscitation)
Continuous Vital signs monitoring and urine
output
• Monitor vaginal bleeding — strict pad chart
Continuous CTG for fetal heart rate
• Crossmatch 4 units of blood _
coagulopathy
• Dexamethasone — preterm
Decide Mode Of delivery
• Vaginal delivery — when fetal death
• Caesarean section —if maternal/ fetal health
compromised
• Indicated when early DIC sets in
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Lecture cum
Management discussion
• For Rh negative mothers,
Anti-D Ig should be given to all after any
presentation with APH, independent of whether
routine antenatal prophylactic anti-D has been
administered.

In the non-sensitised RhD-negative woman for

all events after 20 weeks of gestation, at least
500 iu
anti-D lg should be given followed by a test to
identify
FMH, if greater than 4 ml red blood cells;
additional anti-D Ig should be given as required.
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7 2 min Enlist bibliography

BIBLIOGRAPHY Lecture cum Power point
discussion
1. DC Dutta’s “TEXT BOOK OF OBSTETRICS AND
GNNACOLOGY” 7th edition
Jaypee brother’s publication pvt Ltd page no-158 to
177.
2. Nima Bhaskar “TEXT BOOK OF MIDWIFERY AND
OBSTETRICAL NURSING”
2nd edition Emmess medical publishers Page no-
3. Kamini Rao “TEXT BOOK OF MIDWIFERY AND
OBSTETRICS FOR NURSES”
Elesevir publication page no- 291 to 295.
4. DC Dutta’s “TEXT BOOK OF OBSTETRICS INCLUDING
PERINATOLOGY
AND CONTRACEPTION” Jaypee brother’s publication
pvt Ltd page no-159 to 168.
5. Mudaliar and menon’s “TEXT BOOK OF CLINICAL
OBSTETRICS” 12thedition universities press page no-138
to 146.
6. Tushar kar “TEXT BOOK OF DO’S AND DONT’S IN
OBSTETRICS AND
GYNACOLOGY PRACTICE” Jaypee brother’s publication
page no-
7. Annamma Jacob “A COMPREHENSIVE TEXTBOOK OF
MIDWIFERY &