4th Stage Obstetrics ‫ مصرية رشاد‬.

‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Antepartum Hemorrhage
This is defined as vaginal bleeding from 24wk to the delivery of the baby.
The causes are placental or local.
Placental causes:
1- Placental abruption.
2- Placenta praevia.
3- Vasa praevia.
Local Causes:
1- Cervicitis.
2- Cervical Ectropion.
3- Cervical CA.
4- Vaginal trauma.
5- Vaginal infection.

PLACENTA PREVIA
Definition:
Placenta Previa:
Abnormal location of the placenta over, or in close proximity to the internal OS.
Incidence:
- Approximately 1 /250 pregnancy.
- Nulliparas: 1/1000~1/1500 pregnancy.
- Grand multiparas: 1/20.
Classification:
1- Complete (total) placenta previa: entire cervical OS is covered.
2- Partial placenta previa: the margin of the placenta extends across but not
all of the internal OS.
3- Marginal: edge of the placenta lies adjacent to the internal OS.
4- Low lying placenta: placenta is located near but not directly adjacent to the
internal OS.

1
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Etiology:
- Mechanism: abnormal vascularization.
- Predisposing factors:
• Twin pregnancy.
• Increasing maternal age.
• Increasing parity.
• Previous cesarean section.
Diagnosis:
- Painless vaginal bleed:
First bleeding episode is 29~30 weeks.
- Ultrasonography:
Benefit in localizing the placenta and diagnosis placenta previa.

Caution:
- Double setup vaginal examination
No digital vaginal or rectal examination is performed in case of placenta
previa, only as a final and definitive event and only under conditions of
double set up.
This procedure involves careful evaluation of the cervix in the operation
room with full preparations for rapid cesarean section.

Management:
a- Basic management:
1- Initial hospitalization with hemodynamic stabilization.
2- Enforced bed rest.
3- Restrictions of activity.
b- Expectant management
- (allow for further fetal growth and maturation)
1- Blood transfusion is given as necessary.
2- Amniocentesis for fetal lung maturity testing.
3- Cesarean birth if fetus is thought to be mature.

2
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Indication of vaginal delivery:

1- Delivery can be accomplished with minimal blood loss.
2- Fetus is dead.
3- Major fetal malformation

Complication:
1- Placenta previa accrete.
2- Postpartum hemopphage.
3- Increasing maternal mortality and perinatal mortality.
Vasa Previa:

VASA PREVIA:
Definition:
Vasa previa refers to fetal vessels running through the membranes over
the cervix and under the fetal presenting part, unprotected by placenta or
umbilical cord.
The condition usually results either from a velamentous insertion of the
cord into the membranes rather than the placenta or from vessels running
between lobes of a placenta with one or more accessory lobes.

3
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Clinical Importance:
Vasa previa is a condition which, undiagnosed, is associated with a
perinatal mortality of approximately 60%.76 The condition is important because,
when the membranes rupture, spontaneously or artificially, the fetal vessels
running through the membranes have a high risk of concomitant rupture,
frequently resulting in fetal exsanguinations and death.
Because the fetal blood volume is only about 80–100 mL/kg, loss of even
small amounts of blood could prove disastrous to the fetus. Pressure on the
unprotected vessels by the presenting part could lead to fetal asphyxia and
death.

Placental Abruption
General Consideration
- Definition:
Premature separation of the placenta from its site of implantation from 24
weeks of gestation until delivery of baby.
- Incidence: 0.4-2%.
GRADING:
- Grade 0: Separation not apparent until placenta examined > delivery.
- Grade 1: minimal - causes vaginal bleeding & alterations in maternal VS.
- Grade 2: moderate - + signs of fetal distress. Uterus tense & painful when
palpated.
- Grade 3: extreme (total) separation. Maternal shock/fetal death if immediate
intervention not done.
Etiology:
- Uncertain (primary cause).
- Risk factors:
1- Increased age and parity.
2- Vascular diseases: preeclampsia, chronic hypertension, renal disease.
3- Mechanical factors: trauma, intercourse, polyhydramnios.
4- Supine hypotensive syndrome.
5- Smoking, cocaine use, uterine myoma.

4
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Pathology:
- Main change:
Hemorrhage into the decidua basalis → decidua splits → decidural
hematoma → separation, compression, destruction of the placenta adjacent
to it.
- Types:
1- Revealed abruption. 2- Concealed abruption. 3- mixed type

5
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Manifestation:
- Vaginal bleeding companied with abdominal pain.
- Mild type:
Abruption≤ 1/3, apparent vaginal bleeding.
- Severe type:
Abruption > 1/3, large retroplacental hematoma, vaginal bleeding
companied by persistent abdominal pain, tenderness on the uterus, change
of fetal heart rate, shock and renal failure.
Examination:
- Abdominal examination:
1- Tender tense uterus (woody hard).
2- The fetus is difficult to palpate.
3- Fetus may be dead, in distress or unaffected (size-location of abruption).

Diagnosis:
- sign and symptom:
1- Vaginal bleeding. 4- High frequency contractions.
2- Uterine tenderness or back 5- Idiopathic preterm labor.
pain. 6- Dead fetus.
3- Fetal distress.
- Ultrasonography:
1- Position of placenta, severity of abruption, survival of fetus.
2- Signs: retro placental hematoma.
3- Negative findings do not exclude placental abruption

Complication:
1- DIC. 5- Fetomaternal hemorrhage.
2- Hypovolemic shock. 6- Perinatal mortality.
3- Amniotic fluid embolism. 7- Fetal growth restriction
4- Acute renal failure.

6
 4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Treatment:
1- Treatment will vary depending upon gestational age and the status of
mother and fetus.
2- Treatment of hypovolemic shock: intensive transfusion with blood.
3- Assessment of fetus.
4- Termination of pregnancy: CS or Vaginal delivery.

Postpartum Haemorrhage
Definitions:
- Primary PPH: blood loss of 500ml or more within 24hours of delivery.
- Secondary PPH: significant blood loss between 24 hours and 6 weeks after
birth.
Risk Factors:
- Most cases have no risk factors:
1- Previous PPH. 5- Polyhydramnios.
2- Antepartum haemorrhage. 6- Fibroids.
3- Grand multiparity. 7- Placenta praevia.
4- Multiple pregnancy. 8- Prolonged labour (&oxytocin).
Causes 4 T’s:
1- Tone. 3- Thrombin.
2- Tissue. 4- Trauma.

Tone Tissue Thrombin Trauma

- Previous PPH. - Retained - Abruption - Caesarean section
- Prolonged labour. placenta/ - PET (emergency >
- Age > 40 years. membrane/ clot. - Pyrexia elective).
- Big baby. - Intrauterine - Perineal trauma.
- Multiple death - Operative delivery.
pregnancy. - Amniotic fluid - Vaginal and
- Placenta praevia. embolism cervical tears.
- Obesity. - Uterine rupture.
- Asian ethnicity
DIC

7
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

Management:
- Nursing Management of Postpartum Hemorrhage
• Assessment:
 Identify Risk Factors in the Patient’s History.
 Assess:
1- Vital signs and general condition.
2- State of uterus.
3- Nature of bleeding.
4- Signs and symptoms of blood loss.
5- Amount of blood loss.
6- Compare laboratory reports.
Nursing Interventions:
- If atonic uterus:
 Inform the obstetrician. Feel consistency of the uterus.
 Massage the uterus to express clots and make it hard as follows. The
fundus is first gently felt with the fingertips to assess its consistency. If it is
soft and relaxed, the fundus is massaged with a smooth circular motion,
applying no undue pressure. When a contraction occurs, the hand is held
still.
 Assess the general physical condition of the mother. (Face, skin...).
 Monitor PR and blood pressure.
 Put the infant to the breast to suck or stimulate the nipple manually.
 Prepare instruments and equipment such as sterile gloves, cannula # 18,
IV set, catheter set... etc.
 Administer oxytocic's as ordered.
 Start IV infusion and oxytocin drip.
 Empty the bladder.
 Examine the expelled placenta and membranes for completeness.
 Administer medications as ordered.
- Reassure the mother:
 Never leave the mother alone.
 Touch the mother’s hand and talk to her.

8
4th Stage Obstetrics ‫ مصرية رشاد‬.‫د‬
Antepartum Hemorrhage, Placenta Previa, placenta abruption, Postpartum Hemorrhage

- In cases of traumatic bleeding:

 Press on the tear or laceration.
 Prepare equipment and instruments, sterile gloves, sterile needles and
catgut, sterile needle holder, forceps, sterile kidney basin, scissors, sterile
gauze etc.
Secondary Postpartum Hemorrhage:
- Commonly occurs between 10 to 14 days after delivery.
- Common causes:
1- Retained bits of cotyledon or membranes.
2- Separation of a slough exposing a bleeding vessel.
3- Sub involution at the placental site due to infection.
Clinical Manifestations:
1- Sudden episodes of bleeding with bright red blood of varying amounts.
2- Sub involution of uterus.
3- Sepsis.
4- Anemia.
Nursing Management:
- Follow the same steps as in the case of postpartum hemorrhage due to
retained parts of placenta.
- In cases of postpartum hemorrhage due to infection the following should be
done:
 Reassure the mother.
 Monitor TPR and blood pressure.
 Start IV infusion and blood transfusion according to doctor’s orders.
 Prepare sterile instruments and equipment needed for examination.
 Empty the bladder.
 Administer medications as ordered (broad-spectrum antibiotic).
 Follow strict aseptic technique while providing care to the woman.
 Frequent changing of sanitary pads.