Bleeding in late pregnancy

Unit 8
Bleeding in late pregnancy
 Placenta previa
 Placental abruption
Ante partum Haemorrhage
 Ante partum Haemorrhage is the bleeding
from the genital tract in late pregnancy, after
the 28th week of gestation and before the
onset of labour.
  
-:Bleeding may be due to
 Placenta Previa

 Placental abruption

 Incidental causes such as vaginitis, cervical

polyp, and cervical eversion.
Effects of ante partum hemorrhag
on the fetus
 Increase fetal mortality and morbidity rate

 Still birth or Perinatal or neonatal death

 Hypoxia which may result in mentally and

physically handicapped baby

 Premature placental separation

Effects of Ante partum Haemorrhage
on the Mother:-
 Shock due to sever bleeding

 Disseminated intravascular coagulation “DIC”

 Renal failure

 Death or permanent ill-heath

-:Aim of Treatment of APH
 The most important aim is to restore the
physical condition of the mother by:

◦ Fluid replacement with plasma expander and later

with whole blood

◦ Analgesia to decrease pain and stress

Assessment of physical condition
Maternal condition
 The first priority is the well-being of the

mother.
 Assess woman’s emotional state and begin to

ask for a history of events.

 Observation of vital signs
 The nurse must assess the amount of blood

lost in order to ensure adequate fluid

replacement
 Don’t do any vaginal or rectal examination.
:Fetal condition
 The mother should be asked if the baby has
been moving as much as normal.

 The nurse must attempt to auscultate the

fetal heart
Factors to aid differential diagnosis
The location of the placenta
 Pain, Did pain precede((‫ يسبق‬bleeding and is it

continuous or intermittent?.

 Onset of bleeding, Was this associated with any event

such as coitus?

 Amount of visible blood loss, Is there any reason to

suspect some blood has been retained in utero?

 Colour of the blood. Is it bright red or darker in colour?

 Degree of shock, Is this equal with the
amount of blood visible or more severe?

 Consistency of the abdomen, Is it soft or

tense and board-like?

 Tenderness of the abdomen, Does the mother

resent abdominal palpation?
 Lie, presentation and engagement, Are any of
these abnormal when taking account of parity
and gestation?

 The fetal heart, Is the fetal heart heard?

 Ultrasound scan, Does a scan suggest that

the placenta is in the lower uterine segment?
 
Supportive treatment
 After emotional reassurance
 the first need is for restoration of physical

condition.
 This will need fluid replacement
 If the mother is in severe pain she must have
strong analgesia to help counteract shock.
Placenta praevia
 The placenta is partially or wholly implanted
in the lower uterine segment on either the
anterior or posterior wall.

 The lower uterine segment grows and

stretches progressively after the 12th week of
pregnancy.

 In later weeks, this may cause the placenta to

separate and serve bleeding can occur.
Degrees of placenta praevia
Type 1 placenta previa:
 The majority of the placenta is in the upper

uterine segment.

 Vaginal delivery is possible.

 Blood loss is usually mild

 mother and fetus remain in good condition.

:Type 2 placenta praevia
 The placenta is partially located in the lower uterine
segment near the internal cervical os (marginal
placenta praevia).

 Vaginal delivery is possible particularly if the placenta

is anterior.

 Blood loss is usually moderate, although the

conditions of the mother and fetus can vary

 Fetal hypoxia is more likely to be present than

maternal shock
:CLASSIFICATIONS

Marginal
Placenta Previa

The placenta is near 

the edge of the cervix
Type 3 placenta praevia
 The placenta is located over the internal
cervical os but not centrally

 Bleeding is likely to be severe particularly

when the lower segment stretchers and the
cervix begin to efface and dilate in late
pregnancy.

 Vaginal delivery is inappropriate because the

placenta precedes the fetus.
:CLASSIFICATIONS

Partial
Placenta Previa

The placenta is 

partially over the
cervix
Type 4 placenta praevia
 The placenta is located centrally over the
internal cervical os.

 severe haemorrhage is very likely.

 Vaginal delivery should not be considered.

Caesarean section is essential in order to save
the life of the mother and fetus.
:CLASSIFICATIONS

Top Placenta Previa

(Complete)

The placenta 
completely covers the
cervix
classification
Diagnosis of Placenta Previa:-
◦ Painless vaginal bleeding
◦ Uterus is soft, not tender or tense.
◦ U/S is done to locate the placenta before doing
vaginal examination.
Placenta Previa is suspected when
 The fetal head remains unengaged in PG

 There is mal presentation especially breech

presentation

 The lie is oblique or transverse

 The lie is unstable in multigravidae

Assessing the mother’s condition
 The amount of vaginal bleeding is variable.

 The haemorrhage may be mild, moderate or

severe, is often not associated with any
particular type of activity and many occur at
rest.

 The colour of the blood is bright red,

distinguishing fresh bleeding.
 The low placental location allows all of the
lost blood to escape unimpeded.

 For this reason pain is not a feature of

placenta praevia.
:General examination
 If the haemorrhage is slight the mother’s
blood pressure, respiratory rate and pulse
rate may be normal.

 In sever haemorrhage the blood pressure will

be low and the pulse rate raised due to
shock.

 The degree of shock correlates with the

amount of blood lost per vagina.
 Respirations are also rapid.

 The mothers colour will be pale and her skin

cold and moist.

 The temperature is usually normal as

haemorrhage from a placenta praevia is not
associated with infection.
:Abdominal examination
 The nurse may find that the lie of the fetus is
oblique or transverse.

 the fetal head may be high in a primigravida near

term.

 The uterine consistency is normal and there is no

pain experienced by the mother when her
abdomen is palpated.

 A vaginal examination should not be done

Assessing the fetal condition
 The mother should be asked whether fetal
activity has been normal.

 She may be aware of cessation of fetal

movements which may occur if fetal hypoxia
is severe.

 In some instances she may report that her

fetal movements have been excessive which
another indication of severe fetal hypoxia is.
 The nurse should assess the fetal condition
using an electronic fetal monitor such as a
cardiotocograph or Sonicaid machine.

 Fetal hypoxia is an emergency and medical

assistance should be called urgently.
Management of placenta praevia
The management of placenta praevia depends
on:
 The amount of bleeding.

 The conditions of mother and fetus.

 The location of the placenta.

 The stage of the pregnancy (gestational age).

Conservative management
 Is appropriate if bleeding is slight and the
mother and fetus are well

◦ The woman will be kept in hospital at rest until

bleeding has stopped.
◦ A speculum examination will have ruled out
incidental causes.
 Ultrasound scans are repeated at intervals in
order to observe the position of the placenta
in relation to the cervical os as the lower
segment grows.

 Fetal growth is also monitored

Active management
 Severe vaginal bleeding will necessitate
immediate delivery by caesarean section.
◦ This should take place in a unit with facilities for
special care of the newborn especially if the body
will be preterm.

◦ An intravenous infusion will be in progress and

several units of blood must be cross-matched.
 During the assessment and preparation for
theater the mother will be extremely anxious
 the nurse must comfort and encourage her,

 giving her as much information as possible.

 The partner will also need to be supported.

 In major degrees of placenta praevia (type 3
and 4) caesarean section is required even if
the fetus has died in utero.

 This will prevent profuse haemorrhage and

possible maternal death
Complications
 Postpartum haemorrhage is the most
probable complication following delivery.

 Occasionally uncontrolled haemorrhage may

continue and a caesarean hysterectomy may
be required.
:Other complications
 Maternal shock may result from blood loss
and hypovolaemia.

 Maternal death.

 Fetal hypoxia due to placental separation.

 Fetal-death.
Placental abruption
 It is the premature separation of a normally
situated placenta occurring after the 28th
week of pregnancy.

 Partial separation of the placenta causes

bleeding from the maternal venous sinuses in
the placental bed.
 Further bleeding continues to separate the
placenta to a greater or lesser degree.

 If blood escapes from the placental site it

separates the membranes from the uterine
wall and drains through the vagina.
 Blood which is retained behind the placenta
may be forced into the myometrium and it
infiltrates between the muscle fibers of the
uterus.

 The uterus appears bruised and oedematous.

 The mother will have all the signs and
symptoms of hypovolaemic shock.

 This is caused by concealed bleeding into the

muscle of the uterus.
 The concealed haemorrhage causes uterine

enlargement and extreme pain.

Types of placental abruption
 The blood loss from a placental abruption may
be defined as revealed, concealed

 mixed haemorrhage. The nurse cannot rely on

visible blood loss as a guide to the severity of
the haemorrhage;

 on the contrary, the most severe haemorrhage

is that which is totally concealed.
Assessing the mother’s condition
 There may be a history of pregnancy-induced
hypertension.

 A recent history of headaches, nausea,

vomiting, epigastric pain and visual
disturbances may be a feature.

 Road traffic accidents are probably the most

likely cause of trauma to the abdomen.
General examination
 The mother is likely to be anxious,
experiencing constant and severe abdominal
pain and her skin will be pale and moist if she
is shocked.

 On clinical examination the mother may have

obvious oedema of the face, fingers and
pretibial area of the lower limbs(S+S of PET).
 The blood pressure and pulse should be
taken immediately.

 A low blood pressure and raised pulse rate

are signs of shock, if the mother has
pregnancy-induced hypertension the blood
pressure may be within normal limits, having
been raised prior to the haemorrhage.
 The respirations may be normal or rapid.

 The temperature will usually be normal but as

placental abruption may be caused by severe
infection, it should be taken.
 The amount of any visible blood loss should
be estimated. Its colour is noted.

 Freshly lost blood is bright red, blood that

has been retained in utero for any length of
time changes to a brown colour.
:Abdominal examination
 Concealed haemorrhage may lead to uterine
enlargement in excess of gestation.

 The uterus has a hard consistency and there is

tens and tender abdomen on palpation.

 Palpation may be difficult and should not be

attempted if the uterus is rigid and excessively
painful.

 Fetal parts may not be palpable

Assessing the fetal condition
 The mother may be aware of a cessation of
fetal movements. It is said that excessive fetal
movements may also occur as a result of
profound hypoxia.

 A cardiotocograph recording will give more

complete information about fetal condition.
 Failure to hear the fetal heart sounds with a
Painard or a fetal stethoscope is not
confirmation of fetal death but in cases of
severe haemorrhage this is unfortunately the
usual outcome.

 The nurse should take care how she give

information about the fetus to the mother.
Management
 Any woman with a history suggestive of
placental abruption needs urgent medical
attention.

 The nurse should offer the mother comfort

and encouragement by attending to her
physical and emotional needs, including her
need for information.
 Pain, Pain exacerbates shock and must be
alleviated. As it may be extreme, a suitable
analgesic would be morphine 15 mg or
pethidine 100mg.
 The acute pain of concealed haemorrhage

from placental abruption is due to the extra

vasation of blood between the muscle fibers
of the uterus.
 Shock may be due to hypovolaemia, to extra
vasation and consequent pain.

 Whole blood is traditionally used to restore

the blood volume.

 If blood is not available for immediate

transfusion, hypovolaemia may be reduced by
administering a suitable plasma expander.
 The mother should rest on her side in order
to prevent vena caval occlusion and aortic
compression by the gravid uterus.

 The legs may be raised but the body must

remain horizontal. Elevating the foot of the
bed will cause pooling of blood in the vagina
and is unlikely to reduce shock.
:Observations
 The mother’s blood pressure and pulse rate
should be taken at frequent intervals, which
would depend on the severity of her
condition.

 If pyrexia is present, the temperature may be

recorded every 1 or 2 hours, if the mother is
not feverish a 4-hourly recording is
adequate.
 A central venous line is usually inserted in
order to monitor the central venous pressure
2-hourly or more frequently as necessary.

 Urinary output is accurately assessed by the

insertion of an endwelling catheter. Oligouria
or anuria indicates suppression of renal
function
 The urine should be tested for the presence
of protein, which may also be tested for the
pregnancy-included hypertension.

 Fluid intake must also be recorded accurately

and fluid balance assessed with the aid of the
central venous pressure recordings.
 Fundal height and abdominal girth are measured
hourly. An increase indicates continued bleeding
behind the placenta.

 If the fetus is alive, the fetal heart rate should be

monitored continuously with the aid of a
cardiotocograph.

 Any deterioration in the maternal or fetal

condition must be immediately reported to the
obstetrician.
Management of different degrees of
placental abruption
 Mild separation of the placenta: In this case
the placental separation and the
haemorrhage are slight.
 Mother and fetus are in a stable condition.
 There is no indication of maternal shock and

the fetus is alive and the heart sounds are

normal.
 The consistency of the uterus is normal and

there is no tenderness on abdominal

palpation.
 It may be difficult to differentiate this
condition from placenta praevia and from an
incidental cause of vaginal bleeding.

 Ultrasonic scan can determine the placental

location and identify any degree of concealed
bleeding.
 Fetal condition should be continuously
assessed while bleeding persists, using an
electronic fetal monitor.

 Subsequently electronic monitoring should be

carried out once or twice daily because any
degree of abruption by definition involves
partial separation of the placenta.
 If the mother is not in labour and the
gestation is less than 37 weeks she may be
cared for an antenatal area for a few days.

 She may then be allowed home if there is no

bleeding and the placenta has been found to
be in the upper uterine segment.
 Mothers who have passed the 37th week of
pregnancy will have an amniotomy to induce
labour.

 Further bleeding or evidence of fetal distress

may indicate that a caesarean section is
necessary.
:Moderate separation of the placenta
 This describes placental separation of about
one quarter. Up to 1000ml of blood may be
lost,

 some of which will escape per vagina and

some be retained behind the placenta as retro
placental clot or extravasations into the
uterine muscle.
 The mother will be shocked, with a raised
pulse rate and a lowered blood pressure.

 There will be a degree of uterine tenderness

and abdominal guarding. The fetus may be
alive although hypoxic, intra-uterine death is
a probability.
:Management
 The immediate aims of care are to reduce shock
and to replace blood loss.

 Fluid replacement should be monitored with the

aid of a central venous pressure line.

 The fetal condition should be assessed with an

electronic fetal monitor.

 if the fetus is alive, immediate caesarean section

may be indicated.
 If the fetus is in good condition or has
already died, vaginal delivery may be
contemplated.

 Delivery is advantageous because it enables

the uterus to contract and control the
bleeding.

 Amniotomy is usually sufficient to induce

labour but oxitocin may be used if necessary.
Severe separation of the placenta
 This is an acute obstetric emergency, at least
two-thirds of the placenta has become detached
and 2000 ml of blood or more are lost from the
circulation.

 Most or all of the blood will be concealed behind

the placenta.

 The mother will be severely shocked to a degree

far beyond what might be expected from the
amount of visible blood loss.
 The blood pressure will be lowered; the
reading may lie within the normal range due to
a preceding hypertension.

 The fetus is almost certainly dead. The woman

with have severe abdominal pain with
tenderness, the uterus has a board-like
consistency.
 Features associated with severe haemorrhage
are coagulation defects, renal failure and
pituitary failure.

 Treatment is the same as for moderate

haemorrhage.
 
Care of the baby
 Preparation should be made for an
asphyxiated baby. The pediatrician must be
present at the birth to resuscitate the infant.
The baby may need neonatal intensive care
following delivery.
 A baby who is born in good condition will of

course require minimal resuscitation and may

be transferred to the postnatal area with his
mother.
Psychological care
When a woman has a placental abruption she
and her partner must be kept fully informed
of what is happening at all times.
 The doctor should have a full and discussion

with them about the events and the

prognosis.
 The nurse should ensure that the partner is

offered support and adequate explanation if

the woman requires emergency surgery or if
her condition deteriorates suddenly.
Complications
 Disseminated intravascular coagulation is a
complication of moderate to severe placental
abruption.

 Postpartum haemorrhage may occur.

 Renal failure.

 Fetal hypoxia and fetal death.