Professional Documents
Culture Documents
pregnancy
Presentation by
Prativa Dhakal
M.Sc. Nursing
Maternal health nursing
Batch 2011
Contents
• Antepartum Hemorrhage • Clinical Features
• Causes of Antepartum • Conformation of
hemorrhage diagnosis
• Definition of Placenta • Complications
Previa • Prognosis
• Incidence • Management
• Etiology • Nursing Management
• Pathological anatomy • Research Evidence
• Types of placenta Previa • References
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Antepartum hemorrhage
• It is defined as bleeding from or into the genital tract after
the 28th week /22nd week of pregnancy but before the
birth of baby.
• Placenta previa
• Abruptio placenta
• Rupture of uterus
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Causes of Antepartum Hemorrhage
Presenting symptoms and Probable
other symptoms and signs Symptoms and signs sometimes present diagnosis
typically present
Bleeding after 22nd weeks Shock Abruptio placenta
gestation Tense/tender uterus
Intermittent or constant Decreased/absent fetal movement
abdominal pain Fetal distress or absent fetal heart sounds
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Causes of antepartum hemorrhage cont…
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Causes of antepartum hemorrhage
A.P.H.
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Placenta previa
• When placenta is implanted partially or completely over
the lower uterine segment it is called placenta previa.
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Incidence of Placenta Previa
United States:
• 0.3-0.5% of all pregnancies.
• Risks increase 1.5- to 5-fold with a history of cesarean delivery.
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Etiology
• Dropping down theory
• Defective decidua
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Predisposing factors
• Multiparity
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Pathological anatomy
Placenta:
• Placenta may be large and thin.
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Pathological anatomy cont…
Umbilical cord:
• Cord may be attached to the margin or onto the
membranes.
• Insertion of cord may be close to the internal os or the
fetal vessels may run across the internal os in
velamentous insertion giving rise to vasa previa
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Types/degree of placenta previa
• Low-lying placenta (Type I)
• Vasa previa
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Cause of bleeding
• As the placental growth slows down in later months and the
lower segment progressively dilates, inelastic placenta is
sheared off the wall of lower segment.
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Clinical features
Symptoms:
• Painless, apparently causeless and recurrent
hemorrhage
• Hemorrhage from the implantation site in the lower
uterine segment may continue after placental delivery.
Signs:
• General condition and anemia are proportionate to
the visible blood loss.
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Clinical features cont…
Abdominal examination
– Size of uterus is proportionate to POG.
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Clinical features cont…
Vulval inspection
• Only inspection has to be done to note the amount,
character of blood.
Vaginal examination
• Must not be done outside the operation theater in the
hospital.
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Confirmation of diagnosis
Localization of placenta
• Sonography: Transabdominal ultrasound (TAS)
• Transvaginal ultrasound (TVS)
• Transperineal ultrasound
• Colour Doppler flow study
Clinical
• By internal examination (Double setup examination)
• Direct visualization during caesarean section
• Examination of the placenta following vaginal delivery
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Complications
Maternal
During pregnancy: During Labour:
• Early rupture of membrane
• APH with varying
• Cord prolapse
degrees of shock
• Slow dilatation of cervix
• Malpresentation • Intrapartum hemorrhage
• Premature labour • Increased incidence of
operative interference
• PPH
• Retained placenta
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Complications cont…
Puerperium Fetal
• Sepsis is increased due to • Low birth weight
– Increased operative
• Asphyxia
interference
• Intrauterine death
– Placental site near to
vagina and anemia • Birth injuries
– Subinvolution
• Congenital
malformation
– Embolism
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Prognosis
Maternal
• Substantial reduction of maternal deaths in placenta
previa throughout globe.
• Ultimate cause of death are hemorrhage and shock.
• Morbidity is raised due to hemorrhage and operative
interference
Fetal
• Perinatal mortality ranges from 10-25%.
• The causes of death are prematurity, asphyxia and
congenital malformation.
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Prognosis cont…
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Prevention
• Adequate antenatal care to improve the health status of
women and correction of anemia
• Antenatal diagnosis of low lying placenta at 20 weeks with
routine ultrasound needs repeat ultrasound examination
at 34 weeks to confirm diagnosis.
• Significance of warning hemorrhage should not be
ignored
• Family planning and limitation of births reduce the
incidence.
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Management
At home:
• The patient is immediately put in bed.
• To assess the blood loss
• Inspection of clothing soaked with blood
• To note the pulse, blood pressure and degree of anemia
• Quick but gentle abdominal examination to mark height of
uterus, to auscultate the FHS and to note any tenderness on
the uterus.
• Vaginal examination must not be done.
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Treatment
1. Immediate attention: Quickly assess
• Amount of blood loss: General condition, pallor, pulse rate and
blood pressure.
• Blood samples: Cross matching, group and hemoglobin.
• An infusion of normal saline is started and blood transfusion
• Gentle abdominal palpation: Uterine tenderness and auscultation
to note the fetal heart rate.
• Inspection of vulva to note the presence of any active bleeding.
Confirmation of diagnosis: History, physical examination and
sonographic examination.
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Treatment cont…
2. Formulation of line of treatment
• Depends upon the duration of pregnancy, fetal and maternal status
and extent of the hemorrhage.
a. Expectant treatment
• Vital prerequisites: Availability of blood for transfusion, facilities for
caesarean section
• Selection of cases:
– Mother is in good health status (Hemoglobin ≥ 10 gm%,
hematocrit > 30%),
– Duration of pregnancy is <37 weeks,
– Active vaginal bleeding is absent,
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Treatment cont…
– Fetal well being is assured.
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Treatment cont…
Conduct of expectant treatment:
• Bed rest with bathroom facilities
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Treatment cont…
Termination of the expectant treatment: Expectant treatment is
carried upto 37 weeks of pregnancy.
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Treatment cont…
Active interference:
• Bleeding occurs at or after 37 weeks of pregnancy.
• Patient is in labour
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Definitive treatment
1. Vaginal examination in operation theatre followed by low rupture
of membranes or Caesarean section.
2. Caesarean section without internal examination
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Definitive treatment cont…
a. Low rupture of membrane: Done in lesser degree of placenta
previa (Type I and Type II anterior).
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Nursing Assessment
• Determine the amount and type of bleeding; also, review any
history of bleeding throughout this pregnancy.
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Nursing Assessment
• Assess fetal status with continuous fetal monitoring.
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Nursing Diagnoses
• Ineffective Tissue Perfusion, Placental, related to
excessive bleeding causing fetal compromise
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Definition
• It is one form of antepartum hemorrhage where bleeding
occurs due to premature separation of normally situated
placenta.
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Pathology
• Initiated by hemorrhage into the decidua basalis.
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Pathology cont…
• Early stage: May be no clinical symptoms, and separation
is discovered upon examination of the freshly delivered
placenta.
– There is a circumscribed depression on the placenta's maternal
surface.
– Usually measures a few centimeters in diameter and is covered
by dark, clotted blood.
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Pathology cont…
• The area of separation rapidly becomes more extensive
and reaches the margin of the placenta.
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Varieties of abruptio placenta
• Concealed Hemorrhage
• Revealed
• Mixed
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Revealed Mixed
Concealed
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Risk factors
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Abruptio placenta cont…
Couvelaire uterus
• Widespread extravasation of blood into the uterine
musculature and beneath the uterine serosa.
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Abruptio placenta cont…
• These myometrial hemorrhages seldom interfere with
myometrial contraction to cause atony, and they are not
an indication for hysterectomy.
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Abruptio placenta cont…
Changes in other organs
• Liver: fibrin knots in the hepatic sinusoids
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Abruptio placenta cont…
Blood coagulopathy:
• It is due to excess consumption of plasma fibrinogen due
to DIC and retroplacental bleeding.
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Clinical classification
Depending upon the degree of placental abruption and its
clinical effects, the cases are graded as follows:
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Clinical classification cont…
• Grade 2: External bleeding is mild to moderate. Uterine
tenderness is always present. Shock is absent. Fetal
distress or even fetal death occurs.
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Clinical features
Depends upon
• Degree of separation of placenta
• Speed at which separation occurs and
• Amount of blood concealed inside the uterine cavity.
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The clinical features of the revealed and mixed variety are given below:
Revealed Mixed
Symptoms: Abdominal discomfort or pain Active intense pain abdomen
followed by vaginal bleeding followed by slight vaginal bleeding.
The pain becomes continuous.
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The clinical features of the revealed and mixed variety are given below:
Revealed Mixed
Features of May be absent Frequent association either
preeclampsia preexisting or appear.
Uterine height Proportionate to POG Disproportionately enlarged and
globular.
Uterine feel Normal feel with localized Uterus is tense, tender and rigid
tenderness, contractions frequent
and local amplitude
Fetal parts Can be identified easily Difficult to make out
FHS Usually present Usually absent
Urine output Normal Usually diminished
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The clinical features of the revealed and mixed variety are given below:
Revealed Mixed
Laboratory Low value proportionate Markedly lower, out of proportion to
Blood Hb% to blood loss blood loss
Coagulation Usually unchanged Variable changes :
profile Clotting time increased (>6 min)
Fibrinogen level low (<150mg/dl)
Platelet count low
Increased PTT
Increased FDP and D dimer
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Abruptio placenta cont…
Sheehan Syndrome
• Severe intrapartum or early postpartum hemorrhage rarely is
followed by pituitary failure.
• Characterized by failure of lactation, amenorrhea, breast atrophy,
loss of pubic and axillary hair, hypothyroidism, and adrenal cortical
insufficiency.
• Exact pathogenesis is not well understood but such endocrine
abnormalities develop infrequently in women who hemorrhage
severely.
• Varying degrees of anterior pituitary necrosis and impaired
secretion of one or more trophic hormones (in some cases)
• Diagnosis: MRI
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Distinguishing features of placenta previa and abruptio placenta
Placenta previa Abruptio placenta
Clinical features
Nature of bleeding Painless, apparently Painful, often attributed to
causeless and recurrent preeclampsia or trauma
Character of Bleeding is always revealed and continuous
bleeding Bright red Revealed, concealed or
usually mixed
Dark coloured
Proportionate to visible blood
General condition loss Out of proportion to the
and anemia visible blood loss in concealed
or mixed variety
Features of pre- Not relevant
eclampsia Present in one-third cases
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Distinguishing features contd…
Placenta previa Abruptio placenta
Abd. examination
Height of uterus Proportionate height May be disproportionately
enlarged in concealed type
Feel of uterus Soft and relaxed May be tense, tender and rigid
Malpresentation Malpresentation is common. Head may be engaged
The head is high floating
FHS Usually present Usually absent specially in
concealed type
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Prevention
• Prevention, early diagnosis and effective therapy of
preeclampsia and other hypertensive disorders of pregnancy.
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In the hospital
1. Revealed type: assessment is to be done as regards:
– Amount of blood loss
– Maturity of fetus
– Whether the patient is in labour or not
Preliminaries
• Blood for Hemoglobin and hematocrit estimation, coagulation
profile, ABO and Rh grouping and urine for detection of
protein.
• RL solution drip started with wide bore cannula and
arrangement for blood transfusion.
• Close monitoring of maternal and fetal condition.
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Management cont…
Patient is in labour
• Labour is accelerated by low rupture of membranes.
• Oxytocin drip is started to accelerate labour.
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Management cont…
• Pregnancy less than 37 weeks:
– Bleeding moderate to severe and continuing—low
rupture of membrane, administration of oxytocin drip
– Bleeding slight or has stopped—the patient is put on
conservative management, close observation of the
mother and careful monitoring is essential.
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Management cont…
2. Mixed or concealed type
Principles of management of concealed type are:
• To correct hypovolemia and to restore blood loss. Normal
saline or hemaccel infusion is started
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Management cont…
• Vaginal delivery
• Caesarean section:
– Early: Unfavourable cervix where speedy vaginal delivery is not
possible and there is good prospect of fetal survival.
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Nursing Diagnoses
• Ineffective Tissue Perfusion: Placental related to excessive
bleeding, hypotension, and decreased cardiac output,
causing fetal compromise
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Rupture of uterus
• Dissolution in the continuity of uterine wall any time
beyond 28 weeks of pregnancy is called rupture of uterus.
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Classification of rupture uterus
Uterine rupture typically is classified as either:
• Complete
• Incomplete
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Causes
1. Spontaneous
2. Scar rupture
3. Iatrogenic
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Causes cont…
Spontaneous
1. During pregnancy: previous dilatation and curettage operation or
MRP, grand multiparity, congenital malformation of the uterus of
bicornuate variety, in couvelaire uterus.
• Usually complete, involves the upper segment and usually occurs in
later months of pregnancy.
2. During labour:
• Obstructive rupture: involves lower segment and usually extends
through one lateral side of the uterus to the upper segment.
• Non-obstructive rupture: Grand multiparae , rupture usually occurs
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Causes cont…
in early labour, usually involves fundal area and is complete.
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Causes cont…
Scar rupture
• Incidence of lower uterine segment scar rupture is about 1-2%,
Classical: 5-10 times higher.
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Causes cont…
Iatrogenic or traumatic:
During pregnancy:
– Injudicious administration of oxytocin
– Use of prostaglandins for induction of abortion or labour.
– Forcible external version specially under general anesthesia
– Fall or blow on the abdomen
During labour:
– Internal podalic version, Destructive operation
– Manual removal of placenta
– Application of forceps or breech extraction through incompletely
dilated cervix
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Causes cont…
– Injudicious administration of oxytocin for augmentation of labour.
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Dehiscence and scar rupture
Dehiscence:
– Disruption of part of scar and not the entire length
– Fetal membranes remain intact and
– Bleeding is almost nil or minimal
Rupture includes:
– Disruption of the entire length of scar
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Diagnosis
During pregnancy
1. Scar rupture
Classical or hysterotomy
• Dull abdominal pain all over the area with slight vaginal
bleeding.
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Diagnosis cont…
2. Spontaneous rupture in uninjured uterus:
• Confined to the high parous women.
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Diagnosis cont…
3. Rupture following fall, blow or external version or use of
oxytocics:
• History of such accident followed by acute pain abdomen
and slight vaginal bleeding.
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Diagnosis cont…
During labour
1. Scar rupture:
• Classical or hysterotomy scar rupture: Features are same as
those occur during pregnancy. The onset is usually acute.
• Lower segment scar rupture (silent rupture): The onset is
insidious, no classical feature of lower segment scar rupture,
confirmation is by laparotomy.
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Diagnosis of spontaneous obstructive rupture cont…
Premonitory phase:
• Multipara in labour with features of obstruction.
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Diagnosis of spontaneous obstructive rupture cont…
• Pulse rate and temperature rise.
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Phase of rupture in spontaneous obstructive rupture
• Sense of something giving way at height of uterine
contraction.
• Constant pain is changed to dull aching pain with cessation of
uterine contraction.
• Features of exhaustion and shock.
• Abdominal examination: Superficial fetal parts, absence of
FHS, absence of uterine contour and two separate swellings,
one contracted uterus and the other fetal ovoid.
• Vaginal examination: Recession of presenting part and varying
degrees of bleeding.
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Diagnosis cont…
3. Spontaneous non-obstructive rupture:
• Rare and confined to high parous women.
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Diagnosis cont…
4. Rupture following manipulative or instrumental delivery
• Sudden deterioration of general condition of patient with
varying amount of vaginal bleeding following manipulative
delivery
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Prevention
• At risk mothers likely to rupture should have mandatory
hospital delivery. There are
– Contracted pelvis
– Previous history of caesarean section, hysterotomy or
myomectomy
– Uncorrected transverse lie
– Multiparity with pendulous abdomen
– Grand multiparity
– Known case of hydrocephalous
• General anesthesia should not be used to give undue force in
external version
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Prevention cont…
• Undue delay in the progress of labour in a multipara with
previous uneventful delivery should be viewed with concern
and cause should be sought for.
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Prevention cont…
• Internal podalic version in singleton fetus should never be
done in obstructed labour.
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Treatment
Resuscitation and laparotomy
• Depending upon the state of clinical condition, either
resuscitation is to be done followed by laparotomy or in acute
conditions, resuscitation and laparotomy are to be done
simultaneously.
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Nursing Assessment
• Continuously evaluate maternal vital signs; especially note an
increase in the rate and depth of respirations, an increase in
pulse, or a drop in BP indicating status change.
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Nursing Assessment
situation.
12/13/2013 88
Nursing Diagnoses
• Deficient Fluid Volume related to active fluid loss from
hemorrhage
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References
1. Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition.
Philadelphia: Churchill livingstone elsevier; 2009
2. Dutta DC. Textbook of obstetrics. 6th edition. Calcutta: New central book
agency;2004
3. Pillitteri A. Maternal and child health nursing. Care of the childbearing and
childrearing family. Sixth edition. Philadelphia: Lippincott Williams & Wilkins;
2010.
4. Cunningham, Leveno, Bloom. William’s obstetrics. 23rd edition. United states of
America: Mcgraw Hill companies; 2010.
5. Placenta Previa. Internet [Updated on 5th June 2012, Cited on 21st October
2013] Available form: http://emedicine.medscape.com/article/262063-overview
6. Nettina SM, Mills EJ. Lippincott manual of nursing practice. 8th edition.
Baltimore: Lippincott Williams and Wilkins; 2006
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