Pooja nursing college Bhandara

First Year M.sc Nursing [A. Y 2022-2023.]

SUBJECT: OBSTETRIC AND GYNACOLOGY

SEMINAR
 ON mastitis

SUBMITTED TO SUBMITTED BY
MS.Aishwarya Sontakkey
MS. Sonali Dikondwar
HOD OF OBGY I ST
YR MSC NURSING
Pooja Nursing College, Bhandara. Pooja
Nursing College, Bhandara
SUBMITTED ON

DATE: - / /
 STUDENT PROFILE

Name of students : MS. Sonali Moreshwar Dikondwar

Venue : Pooja Nursing College Bhandara

Date : / /

Group : First year MSc nursing

Topic : Antepartum hemorrhage

Method of teaching : Lecture cum discussion

Audio visual aids : Power Point Presentation, Hand out, Leaflet,
Pamphlet, Chart, Black board.
Previous knowledge: The students have previous knowledge regarding the
topic Antepartum hemorrhage.

GENERAL OBJECTIVES:
At the end of seminar on Antepartum hemorrhage the students acquired indepth
knowledge regarding Antepartum hemorrhage.

and applying this knowledge in their theory and clinical settings.

SPECIFIC OBJECTIVES:
At the end of seminar on Antepartum hemorrhage. the student will able To,
1. Define APH
2. Describe the types of APH
3. Explain etiologic factor of APH.
4. Enlist sign & symptoms of APH.
5. Describe management of APH.
6. Explain nursing process for client with APH
7. Explain nurses role for the patient with APH
OUTLINE
.Aim & Objectives

1. .Introduction
2. .Definition
3. Severity
4. Terminologies
5. .Etiological factor
6. Placenta praevia
7. Vasa praevia
8. Complication of APH
9. Clinical assessment
10. Sign & symptoms
11. management
 Definition

• 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
.

The amount of blood coming from the 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 compromise or fetal demise is an important indicator of
volume depletion.
RCOG Guidelines

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

• 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
Etiology

• Placenta praevia
• Abruptio placenta
• Vasa praevia
• Excessive show

• Local causes ( bleeding from cervix, vagina and vulva )

• Inderterminate APH
Placenta Praevia (PP)

• Implantation of placenta over or near the internal 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.

Classification
 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 or history Of•.
uterine scar
-endometritis
-manual removal Of placenta
curettage
-submucous fibroid
Assisted conception

Clinical classification • Type 1

 • Minor : ( anterior/posterior) Type 2 anterior

• Major:
• Type 2 posterior (dangerous type Caesarean section posterior
> chance of fetal Type 2

• Type 3 distress Type 3 & 4 anterior -cut through

placenta to deliver. Hence •

Type 4 need to be fast and
efficient.
Deliver vaqinallv Type 1 Posterior > likelihood of fetal
distress
Abruptio Placenta (AP)

• Separation of normally located placenta after 22 weeks of gestation

( > 500g) and prior to delivery of fetus.

External Relatively Concealed Co ncealed

Abruption Abruption Abruption
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)

Retroplacental fibroids

• Idiopathic
Obstetrics Emergency!!
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.
Obstetrics today
Vasa Praevia (VP)

• Rupture of fetal vessels that run in membrane below fetal presenting

part which is unsupported by placenta/ umbilical cord. •

Predisposinq Factors:

-Velamentous insertion of the umbilical cord

-Accesory placental lobes
 -Multiple gestations

Obstetrics today
The term velamentous
insertion is used to
describe the condition in
which the umbilical cord
inserts on the
chorioamniotic
membranes rather than on
the placental mass.

Normal Placenta and

Umbilical Vessels vs. Vasa
Previa
 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
• Fetal shock or death can occur rapidly at the 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.
 Obstetrics today
Complications of APH

Anaemia
Infection gestational age and fetal growth
restriction
Maternal shock Prematurity (iatrogenic and
spontaneous) Fetal death
Renal tubular necrosis
Consumptive coagulopathy Postpartum haemorrhage
Prolonged hospital stay
Psychological sequelae
Complications of blood transfusion Small for RCOG Guidelines
 Clinical assessment in APH

• First and foremost *Mother and fetal well being (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.
Intermittent pain : Labour.
• Risk factors for abruption and placenta praevia should be identified.

• reduced fetal movements?

• If the APH is associated with spontaneous or 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.
Examination
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.

RCOG Guidelines
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.
Fetal monitoring: •
CTG monitoring
RCOG Guidelines
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.
Management
• All women with APH heavier than spotting and 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.
Management
• 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
Management
For Placenta Praevia

• Conservative — MaCafee's regime

( premature < 37 weeks;mother haemodynamically stable,no active
bleeding, fetus stable)
Management
-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.

Management
For

Definitivetreat ent

Abruptio placenta,(obs 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
Management
Abruptio Placenta
Decide Mode Of delivery

• Vaginal delivery — when fetal death

• Caesarean section —if maternal/ fetal health compromised
• Indicated when early DIC sets in
• Consent should be taken for hysterectomy in case bleeding could not be
controlled.

Obstetrics today
Management
• 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.
 SUMMARY

At the end of seminar we have seen the, Aim & Objectives, Introduction,
Definition, Etiological factor, Sign & symptoms of antepartum hemorrhage. Nursing
process & Nursing care, role of nurse &
I hope all the topics that, I have covered in the seminar will be beneficial to
the group members and will effectively apply this knowledge in the areas of pratical
in future.

CONCLUSION
The seminar on abortion has provide the group with all the essential
knowledge that the group can apply in their theory and clinical areas effectively also
this knowledge could be useful for the clinical nurse or the tutor who will in teach her
students in more impressively, confidently, practically, efficient and useful way.

BIBLIOGRAPHY
1. DC Dutta’s “TEXT BOOK OF OBSTETRICS AND GNNACOLOGY” 7 th
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-
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no-
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HEALTH
NURSING” Jaypee brother’s publication Pvt Ltd page no-
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GYNACOLOGICAL
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Slideshare. Net
12. https;// slideshare . com.
13. JOURNAL OF FAMILY & REPRODUCTIVE HEALTH, Tehran university
of medical sciences.
14. BMJ GLOBAL HEALTH ARTICLE ON ABORTION COMPLICATIONS IN
INDIA 2015, Bmj publishing group.