2nd Semester

NCM 109
Be the light in the darkness to inspire and
to enlighten others. ...

Ms. Anamae G. Quezon RN RM MN

BLEEDING DURING PREGNANCY

• Any degree of bleeding during pregnancy is potentially serious.

• Any degree of bleeding needs to be evaluated for hypovolemic shock.
• Danger to the fetal blood supply occurs at the point the woman’s
body begins to decrease blood flow to the peripheral organs.
• Signs of hypovolemic shock will occur when 10% of blood volume or
2 units of blood have been lost.
• Fetal distress occurs when 25% is lost.
• The process of shock due to blood loss:
Signs and Symptoms of Hypovolemic Shock
• Increased PR: heart attempting to circulate decreased blood
volume
• decreased BP: less peripheral resistance because of decreased
blood volume
• increased RR: increased blood exchange to better oxygenate
decreased RBC volume
• cold, clammy skin: vasoconstriction occurs to maintain blood
volume in central body core
• decreased urine output: inadequate blood is entering kidney
due to decreased blood volume
• dizziness/ decreased level of consciousness: inadequate blood
is reaching the cerebrum due to decreased blood volume
• decreased CVP: decreased blood is returning to heart due to
reduced blood volume
Emergency Implementation for Bleeding in Pregnancy:

1. Alert health care team of emergency situation

provides maximum coordination of care
2. Place woman flat in bed on her side
maintains optimal and renal function
3. Begin IVF such as LRS with a 16 or 18 angiocath
replaces intravascular fluid volume
IV line is established if blood replacement will be needed
4. Administer oxygen as necessary at 6-10 L/ min by face mask
provides adequate fetal oxygenation despite lowered maternal circulating blood
volume
5. Monitor uterine contractions and FHR by external monitor
assess whether labor is present and fetal status; external system avoids
cervical trauma
Emergency Implementation for Bleeding in Pregnancy:

6. Omit vaginal examination - prevents tearing of placenta previa is present

7. Withhold oral fluid (NPO) - anticipates need for emergency surgery
8. Order type and cross match 2 units of whole blood - preparation for restoring circulating
maternal blood volume
9. MIO - enables assessment of renal function (will decrease to under 30 ml/ hr with massive ci
rculating volume loss)
10. Assess VS every 15 minutes (use of pulse oximeter and automatic BP cuff)
provides baseline data on maternal response to blood loss
11. Assist with placement of CVP or pulmonary wedge catheter and blood determinations
provides accurate date on maternal hemodynamic state
Emergency Implementation for Bleeding in Pregnancy:

12. Measure maternal blood loss by weighing perineal pads; save any tissue passed
Saturating a sanitary pad in less than one hour is heavy blood loss; tissue may be
abnormal trophoblast tissue.
13. Set aside 5 ml of blood drawn IV in a clean test tube; observe in 5 min. for cloth
formation - Test for possible blood coagulation problem

14. Assist with ultrasound examination - supplies information on placental and fetal
well-being

15. Maintain a positive attitude toward fetal outcome - supports mother-child bonding
16. Support woman’s self-esteem - supports problem solving as this is lessened by
poor self-esteem
I. Conditions Associated with First-Trimester Bleeding

Spontaneous Miscarriage

Abortion

- is any interruption of a pregnancy before the fetus

is viable.
- Also called Miscarriage
- Early Abortion- occurs prior to 16th week
- Late Abortion- occurs 16-24 weeks
- Spontaneous miscarriage occurs in 15% to 30%
Immediate Assessment of Vaginal
Bleeding during Pregnancy

1. Confirmation of pregnancy
2. Pregnancy length
3. Duration of bleeding
4. Intensity
5. Description
6. Frequency
7. Associated symptoms
8. Action
9. Blood type
Causes: (AILTIIE)

• Abnormal fetal formation (due to

Teratogenic factor or chromosomal
aberration)
• Implantation abnormalities
• Lack of progesterone production by the
corpus Luteum
• Trauma such as blow to the woman’s
abdomen
• Infection (rubella, poliomyelitis, UTI)
• Ingestion of Teratogenic drugs
• Emotional shock/ stress
Therapeutic Management

Depending on the symptoms and the description of the bleeding a woman

gives, the physician or nurse-midwife will decide whether she needs to be
seen by a health care provider and, if so, whether she should be seen in an
ambulatory setting or the hospital.
Threatened Abortion

- unexplained vaginal bleeding with

cramping or dilation

- Clinical Manifestations:
a. Closed cervix
b. Bleeding or cramping
c. May resolve or progress to miscarriage
Therapeutic Management:
a. Fetal heart sounds assessed or an ultrasound performed to evaluate
the viability of the fetus.
b. Blood for human chorionic gonadotropin hormone (hCG) may be drawn
at the start of bleeding and again in 48 hours (if the placenta is still
intact, the level in the bloodstream should double in this time).
c. Avoidance of strenuous activity for 24 to 48 hours is the key
intervention, assuming the threatened miscarriage involves a live fetus
and presumed placental bleeding.
d. Complete bed rest is usually not necessary. Bed rest may stop the
vaginal bleeding but only because blood is pooling vaginally.
e. Coitus is usually restricted for 2 weeks after the bleeding episode to
prevent infection and to avoid inducing further bleeding.
Imminent (Inevitable) Miscarriage
- a situation where irreversible uterine evacuation
has begun
- Clinical Manifestations:
a. With cervical dilation, the loss of the
products of conception cannot be halted.
b. reports cramping or uterine contractions
c. any tissue fragments she has passed and
bring them with her so they can be
examined.
d. no fetal heart sounds are detected
Therapeutic Management:
a. an ultrasound reveals an empty uterus or nonviable fetus,
b. may perform a vacuum extraction (dilation and evacuation [D&E]) to ensure
that all the products of conception are
c. Be certain the woman has been told that the pregnancy was already lost and
that all procedures, such as suction curettage, are to clean the uterus and
prevent further complications such as infection, not to end the pregnancy.
d. Save any tissue fragments passed in the labor room, along with any brought
from home
e. After a woman is discharged following the D&E, a woman should assess
vaginal bleeding by recording the number of pads she uses.
Complete Abortion

The entire contents of conception are expelled spontaneously without any

assistance. (fetus, membrane and placenta)
Bleeding usually slows within 2hrs and ceases within a few days after pas
sage of the products of conception

- No therapy, advise woman to report heavy bleeding

Incomplete Abortion

• Part of the conceptus (usually the fetus) is expelled, but

the membranes or placenta is retained in the uterus.
• Danger of maternal hemorrhage
• Management: D & C or suction curettage to evacuate
the remaining product of conception
Missed Abortion
• The fetus dies in utero but is not expelled
• Painless vaginal bleeding may be
manifested.
• Early pregnancy failure

• Management: Labor induced by prostaglandin

suppository or misoprostol (Cytotec) followed by
oxytocin stimulation
• Woman needs support in accepting the reality
(needs counseling)
Recurrent Abortion (Habitual Abortion)
- an abortion that occurs following 2 previous consecutive losses
- occurs in about 1% of women who want to be pregnant.
- Causes:
• defective spermatozoa or ova
• endocrine factors - lowered levels of protein-bound iodine (PBI), butanol-extractable io
dine (BEI), and globulin-bound iodine (GBI); poor thyroid function; or luteal phase
defect
• deviation of the uterus - such as septate or bicornuate uterus
• infection (infection of the developing embryo (Listeriosis))
• autoimmune disorders - such as those involving lupus anticoagulant and
antiphospholipid antibodies
Complications of Miscarriage
1. Hemorrhage
With a complete spontaneous miscarriage, serious or fatal hemorrhage is
rare. With an incomplete miscarriage or in a woman who develops an
accompanying coagulation defect (usually DIC), major hemorrhage is a
possibility.
2. Infection
tends to develop in women who have lost appreciable amounts of blood.
second and possibly fatal complication.
the danger signs of infection, such as fever, abdominal pain or
tenderness, and a foul vaginal discharge.
3. Septic Abortion
an abortion that is complicated by infection
Infection can occur after a spontaneous miscarriage
4. Isoimmunization
production of antibodies against Rh-positive blood.
If the woman’s next child should have Rh-positive blood, these antibodies would
attempt to destroy the red blood cells of this infant during the months that infant
is in utero (Crowther & Middleton, 2009).
After a miscarriage, because the blood type of the conceptus is unknown, all
women with Rh-negative blood should receive Rh (D antigen) immune globulin
(RhIG) to prevent the buildup of antibodies in the event the conceptus was Rh
positive.
5. Powerlessness or Anxiety
Sadness and grief over the loss or a feeling that a woman has lost control
of her life is to be expected.
Spontaneous miscarriage can be particularly heartbreaking for an older
woman, because she realizes that her window of childbearing is limited.
Ectopic Pregnancy
- Implantation occurs outside of the uterine cavity
- Sites/ Types:
1. Fallopian tube/ Tubal
- Ampullar portion 80%
- Isthmus 12 %
-Interstitial 5%
2. Surface of the ovary/ Ovarian
3. Cervix/ CERVICAL
4. Intestine/ Abdominal
- Approximately 1 in every 200 pregnancies
- Second most frequent cause of bleeding early in pregnancy
Predisposing factors:
1. Pelvic inflammatory disease (PID)
2. Tubal surgery (scarring, adhesions)
3. Endometriosis
4. Salpingitis
5. Congenital defects of the tube
6. Prolonged use of IUD
7. Previous history of ectopic pregnancy
8. Uterine or tubal tumor
Pathophysiology: fertilization occurs as usual in the distal third of the fallopian tube.

Immediately after the union of ovum and spermatozoon, the zygote begins to divide and grow.

Unfortunately, because an obstruction is present, such as an adhesion of the fallopian tube from a
previous infection (chronic salpingitis or pelvic inflammatory disease), congenital malformations,
scars from tubal surgery, or a uterine tumor pressing on the proximal end of the tube,

the zygote cannot travel the length of the tube.

It lodges at a strictured site along the tube and implants there instead of in the uterus.

ectopic pregnancy
Signs and Symptoms of ectopic pregnancy

Early signs:
• No menstrual flow occurs.
• A woman may experience the nausea and vomiting of early pregnancy,
• pregnancy test for hCG will be positive.
• Many ectopic pregnancies are diagnosed by an early pregnancy ultrasound
. Magnetic resonance imaging (MRI) is also effective to use for this.
• Tubal rupture: 6-12 weeks or 4-10 weeks after the missed period
• Sudden, sharp, severe low quadrant pain radiating to shoulders
• Vaginal bleeding or spotting
• Signs of shock
• Cullen’s sign
• Excruciating pain in the cervix upon pelvic examination
• A tender mass palpable in the cul-de-sac of Douglas
• Laboratory findings; decreased Hgb, Hct, increased WBC (due to
trauma)
Diagnostic Exam:

• HCG titer
• Culdocentesis-
• Laparascopy- is a type of surgical procedure that allows a surgeon to
access the inside of the abdomen and pelvis without having to make
large incisions in the skin.
• Culdoscopy- is an endoscopic procedure performed to examine the
rectouterine pouch and pelvic viscera by the introduction of a culdoscope
through the posterior vaginal wall.
• Ultrasound
Therapeutic Management

• Laparatomy- A laparotomy is a surgical procedure involving a large incision

through the abdominal wall to gain access into the abdominal cavity.

• Salpingectomy- is the surgical removal of one (unilateral) or both (bilateral)

fallopian tubes.

• Oral administration of Methotrexate- medicine that stops cells from dividing. It

can be used as a way (other than surgery) to treat a pregnancy that is implanted
outside the uterus (ectopic pregnancy). ... The methotrexate will stop
the pregnancy and the level of pregnancy hormone in your blood should
decrease over 2 to 4 days.
Nursing Management

- Place patient in Trendelenburg position

- Observe for increasing pain most especially at the shoulder
- Assessment of vaginal bleeding
- Observe for signs of hypovolemic shock
- O2 administration
- Carry out and follow up laboratory request
- Start IV fluid and blood transfusion as ordered
- Monitor VS
- Pain relief:
- Care of a woman in grief
- Prepare for pelvic laparatomy
Nursing Diagnosis:

• Potential for fluid volume deficit r/t blood loss or restricted fluid intake
• Alteration in comfort: pain r/t rupture of tube and seeping of blood into the
peritoneal cavity
• Anxiety r/t uncertainty about her condition/ threat of death; possible loss
of ability to conceive
Abdominal Pregnancy

- Very rarely to happen after ectopic pregnancy rupture

- The product of conception is expelled into the pelvic cavity with a
minimum of bleeding
- The placenta continues to grow in the fallopian tube, spreading
into the uterus for a better blood supply or it may escape into the
pelvic cavity.
- It may implant in an abdominal organ such as the intestine.
CONDITIONS ASSOCIATED WITH SECOND TRIMESTER BLEEDING

A. Gestational Trophoblastic Disease( Hydatidiform Mole )

• There is proliferation and degeneration of the trophoblast villi which beco
me filled with fluid, appearing as fluid filled, graped- sized vesicles.
• The embryo fails to develop beyond a primitive start
• there is no chorionic circulation
Types of Molar Growth:

1. Complete mole
- All trophoblasti villi swell and become cystic
- No fetal blood is present in the villi

2. Partial mole
- Some of the villi forms normally.
- No embryo is present, but fetal blood is present in the villi
- Has 69 chromosomes ( a triploid formation in which there are 3 chromosomes
instead of 2 for every pair ).
Predisposing Factors:
• The incidence :1 in every 1500 pregnancies.
• occur most often in women who have a low protein intake
• women older than age 35 years
• in women of Asian heritage
• in blood group A women who marry blood group O men
Signs and Symptoms of H-Mole:
1. S/ S of pregnancy
2. Uterus grows rapidly
3. UTZ shows no developing fetus within the uterus.
4. HCG titer is high
5. Vaginal bleeding, that may be accompanied by discharge of clear – fluid filled
vesicles.
6. S/S of Hyperemesis Gravidarum or HPN of pregnancy.
7. S/ S of respiratory distress if vesicles will enter the circulation.
• Diagnostic Tests:
History taking
Clinical examination
Ultrasound
Serum hcG levels
• Therapeutic Management:
- Molar evacuation- involves dilation and curettage (use of a tool to remove tissue) with
suction to remove all abnormal tissue from the uterus.
- Hysterectomy- surgical removal of the entire uterus
- Follow up supervision for one year after molar evacuation.
- Drugs ( Chemotherapy )
- Chest x-ray
- Oral contraceptive
Nursing Assessment

 Assess the abdominal girth of the pregnant woman to check if it is within

the usual landmark of pregnancy.
 Assess for signs and symptoms of pregnancy induced hypertension,
because for a woman with H-mole, they occur earlier than the 20th week
of pregnancy.
 Instruct the woman to save all perineal pads containing any clots or tissue
that has passed out of her during bleeding.
Nursing Diagnosis

• Grieving related to loss of pregnancy as evidenced by anger and social detachment.

Nursing Interventions
 Measure abdominal girth and fundal height to establish baseline data regarding the growth of
the uterus.
 Assist patient in obtaining a urine specimen for urine test of hCg.
 Save all pads used by the woman during bleeding to check for clots and tissues she may have
discharged.
 Provide your patient with an open environment and a trusting relationship so she would be
encouraged to express her feelings.
 Honestly answer the patient’s questions to foster a trusting relationship between nurse and
client.
 Provide an assurance that it is not her own fault that this happened to her to lessen her sense
of guilt and self-blame.
B. Incompetent Cervix
A cervix that dilates prematurely and cannot hold the
fetus until term.

Causes: Unknown
Risk Factors
• Increased maternal age.
• Congenital structural defects.
• Trauma to the cervix.
Signs and Symptoms:

a. first symptom is show (a pink-stained vaginal discharge)

b. increased pelvic pressure, which may be followed by rupture of the
membranes and discharge of the amniotic fluid.
c. Uterine contractions begin, and after a short labor the fetus is born.

Unfortunately, this commonly occurs at approximately week 20 of pregnancy,

when the fetus is still too immature to survive.
Therapeutic Management:

Cervical Cerclage
• A surgical treatment wherein a pursestring suture is
placed in the cervix to prevent relaxation and
dilatation of the cevix
• Cervical cerclage can be performed to prevent this
from happening in a second pregnancy
• An ultrasound confirms that the fetus of a second
pregnancy is healthy, at approximately weeks 12 to 14
purse-string sutures are placed in the cervix by
the vaginal route under regional anesthesia.
• This procedure is called a McDonald or a Shirodkar
procedure
• The sutures serve to strengthen the cervix and
prevent it from dilating
Types of Cerclage:

• Shirodkar technique
sterile tape is threaded in a pursestring
manner under the submucous layer of the
cervix and sutured in place to achieve a
closed cervix

• Mc Donald technique
nylon sutures are placed horizontally
and vertically across the cervix and pulled
tight to reduce the cervical
canal to a few millimeters in diameter.
Post- operative Care After cervical Cerclage:

• Ask client who are reporting painless bleeding (the symptoms of

spontaneous miscarriage also) whether they have had past cervical
operations, to remind them they may have sutures in place.
The prognosis for a successful pregnancy after surgical correction for premature
cervical dilatation is very favorable.
The success rate with both types of cerclage techniques is 80% to 90%.

• After cerclage, bed rest (slight or modified Trendelenburg position) for a

few days to decrease pressure on the new sutures.
• Usual activity and sexual relations can be resumed in most instances
after this rest period.
CONDITIONS ASSOCIATED WITH THE THIRD
TRIMESTER BLEEDING
A.Placenta Previa
is a condition of pregnancy in which the placenta is implanted abnormally in
the uterus. It is the most common cause of painless bleeding in the third trim
ester of pregnancy

Degrees:
1. Low - Lying implantation in the lower rather than in the upper
portion of the uterus (low-lying placenta);
2. Marginal - the placenta edge approaches that of the cervical os
3. Partial - implantation that occludes a portion of the cervical os
4. Total - implantation that totally obstructs the cervical os
Types of Placenta Previa
Conditions Associated with Placenta Previa:

1. Multiparity
2. Multiple Gestation
3. Alteration in uterine structure
4. Uterine scars
5. Increased maternal age
Pathophysiology:

Atrophic or inflammatory changes in the endometrium

(Multiparity)

Decreased blood supply

Placenta will spread out more than normal to get enough blood for its nutrition

Placenta covers the cervical os

Signs and Symptoms:

1. Painless, bright red vaginal bleeding late in pregnancy

2. Boggy uterus
3. Fetal heart tones and activity is weak
4. Fetus is usually in an abnormal presentation

Diagnostic Tests
• Ultrasound. Early detection of placenta previa is always possible through
ultrasonography. It is the most common and initial diagnostic test that
could confirm the diagnosis.
Medical management:

will depend on the; location of the placenta, amount of bleeding and gestational a
ge of the fetus.

1. Conservative management - Appropriate when the fetus is premature and the

bleeding is not excessive.
2. Active Approach - indicated if the fetus is at term by size and age, if labor has
begun or if bleeding is severe
 Vaginal delivery

 C- Section

 Medications to stop bleeding-

Nursing Diagnosis: Fear related to outcome of pregnancy due to bleeding.

Goal of Care: To prevent premature delivery and to prevent hemorrhage.

Nursing Care:
• Assess fetal heart sounds so the mother would be aware of the health of her baby.
• Allow the mother to vent out her feelings to lessen her emotional stress.
• Assess any bleeding or spotting that might occur to give adequate measures.
• Answer the mother’s questions honestly to establish a trusting environment.
• Include the mother in the planning of the care plan for both the mother and the baby
Complications:

• Bleeding
• Preterm Birth
• Placenta accrete
• Abruptio Placenta
B. Abruption Placenta / Premature Separation of the Placenta
It is the separation of part or all of a normally implanted placenta after
the 20th week of pregnancy or before the birth of the baby

Predisposing Factors:
1. Chronic hypertensive disorders
2. Cocaine use by the mother
3. Multiple gestation and Hydramnios
4. Short umbilical cord
5. Direct trauma
6. Manual manipulation of the uterus during pregnancy
7. Cigarette smoking
Types of Hemorrhage:

1. Concealed-
2. Apparent- partial separation
Types of Hemorrhage According to Placental Separation:

1. Covert/ Severe / Central

2. Overt/ Partial / Marginal
3. Placental Prolapse / Complete
Clinical Manifestations:

1. If marginal- painless vaginal bleeding

2. If centralis- painful vaginal bleeding with dark red color
3. Couvelaire Uterus / UteroPlacental Apoplexy - forming a hard,
boardlike uterus with no apparent, or minimally apparent, bleeding
present occurs.
4. S/S of shock -
5. Absence of fetal heart tones
6. Difficulty of palpating the fetus
Therapeutic Management:

1. For Moderate Bleeding:

2. For Profuse Bleeding:

Nursing Diagnosis:
Nursing Intervention Complications:
 Asses bleeding • Hemorrhage / Shock
 Initial blood works- • Coagulation defect ( DIC )
 O2 by mask • Couvelaire uterus
 Monitor maternal status, V/ S and • Infection
fetal status
 IVF/ BT as ordered
 Prepare patient for surgery
 Place on CBR
 Avoid vaginal exam or enema
Disseminated Intravascular Coagulation (DIC)

is an acquired disorder of blood clotting in which the

fibrinogen level falls to below effective limits.

Early symptoms include

• easy bruising or bleeding from an intravenous site
• Conditions such as premature separation of the placenta
• pregnancy-induced hypertension
• amniotic fluid embolism
• placental retention
• septic abortion
• retention of a dead fetus are all associated with its development
Disseminated Intravascular Coagulation (DIC)

Bleeding oozing from wound

Impaired gas exchange; Decreased perfusion;
Abdominal distention
Occult blood in stool/ emesis
Gi bleeding
Petechiae (ecchymosis)
DIC
Management
 Monitor respiratory status
 Maintain ventilator support
 Admininster fluid (IVF)
 MIO and vital signs
 Monitor occult blood in stool
 Monitor for overt signs of bleeding from gums
 Measure abdominal girth every 4 hrs.
Evaluation

• determining whether a woman’s blood coagulation studies are returning

to normal and if any anoxia has occurred, particularly in renal or brain
cells from occluded coagulated capillaries.
• Fetal and newborn assessment is important to evaluate the efficiency of
the placental circulation in light of increased clotting.