Zagazig university Faculty of

nursing
Doctorate degree (First term)

Ante partum hemorrhage

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 Table of contents
No. of Contents Page number
lecture
I Ante partum hemorrhage
1.  Vasa previa. 4
2.  Placenta previa. 6
3.  Abruptio placenta. 20

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 Ante partum hemorrhage

Definition :-

 Bleeding from genital tract after fetal viability (after 28 weeks) or

during 1st or 2nd stage of labor.

Classification of ante partum hemorrhage:-

I-Maternal:-

A. Placental site bleeding:-

1- From normally situated placenta:- Accidental hemorrhage

- Marginal placental separation.
2- From abnormally situated placenta (LUS):- Placenta previa

B.Extra placental site bleeding:-

1- Local causes as cervical polyp.

2- A heavy show.
3- Rupture uterus.
4- Idiopathic.

II. Fetal: - Vasa previa

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 1- Vasa Previa
Definition:-

Fetal blood vessel lies over the os in front of the presenting part.

Etiology:-

Placenta Previa with:

1- Velamentous insertion of the umbilical cord.

2- Succenturiate Placenta (Placenta with accessory lobe).

Diagnosis
(A) Clinically:
1- Careful examination before rupture of the membrane , palpate a tubular
fetal vessels in the membrane overlying the presenting part.
2- Compression of these vessels between the examining and the presenting
part lead to change FHR.
3 – A minoscopy:- Vessels can be seen.
4 – After aminotomy (Artificial or Spontaneous), fetal vessels are torn with
slight intrapartum bleeding and sever fetal distress.

(B) Investigation:-
Fetal blood can be differentiated from maternal blood by
1- Nucleated fetal RBCs(blood film).
2- Different ultraviolet absorption spectrum in the spectrophotometer.
3- Higher affinity to oxygen.
4- Fetal blood resist alkaline medium.

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  APT test ,Singers alkaline denturation test: Adult blood is rapid
changed into greenish-brown color when NaOH is added. Fetal blood
resists alkali denturation (remains reddish-Pink).

Treatment
 Immediate CS is performed if the fetus is alive.

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 2- Placenta previa
Definition
Placenta previa is an obstetric complication in which the placenta is
inserted partially or wholly in the lower uterine segment. It is a leading
cause of ante partum hemorrhage.
Incidence
It affects approximately 0.4-0.5% of all labors (Richard Warren,
2009). Ward & Hisley (2009) found that, placenta previa account for 20.0%
of all ante-partum hemorrhage. Purohit et al., (2014) study in India reported
that, third trimester bleeding due to placenta previa was 39.55%.

Classification of placenta previa:-

1st degree (Low-lying pp):
 It occurs when the placenta is implanted in the lower uterine
segment and is near the internal os but doesn’t reach it.
2nd degree (Marginal placenta previa)
 It occurs when the placental edge extends to within 2 cm of the
internal cervical os.
3rd degree (Partial or incomplete) placenta previa
 It occurs when part of the internal cervical os is covered by placenta.
4th degree (Total PP or complete) placenta previa
 It occurs when the entire internal cervical os is covered by placenta
whether the cervix is partially or completely dilated.

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 Abnormal adhesion of the placenta
 Placenta accreta (75%): abnormal adhesion of the placenta in which
placenta in contact with myometrium.
 Placenta increate (17%): abnormal adhesion of the placenta in
which placenta across basal layer of endometrium and penetrate
myometrium.
 Placenta percreta (5%):abnormal adhesion of the placenta in which
placenta penetrate uterine layer and reach to peritoneal cavity.
N.B
 Placenta Pravia marginalis posterior is worse and more dangerous
than marginalis anterior because:-
1-It encroaches on the true conjugate….Delay engagement of the head.
2-engagement of the head will compress the placenta against long sacrum..
Fetal asphyxia.

Causes of PP:-
The cause of placenta previa is unknown, may be attributed to:-
1-Rapid embryo transport with arrival in the uterine cavity before the
endometrium is receptive. So it implanted very low in the uterine cavity.
2-Low implantation of the fertilized ovum.
3-Large placental surface area.
4-Decidua capsularis theory.
 Risk Factors Associated with Placenta Previa
- Advanced maternal age. Placenta previa is three times more common at
age 35 than at age 25.
- Increasing parity.
- Previous uterine scar.

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- Prior placenta previa.
- Tobacco and cocaine use.
- Multiple gestations.
- Previous myomectomy to remove fibroid
- Black and minority
- High gravidity
- Previous abortion (induced and spontaneous).
- Prior cesarean section
- Cigarette smoking
Diagnosis of PP
1. Symptoms:
Painless, causeless, recurrent bleeding during the 3rd trimester is the
cardinal symptoms of placenta previa.
 It occurs while the patient is asleep or on awakening.
II. Signs:
(1)General examination:
- The general condition of the patient.
- The degree of shock.
- Amount of bleeding.
(2) Abdominal examination:
• Size of the uterus=Period of amenorrhea.
• No tenderness or rigidity.
• Fetal parts are easily felt.
• FHS are usually audible.
• Mal-presentation and non engagement are common.
• Anterior PP…..Suprapubic fullness.

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 • Posterior PP….Pressure of the head against pelvic brim….Slowing
FHS.
(3) Local examination (PV):
 Double set up in the operating room should never be done except:
Indication Precaution Value

1-Sever bleeding 1-In the theater 1-Acertain diagnosis

2-In labor 2-Under general (PP or not)
3-Mature baby(>37 anesthesia 2-Amount of bleeding
weeks) 3-Complet aseptic 3-Degree of cervical
4-IUFD condition dilatation
4-Blood transfusion 4-Condition of
5-Ready for immediate membrane
CS 5-Prolapse of the cord
6-POresentation and its
level
7-Pelvic capacity

III.Investigation
A. Placental localization:
1- Suspected cases of PP.
2- Cases under expectant treatment.
(1). Sonography:
(a) Trans abdominal Sonography: Is the simple and safest method.
(b) Transperineal Sonography will visualize the internal os and degree of
placenta previa.

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 (c) Transvaginal Sonography the theater or 3 days after cessation of
bleeding.
(2) MRI and Placentography.
They are the most precise methods but expensive.
B. Blood investigation: Hb% , Rh typing and blood group.

IV.DD: Causes of ante partum hemorrhage.

Treatment of Placenta Previa
(A) At home:
1- History taken.
2- General and abdominal examination.
3- No vaginal examination, no vaginal pack
4- Anti shock measures if there is sever bleeding.
5- A sedative as morphine 10 mg IM.
6-A sterile vulval pad is applied.
7-Transfer the patient immediately to the hospital (Flying squad)
(B) At Hospital
1-Adetalied history taken, general and abdominal examination.
2-Blood analysis .
3-U/S for GA and degree of the placenta.
4-Keep 4 units of fresh packed RBCs available, if needed.
5-Anti shock measures (Blood, morphine, fluids and o2).
Two main lines of treatment
 Expectant treatment.
 Active treatment.

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 (1) Expectant treatment:-

Indication Aim PV exam

1-Patient is not in labor -To delay termination of No

2-Premature fetus<37 pregnancy until the fetus
WKS becomes mature.
3-Mild bleeding
4-Baby living not
deformed

Lines of Expectant treatment:-

 Hospitalization
 Bed rest
 Replace blood loss and correct anemia
 Speculum examination 48 hours after stoppage of bleeding to exclude
local causes
 U/S
 Observation (amount of bleeding, labor pains and FHS)
 Dexamethazone is given if the duration of pregnancy is less than 34
wks to stimulate fetal lung maturity
 Methods of termination (ARM +Pitocin drip or LSCS)
 Monitor the fetal well-being (U/S and Non-stress test)
 Check for feto maternal transfusion in Rh (D) negative women and
give anti-D immunoglobin.

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Active treatment
(A) ARM + abdominal binder.
(B) LSCS.

(A) ARM + abdominal binder.

 Indications:
1-PP lateralis
2-Slight bleeding
3-Vertex presentation
4-The cervix is thin and partially dilated
 Value:
1-To control bleeding as the head will compress the placental site and
rupture of the membrane abolish the shearing movement of the placenta on
the uterine wall, so nor further separation occurs.
2- Press on the presenting part upon the cervix …Stimulate uterine
contraction and labor.
(B) LSCS
 Indication:
1-PP centeralis(3rd and 4th degree)
2-PP Marginalis posterior
3-PPwith sever bleeding
4-PPwith closed cervix
5-Failed ARM to control bleeding
6-PPin elderly primigravida
7-PPwith abnormal presentation
8-PPwith pelvic contraction
9-PPwith vasa previa

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10-PP with previous CS.
 Advantages
1- It minimizes blood loss, shock.
2-No trauma to the cervix and vagina
3- Better control of postpartum hemorrhage from placental site.
4- Better fetal prognosis due to decreased fetal hypoxia.

N.B
 General anesthesia is amust, Avoid spinal or epidural anesthesia to
avoid hypotension.
 Anterior PP….Vertical uterine incision as it is safe.
 Today, CS is necessary in all cases of PP.
 Caesarean hysterectomy is indicated when PP is complicated by
Placenta accreta (PP accreta 7%)
Complications of Placenta Previa
(A) During pregnancy
1-Unavoidable ante partum hemorrhage…Shock.
2-Abortion and premature labor.
3-Mal-presentation and non-engagement of the head.
4-Fetal anoxia and death.
(B) During labor
1-Intrapartum hemorrhage.
2-Uterine inertia….Prolonged labor.
3-PROM and Cord prolapse.
4-Postpartum hemorrhage.
5-Retained placenta (accreta).
6-Air embolism.

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(C) During Puerperium
1-2ry Postpartum hemorrhage.
2-Aneamia.
3-Puerperal sepsis.
4- Sub involution of the uterus.
Treatment of complication:-
 Postpartum hemorrhage….Blood, Morphine, Massage of the uterus.
 Shock….Packed RBC, iron.
 Renal failure…..Correct shock, hemodialysis.
 Care of infant: Premature….Incubation.

The Role of the nurse in management of placenta previa

Patient's managements of PP depend upon the following criteria:
• The fetus is preterm and there are no other indications for delivery.
• The fetus is reasonably mature.
• Labor has ensued.
• Hemorrhage is so severe as to mandate delivery despite gestational age.
Expectant management
Expectant management is used in the following criteria:
1- The patient is not in labor.
2- The gestational age is less than 37 weeks.
3- The bleeding has settled or is settling, expectant treatment is under-
taken in order to gain time for fetal maturation.

The role of clinical assessment in women presenting with APH is first

to establish whether urgent intervention is required to manage maternal or
fetal compromise. The process of triage includes history taking to assess

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coexisting symptoms such as pain, an assessment of the extent of vaginal
bleeding, the cardiovascular condition of the mother, and an assessment of
fetal wellbeing. Women presenting with a major or massive hemorrhage that
is persisting or if the woman is unable to provide a history due to a
compromised clinical state, an acute appraisal of maternal wellbeing should
be performed and resuscitation started immediately. The mother is the
priority in these situations and should be stabilized prior to establishing the
fetal condition. If there is no maternal compromise a full history should be
taken: the clinical history should determine whether there is pain associated
with the hemorrhage, risk factors for placenta previa should be identified,
the woman should be asked about her awareness of fetal movements and
attempts should be made to auscultate the fetal heart.

Examination of the woman should be performed to assess the amount

and cause of bleeding. The basic principles of resuscitation should be
adhered to in all women presenting with collapse or major hemorrhage. The
primary survey should follow the structured approach of airway (A),
breathing (B) and circulation (C). Following initial assessment and
commencement of resuscitation, causes for hemorrhage or collapse should
be sought. All women presenting with APH should have their pulse and
blood pressure recorded. Digital vaginal examination should not be
performed.
The nurse should be aware that, cross-matched blood and coagulation
profile should be available at all times. Anemia should be sought and
treated. Anti shock measures should be also prepared. If the patient is
Rhesus negative Rh immune a Kleihauer test should be performed to ensure
that the standard dose of Rh immune globulin is adequate. She should also

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be aware that, if the gestation is 34 weeks consider giving corticosteroids to
accelerate fetal pulmonary maturity. If the ultrasound confirms PP, the safest
course is for the woman to remain in hospital until delivery.

Monitoring Maternal–Fetal Status is a crucial role of a maternity

nurse. She should assess the degree of vaginal bleeding; inspect the perineal
area for blood that may be pooled underneath the woman. Estimate and
document the amount of bleeding. Perform a peri-pad count on an ongoing
basis, making sure to report any changes in amount or frequency to the
health care provider. If the woman is experiencing active bleeding, prepare
for blood typing and cross-matching in the event a blood transfusion is
needed.
The nurse should monitor maternal vital signs and uterine contractility
frequently for changes. Have the patient rate her level of pain using an
appropriate pain rating scale. She should also monitor woman’s
cardiopulmonary status, reporting any difficulties in respirations, changes in
skin color, or complaints of difficult breathing. Have oxygen equipment
readily available if fetal or maternal distress develops. She should encourage
the patient to lie on her side to enhance placental perfusion. If the woman
has an intravenous (IV) line inserted, inspect the IV site frequently.
Alternately, anticipate the insertion of an intermittent IV access device such
as; a saline lock, which can be used if quick access is needed for fluid
restoration and infusion of blood products. She should also obtain laboratory
tests as ordered, including complete blood count (CBC), coagulation studies,
and Rh status if appropriate administration of pharmacologic agents is
required. She can give Rh immunoglobulin if the client is Rh negative at 28

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weeks’ gestation and monitor tocolytic medication if prevention of preterm
labor is needed.

Home care for patients with PP can be used if the following criteria
are met: no active bleeding, no signs and symptoms of preterm labor (PTL),
patient's home is close to medical facility and emergency support readily
available. In this case the nurse should teach the woman signs and symptoms
of hemorrhage; patient has to report to labor and delivery immediately if
bleeding occurs, monitor vaginal discharge and bleeding after each urination
and bowel movement. The patient should be instructed about vaginal and
sexual abstinence. Home uterine activity Monitoring (HUAM) by palpation
and fetal movement counts (kick counts) should be performed on daily basis.
Ante partum testing may be indicated periodically. Lastly, the woman is
advised to have support nurse midwife.

Active management of placenta previa

Active management of PP is considered when the patient reaches 37-
38 weeks gestation, or if there is heavy and sustained bleeding, or if labor
starts. The patient should be admitted and initially at least, placed on bed
rest. Blood pressure, pulse, and urine output should be monitored closely.
In the double set-up examination the nurse midwife should realize
that, the patient is kept fasting and prepared for immediate general
anesthesia if required. The woman should be examined in the operating
theatre with the presence of anesthetist, a nurse and assistant scrubbed, and
the instruments ready to move immediately to CS. The patient is examined
vaginally and initially a finger palpates tissue between the fornix and the
presenting part. If no placenta is suspected the examining finger is gently
pushed through the cervix and digital exploration of the lower uterine

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segment is performed. It can be difficult to distinguish between blood clot
and placental tissue. The most important distinguishing feature is that
placental tissue tends to have a firmer, rubbery and gritty consistency. If no
placenta is found upon digital exploration of the lower uterine segment then
labor can be safely induced with amniotomy and oxytocin infusion. If
placenta previa is confirmed, or if there is active bleeding, then the option is
to move straight to CS.
Concerning the delivery of patient with placenta previa, the
nurse midwife should recognize that cesarean delivery is necessary in
practically all women with PP. Most often, a transverse uterine incision is
possible. However, because fetal bleeding may result from a transverse
incision into an anterior placenta, a vertical incision is sometimes employed.
But, even when the incision extends through the placenta, maternal or fetal
outcomes are rarely compromised. CS is the recommended mode of delivery
for major PP and all women with PP and their partners should have a
discussion regarding the need for a CS birth, indications for blood
transfusion and hysterectomy, with a management plan clearly documented
in medical and hand-held notes. Traditionally, cesarean hysterectomy at the
time of delivery has been the preferred management strategy for placenta
accreta. Not only does this approach preclude future fertility, but it is also a
procedure synonymous with significant preoperative risks. For women who
wish to conserve their reproductive function, other treatment options have
been described .

Concerning the Management after Placental Delivery, the fundus

should always be palpated following either spontaneous or manual placental
delivery to confirm that the uterus is well contracted. If it is not firm,

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vigorous fundal massage is indicated. Most evidence suggests that uterine
massage prevents postpartum hemorrhage from atony. Typically, 20 U of
oxytocin in 1000 mL of lactated Ringer or normal saline proves effective
when administered intravenously at approximately 10 mL/min—200 mU of
oxytocin per minute—simultaneously with effective uterine massage.
Oxytocin should never be given as an undiluted bolus dose, because serious
hypotension or cardiac arrhythmias may occur. Concerning the prevention of
infection the nurse should use sterile technique when providing care,
evaluate temperature periodically; she should teach woman the proper
perineal care and hand-washing techniques. Assess odor of all vaginal
bleeding or lochia .

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 3- Abruptio placenta (Accidental hemorrhage)

Definition of abruptio placenta:-

Is defined as the premature separation of normally situated placenta from the

uterus (UUS) after 28 weeks of pregnancy.
Incidence
**It occurs in 1% of world pregnancies wide with a fetal mortality rate of
20–40% depending on the degree of separation.
**Placental abruption is also a significant contributor to maternal
mortality.
Etiology
 The primary cause of placental abruption is usually unknown, but
multiple risk factors have been identified. However, only a few events
have been closely linked to this condition.
Risk factors:
A)-Toxemia in pregnancy (PIH, chronic hypertension, chronic nephritis(:-
This is the commonest cause.
B) Non Toxemic causes:
1- External trauma.
2- Abnormalities in the placenta.
3- Traction on the placenta by short cord.
4- Sudden decompression of the uterus as sudden rupture of the membrane
in case of hydraminos.
5- Supine hypotension syndrome.
6- Torsion of the uterus.
7- Nutritional deficiency and folic acid deficiency

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8- Cigarette smoking and alcohol consumption.
9-Collagen disease complicating pregnancy

Types of accidental hemorrhage

(A) According to vaginal bleeding
(1)-Concealed accidental hemorrhage (10%)
 It is more sever and serious. It is due to central separation of placenta,
which will progress causing further separation.
 Blood is retained inside the uterus and is collected behind the placenta
(retro placental hematoma) and bleeding can be concealed.
(2)-Revealed accidental hemorrhage (external 40%)
 Blood passes through the cervix due to separation at the edge of the
placenta, the blood will dissect the membrane, and escapes in the
vagina.
(3)-Mixed accidental hemorrhage (50%)
 It is usually start as concealed hemorrhage when uterine contraction,
occur some of blood appears externally as vaginal bleeding (part of
blood is retained inside the uterus and part escapes through the cervix)
(B) According to severity
 It may be mild, moderate or severe. It varies with the type and degree
of placental separation. So:
i. Peripheral detachment and bleeding is mild.
ii. Central detachment with concealed hemorrhage is sever.

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 (C) Grades: There are three grades that correlate with clinical and
laboratory finding:-
Clinical and Grade 1 Grade 2 Grade 3
laboratory finding
Vaginal bleeding Slight Mild-Moderate Moderate to severe but
may concealed
Uterine tenderness Some uterine The uterus is The uterus is tetanic and
irritability irritable, painful
tetanic
contraction
present
Maternal condition BP unaffected BP is Hypotention
maintained,
Pulse rate
increased
Postural blood
volume deficit
may be
present.
Laboratory finding Fibrinogen Decrease 150- Highly decreased<150mg
(Fibrinogen level) level normal 250 mg% %,
Other coagulation
abnormality
FHR Normal Signs of fetal Fetal death
distress

Diagnosis of each type of placental abruption

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**Concealed accidental hemorrhage:
Symptoms:
-sudden severe abdominal pain followed by shock
-No vaginal bleeding
-History of pre- eclampsia or trauma
Signs:
General examination:
- Sign of pre-eclampsia (edema - proteinuria)
- Sign of shock (rapid. weak pulse. Subnormal temperature .lowered BP and
pallor with cold extremities)
- Shock is of two types :
1-Hemrrhagic or hypovolemic
2-Neurogenic due to myometrial damage .stretching and fissuring of the
perimetrium
*Abdominal examination:
-The uterus> period of amenorrhea
-The uterus is tender and tense
-The fetal parts cannot be felt (abdominal rigidity)
-FSH not audible
*Vaginal Examination :
-No bleeding
-The placenta is not felt
Investigations:
1-Colt observation test (Wiener test):
-Leave 10ml venous blood in a test tube
-Clot formed within 3-5 min → Normal fibrinogen
-Clot formed within 10-15min →Hypofibrinogenemia

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-Clot not formed → Afibrinogenemia
-Clot formed but dissolved by shaking→ excessive fibrinolysis
2-Urine analysis for proteinuria
3-Ultrasonography
D.D:
*Causes of acute abdominal pain late in pregnancy:
1-Rupture uterus
2-Red degeneration in a fibroid
3-Rupture surface vein on a fibroid
4-Hematoma in the rectus abdominus muscle
5-Rupture ovarian cyst
6-Retro –peritoneal hematoma
7-Acute Hydramnios
**Revealed accidental hemorrhage :
Symptoms:
-Dark vaginal bleeding
-Slight abdominal discomfort
-History of trauma or PET
Signs:
*General
-The general condition of the patient and the degree of shock α amount of
bleeding
-Signs of toxemia may or may not present
*Abdominal
-Size of uterus=period of amenorrhea
-No tenderness or rigidity
-Fetal parts are easily felt

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 -FSH is audible
*Vaginal
-In the theatre as in placenta previa
-There is dark brown bleeding
-No placenta is felt
 Investigation:
*sonar
* D.D:
Causes of antepartum hemorrhage:
1-placenta pervia: by sonar to visualize the site of the placenta
2-Extra placental site hemorrhage

(3)-Mixed or combined accidental hemorrhage

C/P of concealed accidental hemorrhage but there is vaginal bleeding.
Comparison between Placenta previa and mixed accidental hemorrhage:
Placenta previa mixed accidental
hemorrhage
bleeding Painless Painful
Causeless May be a cause e.g. trauma
recurrent or PET
Not recurrent
General Toxemia is absent General Toxemia usually present
examination condition & shock& Amount of General condition is worse
bleeding than external bleeding

Urine analysis No albumin albumin

Abdominal Size of uterus = period of Size of uterus > period of

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examination amenorrhea amenorrhea
Not tenderness or rigidity Tenderness, rigidity
Fetal parts are felt Fetal parts are not felt
FHS is audible easily
FHS show distress or
absent
Pelvic Bleeding is bright red Blood is dark brown
examination in fullness may be the fornix. No fullness.
the operating If the cervix is dilated , the
theater under placenta is felt in l us If the cervix is dilated , the
anesthesia placenta is not felt in l us

US Placenta in the LUS Placenta in the UUS

Complications of accidental hemorrhage:-

(a) Maternal risks or complications of accidental hemorrhage:-
The majority of serious complications are due to hypovolemia :
1-Shock
2-Postpartum hemorrhage
3-Couvelaire uterus or uteroplacental apoplexy
4-Consumption coagulopathy
5-Acute renal failure
6-Sheehan′s syndrome
7-Puerperal sepsis and post-hemorrhagic anemia
8-Rupture uterus due to couvelaire uterus
(b)Fetal risks:
1-Prematurity
2-Asphyxia

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3-Respiratory distress syndrome (50%)
4-Hyperbillirubinemia
5-Consumption coagulation in the infant
6-Neonatal fetal mortality (12-15%)
Exams and Tests as a general:
- Tests may include:
- Abdominal ultrasound
- Complete blood count
- Fetal monitoring
- Fibrinogen level
- Partial thromboplastin time
- Pelvic exam
- Prothrombin time
- Vaginal ultrasound.
Differential Diagnosis as general: The following conditions should be
considered in the differential diagnosis of Abruptio placenta:
- Blunt Abdominal Trauma
- Acute Appendicitis
- Disseminated Intravascular Coagulation
- Ovarian Cysts
- Ovarian Torsion
- Placenta Previa
- Ectopic Pregnancy
- Pregnancy, Preeclampsia
- Pregnancy, Trauma
- Hemorrhagic Shock
- Hypovolemic Shock

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 - Vaginitis
Treatment of accidental hemorrhage
1)-Treatment of concealed accidental hemorrhage:
1- anti shock measures. Fresh blood transfusion , oxygen, fluids, sedative, warmth
and vasopressor.
2- Monitor the urinary output. Folly's catheter and maintain the urinary output >30
ml/hour
3- Obstetric management. After improvement of shock we must terminate
pregnancy within 6-8 hours of onset of bleeding or symptoms to avoid:
a- hypofibrinogenemia.
b- Massive placental separation.
c- Aggravation of uteroplacental apoplexy.
Active treatment
A- Aminotomy + pitocin drip + abdominal binder
1- Allow for internal monitoring of the fetal heart.
2- Fasten delivery
3-↓↓ intervillous space pressure →↓↓ bleeding
4-prevent thromboplastin from escape to maternal circulation,
↓
Then observation (6-8h): Pulse, Temp, Bp, Uterine contraction, Fundel level and
Vaginal bleeding.

Active treatment
A- If labor is progressive and General condition is good → vaginal delivery.
B- If not →LS CS

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B- LS CS
1- Failure of antis hock measures
2- Failure of ARM pitocin dip
3- Obstetric indication for
CS↓
After extraction of the fetus, suturing the uterus, uterine massage
Uterine stimulant
Hot compression
a- uterus contracted→ no bleeding → close abdomen
b- Uterus lax (atonic) vaginal bleeding →supravaginal hysterectomy.
II- Treatment of revealed accidental hemorrhage
At Home:
-No vaginal examination
-No vaginal pack
-sedative
-Transfer the patient immediately to the hospital
At Hospital:
-ABO and RH blood group
-History and general .abdominal examination
-No vaginal examination

Expectant treatment Active treatment

Indications: Indications:
1-Mild bleeding 1-severe bleeding
2-Not in labor 2-In labor

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3-premature <37weeks 3-Mature≥37weeks
4-Fetus is living 4-fetus is dead
↓ ↓
-Bed rest until the bleeding stops and *AROM +pitocin drip for vaginal
for one week afterwards delivery
-Treat pre-eclampsia *LSCS:
-Blood transfusion →anemia 1-Severe bleeding
-Observe fetal .maternal condition -2-Failure of AROM+pitocin drip

The Role of the nurse in management of abruptio placenta

Management aims for the pregnant woman who presents with a
suspected abruption should be early diagnosis; appropriate measures to stop
hemorrhage, replacement of blood volume with intravenous fluids and blood
transfusions and correction of coagulopathy. Close monitoring of the woman
for signs of cardiovascular compromise and evaluation for external signs of
trauma and recent drug use should be undertaken. Initial blood tests should
include a full blood count with platelets as a baseline, blood group and cross
match.
The nurse midwife should recognize that the management of placental
abruption depends on the extent of abruption, gestational age, and maternal
and fetal condition. When the fetus is still alive, the blood loss is less. In
cases with moderate or severe abruptio placentae and where the diagnosis is
clear, the principles of management are stabilization of the mother and
delivery of the baby. When the diagnosis is uncertain (e.g., antepartum
hemorrhage of uncertain origin) or when the retro placental clot is small,

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self-limited, and asymptomatic, treatment may be individualized taking the
gestational age into account.
Severe abruption with intrauterine fetal death, regardless of
gestational age, should be managed by vaginal delivery if there are no
contraindications. Labor usually progresses rapidly due to continuous
contractions and if not, amniotomy can be performed. Augmentation of
uterine contractions by oxytocin infusion or ripening of cervix by
prostaglandins must be done cautiously as the risk of uterine rupture may
exist in placental abruption. Concealed bleeding into the myometrium,
maternal tachycardia, or hypertension may lead to under estimation of the
blood loss, intravenous cannula should be inserted and blood products and
coagulation factors given if necessary. When labor does not progress rapidly
or mother is unstable; CS may be necessary to avoid worsening of the
coagulopathy. The patient should be monitored closely after vaginal or
operative delivery since severe hemorrhage may occurs. Hysterectomy may
occasionally be necessary.

If the fetus is alive and pregnancy near term, prompt delivery is

indicated. In cases of fetal or maternal compromise, cesarean delivery
should be performed. If both fetal and maternal conditions are reassuring,
vaginal delivery is reasonable. Established labor should be allowed to
progress, otherwise induction of labor should be considered. If abruption is
suspected on the basis of an incidental finding on ultrasound in a term
pregnancy, vaginal delivery is indicated. Partial placental abruption at 20-34
weeks of gestation may be managed conservatively if maternal and fetal
conditions are reassuring.

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 Patient must be closely monitored and fetal growth followed. At 24 to
34 weeks, steroids to promote fetal lung maturation should be given. It may
be possible to discharge these patients if fetal condition is reassuring after
patients have remained stable for several days. If the bleeding episodes are
recurrent but fetal condition is satisfactory, induction is recommend at 37-38
gestational weeks. Tocolytics can be used in selected cases of preterm
placental abruption. Pregnant women should be followed for a minimum of
4 hours after abdominal or other trauma. If uterine contractions, vaginal
bleeding, or fetal heart rate changes occur the follow up should be extended.
All rhesus negative patients with placental abruption should receive anti-D
immunoglobulin within 72 hours.

The Management of the Third Stage of Labor in Women with APH

Postpartum hemorrhage (PPH) should be anticipated in women who
have experienced APH. Women with APH resulting from placental
abruption or placenta previa should be strongly recommended to receive
active management of the third stage of labor. Consideration should be given
to the use of ergometrine-oxytocin to manage the third stage of labor in
women with APH resulting from placental abruption or placenta previa in
the absence of hypertension. Active versus expectant management of the
third stage of labor reduces the risk of PPH and need for blood transfusion.
prophylactic ergometrine-oxytocin versus oxytocin for the third stage of
labor reported that the addition of ergometrine to oxytocin was associated
with a small reduction in the risk of PPH using the definition of PPH of
blood loss of at least 500 ml (OR 0.82, 95% CI 0.71–0.95). The nurse
midwife should follow the clinical guideline or the local protocol of

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management of APH. The following flowchart is an example of the accepted
protocol that could be applied.

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