LESSON PLAN

ON
ANTEPARTUM HEMORRHAGE
 OBJECTIVES
Student Teacher Objectives: End of this session I am able to

 Develop high levels of teaching competence through guided teaching experience.

 Design instruction and assessment to promote student learning.
 Create and implement effective lesson plans to meet the individual needs of diverse learners.
 Develop competence in creating and using instructional materials and techniques.
 Utilize technology for instruction and communication.
 Create an effective classroom management plan.
 Create a positive, productive classroom environment.
 Engage in self-evaluation and professional goal setting.
 Establish professional relationships with fellow teachers, students, administrators, and parents.
 Fulfill professional roles and responsibilities.
 OBJECTIVES

GENERAL OBJECTIVE: At the end of the lesson plan on antepartum hemorrhage, students will be able to gain in-depth
knowledge regarding Antepartum hemorrhage.

SPECIFIC OBJECTIVES: At the end of the class students will be able to,

 To define Antepartum hemorrhage

 To explain the incidence and etiology of Antepartum hemorrhage
 To enlist the classification and grades of Antepartum hemorrhage
 To define Placenta Previa
 To explain the incidence and etiology of Placenta Previa
 To discuss the classification of Placenta Previa
 To enumerate the diagnosis of Placenta Previa
 To discuss about the management of Placenta Previa
 To illustrate and explain the maternal and fetal complications of Placenta Previa
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
2 min ANTEPARTUM HEMORRHAGE Lecture Black
method board
 The uterus is the muscular organ that contains the developing baby during
pregnancy. The lowest segment of the uterus is a narrowed portion called
the cervix. This cervix has an opening (the OS) that leads into the vagina, or
birth canal. The placenta is the organ that attaches to the wall of the
uterus during pregnancy. The placenta allows nutrients and Oxygen from
the mother's blood circulation to pass into the developing baby (the fetus)
via the umbilical cord.
 During labor, the muscles of the uterus contract repeatedly. This allows the
cervix to begin to grow thinner (called effacement) and more open
(dilatation).Eventually, the cervix will become completely effaced and
dilated, and the baby can leave the uterus and enter the birth canal. Under
normal circumstances, the baby will emerge through the mother's vagina
during birth.
 Any bleeding from or into the genital tract after the period of viability (28
weeks in India, 24 weeks in western countries) but before the birth of the
baby is termed as antepartum hemorrhage (APH).
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
To Define 3min DEFNITION Lectuer PPT Define
the method Antepartum
1. Antepartum haemorrhage (APH) defined as bleeding from the genital week of
Antepartum haemorrhag
hemorrhage pregnancy and before the birth of a baby. e?
- B.T. Basvanthappa
2. Antepartum haemorrhage is defined as bleeding from or into the genital tract
after the 28th week of pregnancy but before the birth of the baby.
- D.C. Dutta
3. Any bleeding that occurs from the genital tract after the stage of viability, but
before the birth of the child. -S. N. Daftary

To explain INCIDENCE: Lectuer What is the

the 2 min method PPT incidence
About one third of APH belong to placenta praevia. The incidence of
incidence about
about placenta praevia n from 0.5 - 1% amongst hospital deliveries. In 80% cases, it is Antepartum
Antepartum haemorrhag
found to multiparous women. The overall incidence of Abruptio placentae is about
haemorrhag e?
e 1 in 150 deliveries.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
To discuss 3 min ETIOLOGY: Various causes of APH are Lectuer Black What are all
about the method board the Etiology
I. Maternal causes
etiology of of
Antepartum 1. Placental bleeding (a) Placenta previa 35%(b) Abruptio placentae 35% Antepartum
haemorrhag haemorrhag
2. Marginal placental bleeding and unexplained or indeterminate APH 25%
e. e?
3. Extra placental causes
(a) Excessive show (b) Cervical erosion and ectropion (c) Local infections of
cervix and vagina (d) Cervical and vaginal trauma (e) Cervical polyp (f) CIN
and carcinoma cervix (g) Vulvo-vaginal varicosities (h) Post coital bleeding
(i) Scar dehiscence and uterine rupture j. Medical causes (Factors VIll and I
deficiency)
4. Miscellaneous placental and umbilical cord anomalies
(a) Circumvallate placenta
(b) Velamentous insertion of the umbilical cord
(c) Succenturiate lobe
(d) Congenital arterio-venous malformation
(e) Aberrant blood vessel
II. FETAL CAUSES
Vasa previa< 1%
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
To 1 min CLASSIFICATION OF APH: Lectuer Leafle What are all
enumerate method t the
1. Placenta previa
the classification
classificatio 2. Abruptio Placenta Antepartum
n of haemorrhag
3. Vasa previa
Antepartum e?
haemorrhag 4. Extraplacental bleeding
e.
5. Placental site bleeding

PLACENTA PREVIA
The placenta develops in an abnormal location. Normally, the placenta
should develop relatively high up in the uterus, on the front or back wall. In about
one in 200 births, the placenta will be located low in the uterus, partially or totally
covering the os. This causes particular problems in late pregnancy, when the lower
part of the uterus begins to take on a new formation in preparation for delivery.
As the cervix begins to efface and dilate, the attachments of the placenta to the
uterus are damaged, resulting in bleeding.
Placenta previa is defined as a placenta that is partially or wholly situated in the
lower uterine segment.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING

INCIDENCE:

It is 1 in 300 to 1 in 400 deliveries (0.3%) in different populations. It accounts for

one-third cases of APH.
DEFINITION
To define 2min 1. In placenta praevia, placenta is implanted partially or completely on the Lecture Black What is
the placenta method board Placenta
lower uterine segment
previa. previa?
- C.S. Dawn
2. When the placenta is implanted partially or completely over the lower
uterine segment it is called as placenta praevia.
- D.C. Dutta.
3. In Placenta praevia, the placenta is implanted in the lower uterine segment
near or over the internal cervical os.
-According to Bobak
4. The placenta is partially or wholly implanted in the lower uterine segment
on either the anterior or posterior wall. The anterior location is less serious
than the posterior.
-According to Myles
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING

ETIOLOGY
The exact cause of placenta previa is not known. Lecture PPT
To describe 3min method What are
Various accepted theories are as follows:
the etiology the etiology
of placenta 1. Age: It is more common in old age. of Placenta
previa. previa?
2. Parity: It is more common in multiparous women
3. Dropping down' theory of fertilized ovum and its implantation in the lower
uterine
segment instead of the upper segment. This could be the result of decidual
reaction in
the upper segment. It central placenta previa.
4. Defective decidua basalis as seen in
(i) elderly patients
(ii) grand multipara,
(iii) history of manual removal of placenta,
(iv) endometrial ablation,
(v) previous dilatation and curettage,
(vi) MTP or spontaneous abortion explains
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
5. Hyperplacentosis: Bigger placenta in multiple pregnancy, anemia and Rh
isoimmunization may encroach on lower segment.
6. Previous lower segment cesarean delivery: Incidence increases with each
successive cesarean delivery being 0.3% without any cesarean while it is 0.7%,
139, 470 and 10% withprevious 2, 3, 4 and 5 cesareans respectively (2.5 times
rise
each time).
7. Fetal malpresentations may be the cause or effect.
8. Uterine anomalies
9. Persistence of chorionic laevae which encroach on the lower uterine segment.
Circumvallate
10. Placental and cord abnormalities: placenta, battledore placenta, placenta
Membranous succenturiate lobe, multipartite placenta, velane insertion of the
cord
11. Smoking and drug abuse increases the risk of placenta previa (RCOG 2018).
Carbon monoxide production during smoking leads (cocaine): Smoking to
tissue
Hypoxia with compensatory placental hypertrophy due to possible result of
 OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
inflammatory or atrophic changes.
12. Certain ethnic groups, e.g. Asian women
13. Maternal Serum AFP: Women with otherwise unexplained increased
screening
levels of MSAFP are at greater risk for placenta previa. MSAFP levels of > 2.0
mom
at 16 weeks screening were at increased risk for late-pregnancy bleeding and
preterm birth.
14. Fibroid uterus increases risk of placenta previa.
15. Assisted reproductive techniques (ART)are associated With increased risk of
placenta previa (RCOG 2018).

CLASSIFICATION / GRADES
Fetal medicine workshop of National institute of Health has recommended
following classification: Lecture PPT What are
To discuss 2min method the
1. Placenta previa:
about classification
classificatio The internal os is partially completely covered by placenta. It can be further total or grades of
n of placenta
or partial placenta previa.
placenta previa?
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
previa. 2. Low-lying placenta:
Implantation in lower segment with placental edge lying within 2 cm of perimeter
around os but does not cOver the internal os.
In older classification were four grades or types of placenta previa Type 2
posterior, type 3 and type 4 are called major (degree) placenta previa while types
1 and 2 A are called minor degree of placenta previa.
Dangerous placenta previa (Type 2 posterior placenta previa)
Placenta is situated the posterior wall of the lower uterine segment reaching the
internal os.
EFFECTS
1. Placenta overlies the sacral promontory, thus reducing the antero-posterior
diameter of pelvic inlet by about 2.5 cm (thickness of the placenta).
2. Prevents engagement of the presenting part.
3. Cord compression and cord prolapse can occur causing fetal jeopardy.
4. More chances of fetal hypoxia and mortality due to excessive compression of
the placenta if vaginal delivery is allowed.
5. Interferes with its pressure effect on the separated placenta to stop
hemorrhage.
 OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
6. Type 2 posterior placenta previa is managed like major degree placenta previa
and is an indication of cesarean delivery.
CLINICAL FEATURES OF PLACENTA PREVIA
SYMPTOMS
Lecture
To illustrate 3min The main and often the only symptom of placenta previa is vaginal method PPT What are
the clinical the clinical
bleeding. profuse, recurrent and
features of features of
placenta 1. Sudden onset of painless, apparently causeless (without trauma, coitus, placenta
previa. previa?
etc.) bleeding without onset of labor is characteristic of placenta previa.
(4P's: Painless and profuse bleeding in placenta previa).
2. The first bleeding called warning' hemorrhage is often minor.
Bleeding occurs before 38 weeks and is more severe in major degrees of
placenta previa. About 80% of all women with placenta previa bleed before the
onset of labor. In olden days, placenta previa was called unavoidable or inevitable
antepartum hemorrhage as placenta situated in the developing and stretching
lower uterine segment ultimately causes bleeding during pregnancy or labor.
Chances of bleeding are more if placenta is located partly in upper and
partly in lower segment (type 2 and type 3) due to differential contraction of
upper and lower segments.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
But when bleeding occurs it is much more severe in central placenta
previa.
Signs
General Examination
1. Pallor is proportionate to visible blood loss.
2. The patient may or may not be in shock depending on the amount of
bleeding.
Abdominal examination
1. The abdomen is soft.
2. The uterus is relaxed and non-tender corresponding to the period of
amenorrhoea.
3. Malpresentations like breech, transverse or unstable lie are more common in
placenta previa (35% cases).
4. Fetal parts are easily felt and fetal heart is usually normal.
5. The presenting part is floating. A deeply engaged presenting part usually rules
out placenta previa or points to only minor placenta previa.
6. Fetal heart sound and placental soufflé are well auscultated, unless there is a
major separation of the placenta with the patient in exsanguinated condition.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
Fetal bradycardia on pressing the head down into the pelvis and its prompt
recovery on release of the pressure is suggestive of low lying placenta specially of
posterior type (Stallworthy's sign). But this sign is not very reliable as fetal
bradycardia can be due to fetal head compression even in a normal pregnancy.

Vulval Inspection
Inspection is done to note whether the bleeding is still occurring and the
amount and character of blood loss. It is usually fresh (bright red) as the blood
quickly trickles down through the cervix from the nearby placenta.

DIAGNOSIS
1. CLINICAL
To explain (a) High index of suspicion should be kept if there is fetal malpresentation or free- Lecture PPT
about 5min method What is the
floating presenting part.Pervaginal bleeding in late pregnancy or presence of
diagnosis of diagnosis of
placenta predisposing factors arouse suspicion of placenta previa. placenta
previa. previa?
(b) The mid pregnancy routine anomaly scan after 16 weeks of pregnancy should
include placental localisation to identify placenta previa (placenta lies directly over
the internal os) or low lying placenta, i.e., placental edge is less than 20 mm from
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
the internal os in transabdominal or transvaginal scan. In all such cases a follow-up
ultrasound examination including a TVS is recommended at 32 weeks of gestation
to diagnose persistent placenta previa or low placenta. lying
(c) Vaginal examination. A pervaginal examination is contraindicated in a case of
APH, unless placenta previa has been ruled out because it may result in serious
life- threatening hemorrhage. However, a double set up vaginal examination may
be performed.

2. INVESTIGATIONS
Ultrasound is the modality of choice because it is safe, precise and simple
with accuracy of 98% after 30 weeks of gestation . Maternal obesity and posterior
placenta may obscure the placental view.
Route
1. Transabdominal (TAS) ultrasound is the first test performed. It can give
false positive results due to full bladder and myometrial contraction.
2. Transvaginal ultrasound (TVS) is better as there b less distortion of the
anatomy of the lower uterine required for it. segment and cervix. Full
bladder is not required for it
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
3. Transperineal or translabial ultrasound can also be used. Three-
dimensional scan and Color Doppler flow can also be used.
Difference Between the Placenta Previa and Abruptio placentae
Characteristics Placenta previa Abruptiopreviaprevia
Lecture PPT
1. Definition It is defined as a It is defined as an antepartum
To explain method What is the
placenta that is hemorrhage from premature
the 6 min difference
partially or wholly separation of a normally situated
difference between
situated in the lower placenta in the upper segment
between placenta
uterine segment.
placenta previa and
2. Incidence 1 in 300 deliveries. 1 in 200 deliveries.
previa and abruption
abruption 3. Etiology Not known exactly. Not known exactly. It is common placenta?
placenta. It is more common in hypertensive disorders of
in elderly and pregnancy, trauma,
multiparous women thrombophilias, nutritional
with deficiencies (folate deficiency),
hyperplacentosis, sudden decompression of uterus
previous cesarean and with past history of
delivery and abruption.
placental and cord
anomalies.
4. History taking
Vaginal bleeding Vaginal bleeding is Vaginal bleeding is usually
sudden, painless, painful, continuous and is often
profuse, recurrent related to some cause like
and apparently hypertensive disorders of
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
causeless (no pregnancy% trauma, etc. Blood is
trauma) and usually dark coloured and
without onset of concealed or mixed in nature.
labor. Blood is
bright red and is
always revealed in
nature.
Pain abdomen Usually absent Usually present, acute in severe
cases
Hypertensive Usually absent May be present in about 35%
disorders of cases.
pregnancy
5. General Physical There may be pallor, Pallor, tachycardia, hypotension
Examination sweating, and shock may be more (out of
hypotension proportion) in concealed and
tachycardia which mixed abruption. There may be
are proportionate to hypertension in some cases.
the amount of
revealed blood loss.
Hypertension is
usually absent.
Heart and chest Usually normal or Tachycardia is usually present.
examination tachycardia
6. Abdominal
Examination
Fundal height Usually as per Fundal height may be more than
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
gestation gestation due to concealed or
mixed hemorrhage.
Consistency Uterus is usually soft Uterus is usually tense, tender
and relaxed. and hard especially in concealed
and mixed abruption.
Fetal parts They are easily felt. They are not easily palpable.
Fetal heart sound It is usually normal It may be absent due to placental
and regular. separation, especially in
concealed or mixed abruption.
Malpresentations Malpresentations Malpresentations absent. usually
like breech, absent.
transverse lie or Presenting part (usually head)
oblique lie are more tends to get engaged early.
common as placenta
does not let head
descend down in
the pelvis.
Presenting part is
usually high up due
to placenta being
there.
7. Vaginal It is contraindicated Placenta is not felt in the lower
examination in placenta previa uterine segment within reach of
due to risk of brisk the finger. Instead, soft and
hemorrhage. If friable blood clots are palpable.
performed in
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
operation theatre
with arranged
blood, placenta is
felt in the lower
segment .

MANAGEMENT
To discuss TREATMENT Lecture
the 3 min method PPT
At Home and Transfer to Hospital :
managemen What is the
t of placenta After quick history, general physical examination and gentle abdomen managemen
previa. t of placenta
examination (but no vaginal examination), once antepartum hemorrhage is
previa?
visible, patient is shifted in an ambulance to a suitable hospital where there
are adequate facilities for blood transfusion, 24 hour cesarean delivery and
nursery care. A health care personnel should be with the patient. An
intravenous drip is started with Ringer lactate or dextrose saline solution and
is continued in the ambulance. Preferably relatives fit to donate blood should
also go with the patient. The woman should be Iying down during transfer.
Expectant Management (Macafee and Johnson regimen)
The aim is to continue pregnancy in gestation less than 37 weeks for fetal
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
maturity without compromising maternal health in a centre with round-the-
clock facilities for blood transfusion and cesarean delivery by providing bed
rest, iron and calcium supplementation.
Indications for Expectant Management
1. Good general condition of the mother (hemoglobin > 10 g/dL).
2. Gestation is less than 37 weeks.
3. Absence of active vaginal bleeding
4. Patient not in labour.
5. Good fetal condition as assessed by ultrasound and non-stress test (NST).
There are no major congenital malformations.
CESAREAN SECTION DELIVERY
Cesarean delivery without vaginal examination is treatment of choice for
major degree placenta previa.
It enables not only to reduce maternal risk but also to improve fetal
outcome.
The indications of cesarean delivery
1. Major degree of placenta previa (Type 2 posterior, Type 3 and Type 4)
irrespective of fetal condition tor maternal sake.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
2. Minor degree of placenta previa with excessive bleeding inspite of
amniotomy with fetal distress.
3. Presence of other complicating factors with minor degrees of placenta
previa where vaginal delivery is unsafe.

Elective cesarean section for placenta previa must be done during daytime so
that there are senior doctors of the obstetrics, pediatrics and anesthesia
departments either directly performing or supervising the procedures.
Keeping adequate blood in hand is life saving especially in complicated cases like
placenta accreta, percreta, etc., or cases with previous history of cesarean delivery
in an emergency situation.
However, if patient is in shock and bleeding continues, cesarean section is
to be performed inemergency alongwith concomitant resuscitation by starting
two intravenous drips using wide bore cannulae and arranging 4 units of blood.
Skin incision can be infraumbilical vertical incision which is fast and gives
better visualization and also allows classical cesarean delivery if needed. Placenta
can be cut if anterior. Postpartum hemorrhage is energetically treated with
oxytocics and prostaglandins.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING

MATERNAL COMPLICATIONS
To explain 5 min Lecture PPT What are
During Antenatal Period bleeding:
about method the maternal
maternal 1. Vaginal bleeding : Antepartum hemorrhage with different severity of shock is andfetal
and complication
the most important and inevitable complication of placenta previa. First bout of
fetalcomplic of placenta
ations of vaginal bleeding is usually a smaller bleed (warning hemorrhage) but a severe and previa?
placenta
potentially life threatening hemorrhage can be provoked by a vaginal examination
previa.
done outside the hospital setting.
2. Malpresentations: Placenta situated in the lower uterine segment prevents
engagement of fetal head causing increased incidence of malpresentations like
breech presentation, transverse, oblique and unstable lie. One should always do
ultrasound in presence of a malpresentation at term in a primigravida.
3. Preterm labor both spontaneous or iatrogenic is more common.
4. Long hospital stay
5. Anemia
6. Rhesus sensitization in Rh-negative woman.
7. Hemorrhagic shock with hypotension
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
8. Adult respiratory distress syndrome
9. Disseminated intravascular coagulation (rare)
10. Acute renal failure (rare).
During Labor
1. Premature rupture of membranes.
2. Cord prolapse
3. Intrapartum hemorrhage
4. Slow dilatation of cervix
5. More operative interference
6. Increased incidence of postpartum hemorrhage due to imperfect
contraction and retraction of the lower uterine segment, large surface
area of placenta with atonic uterus, pre-existing anemia, association
of morbidly adherent placenta and tears in the cervix and uterus due
to excess softness and vascularity.
7. Retained placenta is more common due to larger surface area and
morbidly adherent placenta necessitating manual removal of
placenta.
8. Abruption of placenta can co-exist with placenta previa.
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
9. Hysterectomy may be needed.
10. Air embolism.
During Puerperium
1. Secondary postpartum hemorrhage
2.Puerperal sepsis due to increased need of operative interference, pre-existing
anemia and placental site being near to vagina.
3. Non-involution and subinvolution of uterus due to imperfect retraction of
uterus,
anesthesia and more operative interference.
4. Venous thromboembolism is more common (0.5%).
FETAL COMPLICATIONS
The reduction of fetal deaths is mainly due to judicious use of expectant
treatment (thereby reducing the loss from prematurity), liberal use of cesarean
delivery, which greatly lessens the loss from anoxia and improvement in the
neonatal care unit.
1. Perinatal mortality ranges from 7-25% and is three times higher than the
general population.
The causes of death are: (a) Prematurity
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
(b) Asphyxia due to separation of placenta
(c) Congenital malformations
(d) Cord accidents
(e) Maternal hypovolemia and shock
2. Prematurity : Spontaneous or iatrogenic
3. Low birth weight babies due to preterm labor or chronic placental insufficiency
due to repeated small bouts of hemorrhage.
4. A Fetal hypoxia can occur due to placental separation and placental and cord
compression.
5 Fetal injuries can occur due to operative delivery.
6. Congenital malformations like spina bifida are three times more common in
placenta previa. 7. Fetal malpresentations are more common.
8. Fetal hypovolemia is more common.
MATERNAL MORTALITY
There has been a substantial reduction of maternal deaths in placenta previa
throughout the world due to the following reasons.
1. Early diagnosis (diagnosis can even be made prior to bleeding)
2. Avoiding internal examination outside the hospital
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
3. Free availability of blood transfusion facilities
4. Effective antibiotics
5. Liberal use of cesarean delivery with expert anesthetists 6. Skill and judgement
for management.
In developing countries, maternal mortality from placenta previa ranges from 1%
to 5% due to inadequate antenatal care, delay in referral and road and transport
difficulties. The causes of morbidity and mortality are hemorrhage, shock and
operative del
PREVENTION
Placenta previa is not usually preventable as in most cases the etiology is
known. The following modalities are beneficial.
1. Universal institutional antenatal care of all women to improve their general
health and to correct anemia.
2. Family planning and limitation of births reduce the incidence of placenta
previa.
3. Reducing the rising rate of cesarean deliveries as previous
Cesarean delivery predisposes to placenta previa.
4. Universal targetted scan of all weeks can diagnose low lying placenta which
OBJECTIVE TIME CONTENT METHOD AV EVALUATIO
OF AIDS N
TEACHING
can laterbecome placenta previa
PROGNOSIS
Use of expectant management, more liberal use of blood and blood
products, avoiding vaginal examination and liberal use of cesarean section
(delivery) has significantly improved maternal and perinatal outcome in placenta
previa.
NURSING DIAGNOSIS :
1. Ineffective tissue perfusion , placental, related to excessive bleeding causing
fetal compromise
2. Fluid volume deficient related to excessive bleeding
3. Anxiety related to excessive bleeding, procedures and possible maternal- fetal
complications.
4. Risk for infection related to excessive blood loss and open vessels near cervix.
SUMMARY :

Thus the late pregnacy bleeding refers to heavy bleeding during pregnancy, labour, and the puerperium. Bleeding may be vaginally and
external or less commonly but more dangerous, internal into the cavity. Typically bleeding is related to the pregnancy itself, but some forms of
bleeding are caused by other events.
Antepartum hemorrhage is defined as bleeding from the genital tract after fetal viability and before delivery. Causes of APH include Placenta
praevia, Abruption placenta,Local causes like polyp. cancer cervix, varicose veins and local trauma, Circumvallate placenta, Vasa praevia and
Unclassified or indeterminate hemorrhage.
Postpartum haemarrhage is arbitary and is related to the amount of blood loss in excess of 500ml following birth of the baby, this is two types
primary pph and secondary pph and management

CONCLUSION :
Late pregnancy bleeding is a very scary. It's common. However and it isn't always a sign of trouble. Most women who experience vaginal
bleeding during pregnancy particularly during the second & third trimester go on to deliver healthy babies. Still, it's important to take vaginal
bleeding during pregnancy seriously.
Sometimes vaginal bleeding during pregnancy indicates an impending miscarriage or a problem that needs prompt treatment

Thus it is the responsibility of the nurse in perfoming a comprehensive assessment as she is involved in counselling mothers about early and
late pregnancy bleeding, needs to understand their own ethical position on this matter if they render quality of care to their mothers .
 Bibliography

J. B Sharma, " A textbook of midwifery and obstetrical nursing", 2nd edition, Aarya publications, 2021, page no : 260 - 273 & 434 - 442
1. Neelam kumari, Shivani sharma, Dr. Preeti Gupta, " A textbook of midwifery and Gynaecological nursing", 1st edition, 2020, pv publishers,
page no: 261-327.
2. A.Ramadevi,S. Jyothi, S. N. Kalavathi "A text book of midwifery obstetrical nursing", 2021,florence publications, page no : 7.40 - 7.52 & 9.46
- 9.56
3. Dc. Dutta, A textbook of Obstetrics ", edition, publications, page no : 300-320.
4. Lowdermilk, perry, " A textbook of maternity & womens health care",11th edition, Elsevier publication, page no : 802 - 807
5. K. Sandhu, " A textbook of Obstetrics and midwifery ", 1st edition,lotus publishers, 2013, page no :230 - 236 & 177 - 182
6. Daftary chakravarthi, manual of obstetrics, 3rd edition, Elsevier publication 242 – 244,361 - 366