ANTEPARTUM HAEMORRHAGE

Normal Placenta During Childbirth

Process of placental growth and uterine wall changes during pregnancy

1. The placenta grows with the placental site during pregnancy.

2. During pregnancy and early labor the area of the placental site probably changes little,
even during uterine contractions.
3. The semirigid, noncontractile placenta cannot alter its surface area.

Anatomy of the uterine/placental compartment at the time of birth

1. The cotyledons of the maternal surface of the placenta extend into the decidua basalis, which
forms a natural cleavage plane between the placenta and the uterine wall.
2. There are interlacing uterine muscle bundles, consisting of tiny myofibrils, around the branches
of the uterine arteries that run through the wall of the uterus to the placental area.
3. The placental site is usually located on either the anterior or the posterior uterine wall.
4. The amniotic membranes are adhered to the inner wall of the uterus except where the placenta
is located.

In obstetrics, antepartum haemorrhage (APH), also prepartum hemorrhage, is bleeding from

the vagina during pregnancy from twenty four weeks gestational age to term.

It should be considered a medical emergency (regardless of whether there is pain) and medical
attention should be sought immediately, as if it is left untreated it can lead to death of the mother
and/or fetus.

It can be associated with reduced fetal birth weight.[1]

Bleeding without pain is most frequently bloody show, which is benign; however, it may also be
placenta previa (in which both the mother and fetus are in danger). Painful APH is most
frequently placental abruption (which may also lead to adverse fetal and/or maternal outcomes)

Definition:

It is defined as bleeding form or into the genital tract after the 28 th week of
pregnancy but before the birth of the baby (the first and second stage of labour are thus
included). The 28th week is taken arbitrarily as the lower limit of fetal viability. The
incidence is about 3% amongst hospital deliveries.

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Causes:

The causes of antepartum hemorrhage fall into the following categories. The
hospital figures do not give a true picture of the incidence of the different varieties.
However, on an average, the incidence of placenta praevia, abruption placenta and the
indeterminate group is almost the same.

Cause of antepartum hemorrhage

A.P.H.

↓ ↓ ↓

Placental bleeding (70%) Unexplained (25%) Extra placental causes (5%)

↓ or Local cervico-vaginal lesions:

______________ Indeterminate - Cervical polyp

↓ ↓ (Excluding placental - Carcinoma cervix

Placenta Abruptio bleeding and local - Varicose vein

Praevia placentae lesions) - Local trauma

(35%) (35%)

PLACENTA PRAEVIA

Definition:

When the placenta is implanted partially or completely over the lower uterine
segment it is called placenta praevia. The term praevia (L, in front of) denotes the
position of the placenta in relation to the presenting part.

Incidence:

About one-third cases of antepartum hemorrhage belong to placenta praevia.

The incidence of placenta praevia ranges from 0.5% - 1% amongst hospital deliveries.
In 80% cases, it is found to multiparous women. The incidence is increased beyond the
age of 35, with high birth order pregnancies and in multiple pregnancy. Increased family
planning acceptance with limitation and spacing of birth, lowers the incidence of
placenta praevia.

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 ETIOLOGY

The exact cause of implantation of the placenta in the lower segment is not
known. The following theories are postulated.

 Dropping down theory: The fertilized ovum drops down and is implanted in the
lower segment. Poor decidual reaction in the upper uterine segment may be the
cause. Failure of zona pellucid to disappear in time can be a hypothetical
possibility. This explains the formation of central placenta praevia.

 Persistence of chorionic activity in the deciduas capsularis and its subsequent

development into capsular placenta which comes in contact with decidua vera of
the lower segment can explain the formation of lesser degrees of placenta
praevia.

 Defective decidua, results in spreading of the chorionic villi over a wide area in
the uterine wall to get nourishment. During this process, not only the placenta
becomes membranous but encroaches onto the lower segment. Such a placenta
praevia may invade the underlying decidua or myometrum to causes placenta
accrete, increta or percreta.

 Big surface area of the placenta as in twins may encroach onto the lower
segment.

The predisposing factors of placenta praevia are – (a) Multiparity, (b) Increased
maternal age (> 35 years), (c) History of previous caesarean section any other scar in
the uterus (myomectomy or hysterotomy), (d) Placental size (mentioned before) and
abnormality (succenturiate lobes), (e) Smoking – causes placental hypertrophpy to
compensate carbonmonoxide induced hypoxaema.

PATHOLOGICAL ANATOMY:

Placenta – The placenta may be large and thin. There is often a tongue shaped
extension from the main placental mass. Extensive areas of degeneration with infarction
and calcification may be evident. The placenta may be morbidly adherent due to poor
decidua formation in the lower segment.

Umbilical cord – The cord may be attached to the margin (battledore) or into the
membranes (velamentous). The insertion of the cord may be close to the internal or the
fetal vessels may run across the internal or in velamentous insertion giving rise to vasa
praevia which may rupture along with rupture of the membranes.

Lower uterine segment – Due to increased vascularity, the lower uterine segment and
the cervix becomes soft and more friable.

TYPES OR DEGREES:

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 There are four types of placenta praevia depending upon the degree of extension
of placenta to the lower segment.

Type – I (Low-lying): The major part of the placenta is attached to the upper segment
and onlyo the lower margin encroaches onto the lower segment but not upto the os.

Type – II (Marginal): The placenta reaches the margin of the internal os but does not
cover it.

Type – III (Incomplete or partial central): The placenta covers the internal os partially
(covers the internal os when closed but does not entirely do so when fully dilated).

Type – IV (Central or total): The placenta completely covers the internal os even after it
is fully dilated.

In the majority, the placenta lies either in the anterior or posterior wall, the latter
is more common. Type – III and IV constitute about one-third of the cases. For clinical
purpose, the types are graded into mild degree (Type-I and II anterior) and major
degree (Type-II posterior, III and IV).

Dangerous placenta praevia is the name given to the type – II posterior placenta
praevia. (1) Because of the curved birth canal major thickness of the placenta (about
2.5 cm) overlies the sacral promontory, thereby diminishing the antero-posterior
diameter of the inlet and prevents engagement of the presenting to stop bleeding. (2)
Placenta is more likely oto compressed, if vaginal delivery is allowed. (3) More chance
of cord compression or cord prolapse. The last two may produce fetal anoxia or even
death.

CAUSES OF BLEEDING:

As the placental growth slows down in later months and the lower segment
progressively dilates, the inelastic placenta is sheard off the wall of the lower segment.
This leads to opening up of utero-placental vessels and leads to an episode of bleeding.
As it is a physiological phenomenon which leads to the separation of the placenta, the
bleeding is said to b e inevitable. However, the separation of the placenta may be
provoked by trauma including vaginal examination, coital act, external version or during
high rupture of the membranes. The blood is al most always maternal, although fetal
blood may escape from the torn villi specially when the placenta is separated durin g
trauma.

The mechanisms of spontaneous control of bleeding are : (1) Thrombosis of the

open sinuses. (2) Mechanical pressure by the presenting part. (3) Placental infarction.

Placental migration: Ultrasonography at 17 weeks of gestation, reveals placenta

covering the internal os in about 10% of cases. Repeat ultrasonography at 37 weeks
showed no placenta in the lower uterine segment in more the 90% of cases. During

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third trimester there is potential growth of lower uttering segment compared to the
placenta. Due to this disproportionate growth there is apparent migration of placenta
towards the fundus.

Pathophysiology:

Painless Vaginal Bleeding

Ultrasound

Risk Factors

Advanced Previous Uterine

Large Placenta
Surgery (Multiple Gestation, Erythroblastosis)
Maternal
Maternal Age Multiparity Smoking

Complete Previa Marginal Previa

Partial Previa Low-lying placenta

Bleeding Stops
Fetus Stable

Bed Rest

Observe
↓ Urine Output Pale, cool skin

Hypotension (↓BP) ↑ Capillary refill

Bleeding continues
Maternal Hemorrhage Bleeding restarts Tachycardia (↑ Pulse)

Complications:

Congenital Anomalies
Maternal Mortality (rare)
Intrauterine Growth Retardation (IGR)

Cesarean Birth Vaginal or Cesarean birth

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 CLINICAL FEATURES

SYMPTOMS: The only symptom of placenta praevia is vaginal bleeding. The classical
features of bleeding in placenta praevia are sudden onset, painless, apparently
causeless and recurrent. In about 5 % cases, it occurs for the first time during labour,
specially in primigravidae. In about one-third of cases, there is a history of “warning
haemorrhage” which is usually slight.

The bleeding is unrelated to activity and often occurs during sleep and the patient
becomes frightened. Trauma or hypertension are usually absent. However,
preeclampsia may complicate a case of placenta praeva. The first bout of bleeding is
usually not alarming but subsequent bouts may be heavier than the previous one due to
separation of fresh areas of placenta.

SIGNS: General condition and anaemia are proportionate to the visible blood loss. But
in the tropics, the picture is often confusing due to pre-existing anaemia.

Abdominal examination:

 The size of the uterus is proportionate to the period of gestation.

 The uterus feels relaxed, soft and elastic without any localized area of
tenderness.

 Persistence of malpresentation like breech or transverse or unstable lie is more

frequent. There is also increased frequency of twin pregnancy.

 The head is floating in contrast to the period of gestation. Persistent

displacement of the fetal head is very suggestive. The head cannot be pushed
down into the pelvis.

 Fetal heart sound is usually present, unless there is major separation of the
placenta with the patient in exsanguinated condition. Slowing of the fetal heart
rate on pressing the head down into the peivis which soon recovers promptly as
the pressure is released is suggestive of the presence of low lying placenta
specially of posterior type (Stallworthy’s sign). But this sign is not always
significant because it may be due to fetal head compression even in an otherwise
normal case.

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Vulval inspection: Only inspection is to be done to note whether the bleeding is still
occurring or has ceased, character of the blood – bright red or dark coloured and the
amount of blood loss- to be assessed from the blood stained clothing. In placenta
praevia, the blood is bright red as the bleeding occurs from the separated utero-
placental sinuses close to the cervical opening and escapes out immediately.

Vaginal examination must not be done outside operation theatre in the hospital, as it
can provoke further separation of placenta with torrential hemorrhage and may be fetal.
It should only be done prior to termination of pregnancy in the operation theatre under
anaesthesia, keeping everything ready for caesarean section.

CONFIRMATION OF DIAGNOSIS

Diagnosis: Painless and recurrent vaginal bleeding in the second half of pregnancy
should be taken as placenta praevia unless proved otherwise. Ultrasonography is the
initial procedure either to confirm of to rule out the diagnosis.

I. LOCALISATION OF II. CLINICAL

PLACENTA
(PLACENTOGRAPHY)

 Sonography - By internal examination (double

set up examination).
 Magnetic resonance imaging
(MRI) - Direct visualization during
caesarean section.
- Trans abdominal ultrasound
((TAS). - Examination of the placenta
following vaginal delivery.
- Transvaginal ultrasound
(TVS).

- Transperineal ultrasound

- Colour Doppler flow study

PLACENTOGRAPHY

Sonography: It can precisely determine the extent of placental margin in relation to

internal os . It also provides information pertaining to maturity and wellbeing of the fetus
for guiding the management.

Transabdominal (TAS): The accuracy after 30th week of gestation is about 98 percent.
Cases of placenta praevia detected in earlier weeks should be subjected to repeat scan
at 34 weeks or earlier for detection of placental migration.

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Transvaginal (TVS): Transducer is inserted within the vagina without touching the
cervix. The probe is very close to the target area and higher frequencies could be used
to get a superior resolution. It is safe, obviates the discomfort of full bladder and is more
accurate than TAS.

Transperineal (TPS): This is well accepted by patients. Internal os is visulised in 97-

100% of cases.

Colour Doppler flow study: Prominent venous flow in the hypoechoic areas near the
cervix is consistent with the diagnosis of placenta praevia.

Magnetic Resonance Imaging (MRI): It is a noninvasive method without any risk of

ionizing radiation. Quality of placental imaging is excellent.

Advantages: (1) Diagnostic vaginal examination with the risk of causing hemorrhage
can be avoided. (2). Minimize prolonged and unnecessary hospital stay, (3) To
diagnose placenta praevia .

Distinguishing features of placenta praevia and abruption placentae:

Placenta praevia Abruptio placentae

 Clinical features:

- Nature of bleeding (a) Painless apparently (a) Painful, often

causeless and attributed to
recurrent. preeclampsia or
trauma and
(b) Bleeding is always continuous.
revealed.
(b) Revealed
concealed or
usually mixed.

- Character of blood Dark coloured.

Bright red
- General condition Out of proportion to the
and anaemia. Proportionate to visible blood loss in
visible blood loss. concealed or mixed
variety.
Not relevant
- Features of pre- Present in on-third
eclampsia cases.

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  Abdominal
examination

- Height of uterus.
Proportionate height May be
disproportionately
enlarged in concealed
- Feel of uterus type.
Soft and relaxed
May be tense, tender
and rigid
- Malpresentation
Malpresentation is Unrelated, the head
common. The head is high may be engaged.
floating.
- F.H.S. Usually absent
Usually present specially in concealed
type.

 Placentography Placenta in upper

Placenta in lower segment. segment.
 Vaginal
examination Placenta is felt on the lower Placenta is not felt on
segment. lower segment. Blood
clots should not be
confused with placenta.

COMPLICATIONS

 Maternal

 Fetal

Maternal:

During pregnancy:

- Antepartum hemorrhage with varying degrees of shock is an inevitable

complication of placenta praevia. The first bout of haemorrhage is seldom severe
but torrential haemorrhage can easily be provoked by injudicious and ill advised
internal examination done outside soon after the warning haemorrhage.

- Malpresentation is common. There is increased incidence of breech and

transverse lie and the lie often becomes unstable.

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 - Premature labour either spontaneous or induced is common.

During Labour: The following complications occur:

- Early rupture of the membrances.

- Cord prolapse is due to abnormal attachment of the cord.

- Slow dilatation of the cervix is due to the attachment of placenta on the lower
segment.

- Intrapartum haemorrhage may occur due to further separation of placenta with

dilatation of the cervix.

- Increased incidence of operative interference.

- Postpartum haemorrhage is due to:

 Imperfect retraction of the lower uterine segment on which the placenta is

implanted.

 Large surface area of placenta with atonic uterus due to pre-existing anaemia.

 Occasional association (15%) of morbidly adherent placenta (placenta accrete,

increta percreta) on the lower segment.

 Trauma to the cervix and lower segment because of extreme softness and
vascularity.

It should be remembered that because of antepartum anaemic state, the patient may
become shocked with relatively small amount of blood loss.

Retained placenta and increased incidence of manual removal add further

hazard to the postpartum shock. Increased incidence of retained placenta is due to:

(1) Increased surface area and

(2) morbid adhesion.

Puerperium:

1. Sepsis is increased due to: (a) increased operative interference, (b) placental site
near to the vagina and (c) anaemia and devitalized state of the patient.

2. Subinvolution.

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 3. Embolism.

Fetal:

- Low birth weight babies are quite common which may be the effect of preterm
labour either spontaneous or induced. Repeated small bouts of haemorrhage
while carrying on the expepctant treatment can cause chronic placental
insufficiency and fetal growth retardation.

- Asphyxia is common and it may be the effect of – (a) early separation of

placenta, (b) compression of the placenta or (c) compression of the cord.

- Intrauterine death is more related to severe degree of separation of placenta,

with maternal hypovolaemia and shock. Deaths are also due to cord accidents.

- Birth injuries are more common due to increased operative interference.

- Congenital malformation is there times more common in placenta praevia.

PROGNOSIS

Maternal:

(a) Early diagnosis

(b) Omission of internal examination outside the hospital

(c) Free availability of blood transfusion facilities

(d) Potent antibiotics

(e) Wider use of caesarean section with expert anaesthetist and

(f) Skill and judgement with which the cases are managed.

All these factors have led to reduction of maternal deaths from placenta praevia to
less than 1% or even to zero in some centres.

Fetal:

Caesarean section which greatly lessens the loss from anoxia and improvement
in the neonatal care unit. But still the perinatal mortality ranges from 10-25%. The
causes of death are – (a) prematurity, (b) asphyxia and (c) congenital malformation.

MANAGEMENT

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 1. may be given drugs that can prevent premature labor or birth example is
progesterone.
2. Ultrasound exams to determine migration of an early diagnosed previa or
classification of the previa as total, partial, marginal, or low-lying.
3. With a small first bleed, client may sent home on bed rest if she can return to
hospital quickly.
4. If bleeding is more profuse client is hospitalized on bed rest with BRP, IV access;
labs: Hgb and Hct, urinalysis, blood group and type and cross match for 2 units
of blood hold, possible transfusions; goal is to maintain the pregnancy fetal
maturity.
5. No vaginal exams are performed except under special conditions requiring a
double set-up for immediate cesarean birth should hemorrhage result.
6. Low lying or marginal previas may allowed to deliver vaginally if the fetal head
acts as tamponade to prevent hemorrhage.
7. Cesarean birth, often with vertical uterine incision, is used for total placenta
previa.
8. Steroid shots may be given to help mature the baby's lungs.

Placental Abruption
Definition

Placental abruption occurs when the placenta separates from the wall of the uterus prior to the
birth of the baby. This can result in severe, uncontrollable bleeding (hemorrhage).

Definition:

- Premature separation of the placenta from the uterine wall.

- Common cause of bleeding during the second half of pregnancy

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 - Usually occurs after 20 to 24 weeks of pregnancy but may occur as late as during first or
second stage of labor.

Cause: Unknown

Theories proposed relating it’s occurrence to dec. blood flow to the placenta through the
sinuses during the last trimester; Excessive intrauterine pressure caused by hydramnios or
multiple pregnancy may also be contributing factors.

Risk factors:

- women with parity of 5 or more

- women over 30 years of age
- women with pre-eclampsia - eclampsia and renal or vascular disease.

Factors contributing to ABRUPTIO PLACENTA

- multiple gestations
- hydramnios
- cocaine use
- dec. blood flow to the placenta
- trauma to the abdomen
- dec. serum folic acid levels
- PIH

Description

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 go through the mother's vagina during birth.

During a normal labor and delivery, the baby is born first. Several minutes to 30 minutes later,
the placenta separates from the wall of the uterus and is delivered. This sequence is necessary
because the baby relies on the placenta to provide oxygen until he or she begins to breathe
independently.

Placental abruption occurs when the placenta separates from the uterus before the birth of the
baby. Placental abruption occurs in about one out of every 200 deliveries. African-American and
Latin-American women have a greater risk of this complication than do Caucasian women. It

13
was once believed that the risk of placental abruption increased in women who gave birth to
many children, but this association is still being researched.

Causes and symptoms

The cause of placental abruption is unknown. However, a number of risk factors have been
identified. These factors include:

 older age of the mother

 history of placental abruption during a previous pregnancy
 high blood pressure
 certain disease states (diabetes, collagen vascular diseases)
 the presence of a type of uterine tumor called a leiomyoma
 twins, triplets, or other multiple pregnancies
 cigarette smoking
 heavy alcohol use
 cocaine use
 malformations of the uterus
 malformations of the placenta
 injury to the abdomen (as might occur in a car accident)

Symptoms of placental abruption include bleeding from the vagina, severe pain in the abdomen
or back, and tenderness of the uterus. Depending on the severity of the bleeding, the mother
may experience a drop in blood pressure, followed by symptoms of organ failure as her organs
are deprived of oxygen. Sometimes, there is no visible vaginal bleeding. Instead, the bleeding is
said to be "concealed." In this case, the bleeding is trapped behind the placenta, or there may
be bleeding into the muscle of the uterus. Many patients will have abnormal contractions of the
uterus, particularly extremely hard, prolonged contractions. Placental abruption can be total (in
which case the fetus will almost always die in the uterus), or partial.
Placental abruption can also cause a very serious complication called consumptive
coagulopathy. A series of reactions begin that involve the elements of the blood responsible for
clotting. These clotting elements are bound together and used up by these reactions. This
increases the risk of uncontrollable bleeding and may contribute to severe bleeding from the
uterus, as well as causing bleeding from other locations (nose, urinary tract, etc.).

Placental abruption is risky for both the mother and the fetus. It is dangerous for the mother
because of blood loss, loss of clotting ability, and oxygen deprivation to her organs (especially
the kidneys and heart). This condition is dangerous for the fetus because of oxygen deprivation,
too, since the mother's blood is the fetus' only source of oxygen. Because the abrupting
placenta is attached to the umbilical cord, and the umbilical cord is an extension of the fetus'
circulatory system, the fetus is also at risk of hemorrhaging. The fetus may die from these
stresses, or may be born with damage due to oxygen deprivation. If the abruption occurs well
before the baby was due to be delivered, early delivery may cause the baby to suffer
complications of premature birth.

14
Pathophysiology of Abruptio Placentae

15
Clinical manifestations:

16
Covert (severe)/ Mild separation/ Mild Abruptio Placenta

The placenta separates centrally and the blood is trapped between the placenta
and the uterine wall.

Signs and Symptoms:

1. no overt bleeding from vagina

2. rigid abdomen
3. acute abdominal pain
4. dec. BP
5. inc. pulse
6. uteroplacental insufficiency

Overt (partial)/ Moderate separation/ Moderate Abruptio Placenta

The blood passes between the fetal membranes and the uterine wall and
escapes vaginally. May develop abruptly or progress from mild to extensive separation
with external hemorrhage.

Signs and Symptoms:

1. vaginal bleeding
2. rigid abdomen
3. acute abdominal pain
4. dec. BP
5. inc. pulse
6. uteroplacental insufficiency

Placental Prolapse/ Severe separation/ Severe Abruptio Placenta

Massive vaginal bleeding is seen in the presence of almost total separation with
possible fetal cardiac distress.

Signs and Symptoms:

1. massive vaginal bleeding

2. rigid abdomen
3. acute abdominal pain
4. shock
5. marked uteroplacental insufficiency

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Diagnosis

Diagnosis of placental abruption relies heavily on the patient's report of her symptoms
and a physical examination performed by a health care provider. Ultrasound can
sometimes be used to diagnose an abruption, but there is a high rate of missed or
incorrect diagnoses associated with this tool when used for this purpose. Blood will be
taken from the mother and tested to evaluate the possibility of life-threatening problems
with the mother's clotting system.

Treatment

The first line of treatment for placental abruption involves replacing the mother's lost
blood with blood transfusions and fluids given through a needle in a vein. Oxygen will be
administered, usually by a mask or through tubes leading to the nose. When the
placental separation is severe, treatment may require prompt delivery of the baby.
However, delivery may be delayed when the placental separation is not as severe, and
when the fetus is too immature to insure a healthy baby if delivered. The baby is
delivered vaginally when possible. However, a cesarean section may be performed to
deliver the baby more quickly if the abruption is quite severe or if the baby is in distress.

Prognosis

The prognosis for cases of placental abruption varies, depending on the severity of the
abruption. The risk of death for the mother ranges up to 5%, usually due to severe blood
loss, heart failure, and kidney failure. In cases of severe abruption, 50-80% of all
fetuses die. Among those who survive, nearly half will have lifelong problems due to
oxygen deprivation in the uterus and premature birth.

Management:

- monitoring of maternal vital signs, fetal heart rate (FHR), uterine contractions and
vaginal bleeding
- likelihood of vaginal delivery depends on the degree and timing of separation in
labor
- cesarean delivery indicated for moderate to severe placental separation
- evaluation of maternal laboratory values
- F & E replacement therapy; blood transfusion
- Emotional support

Nursing Interventions:

- Assess the patient’s extent of bleeding and monitor fundal height q 30 mins.

18
 - Draw line at the level of the fundus and check it every 30 mins (if the level of the
fundus increases, suspect abruptio placentae)
- Count the number of pads that the patient uses, weighing them as necessary to
determine the amount of blood loss
- Monitor maternal blood pressure, pulse rate, respirations, central venous
pressure, intake and output and amount of vaginal bleeding q 10 – 15 mins
- Begin electronic fetal monitoring to continuously assess FHR
- Have equipment for emergency cesarean delivery readily available:
-prepare the patient and family members for the possibility of an
emergency CS delivery, the delivery of a premature neonate and the
changes to expect in the postpartum period

-offer emotional support and an honest assessment of the situation

- if vaginal delivery is elected, provide emotional support during labor

-because of the neonate’s prematurity , the mother may not receive an
analgesic during labor and may experience intense pain

-reassure the patient of her progress through labor and keep her informed
of the fetus’ condition

- tactfully discuss the possibility of neonatal death

-tell the mother that the neonate’s survival depends primarily on
gestational age, the amount of blood lost, and associated hypertensive
disorders

-assure her that frequent monitoring and prompt management greatly

reduce the risk of death.

- encourage the patient and her family to verbalize their feelings

- help them to develop effective coping strategies, referring them for counseling if
necessary.

Goals of Care:

1. blood loss is minimized, and lost blood is replaced to prevent ischemic necrosis
of distal organs, including kidneys
2. DIC is prevented or successfully treated.
3. normal reproductive functioning is retained
4. the fetus is safely delivered
5. the woman retains a positive sense of self-esteem and self-worth.

Additional lab results:

Hgb- 
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Platelet - 

Fibrinogen - 

Fibrin degradation products - 

Other possible nursing diagnosis:

 Impaired gas exchange: fetal related to insufficient oxygen supply secondary to

premature separation of the placenta.

 Pain related to bleeding between the uterine wall and the placenta secondary to
premature separation of the placenta.

 Fear related to perceived or actual grave threat to body integrity secondary to

excessive bleeding and threat to fetal survival.

 Grieving related to actual or threatened loss of infant.

 Powerlessness related to maternal condition and hospitalization.

 Risk for deficient fluid volume related to excessive losses secondary to

premature placental separation.

Prevention

Some of the causes of placental abruption are preventable. These include cigarette
smoking, alcohol abuse, and cocaine use. Other causes of abruption may not be
avoidable, like diabetes or high blood pressure. These diseases should be carefully
treated. Patients with conditions known to increase the risk of placental abruption
should be carefully monitored for signs and symptoms of this complication.

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Class presentation on
Antepartum
hemorrhage

Submitted to Submitted by
Mrs. Krupa santhosham madam, Mrs. N. Jyothi
Asst. professor M. Sc(N) Iyear

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