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Name of the student teacher : Miss. B. Karuna kumari Course & Class : M.

Sc Nursing, 1st year Subject : Obstetrical & Gynecological nursing Topic : Antepartum Hemorrhage Group : Pear group Date : 24.10.2011 Time : 8am 10am Duration : 2hours Venue : M.Sc Nursing 1st year Class Room Method of teaching : Lecture cum Discussion Av Aids : Black board - meaning of placenta praevia and Abruptio placenta -incidence of antepartum hemorrhage Power point etiology of abruption placenta and - Complications of placenta

praevia and abruptio placenta - Nursing diagnosis for APH

Chart

- Schematic management of

Placenta previa ,abruption placenta

Hand out

- Research studies related to Antepartum hemorrhage

Model

- Types of placenta praevia and abruptio placenta

HOD : Mrs. Rafath Razia madam, Professor Guided by : Mrs. B. Valli Madam, Asst. Professor Govt. College of Nursing

OBJECTIVES
STUDENT TEACHER OBJECTIVES

Develop skills in teaching or explanation of the topic Understand the organisation of topic Develop skills in controlling the group Develop skills in using different types of AV aids

BEHAVIOURAL OBJECTIVES General objective: by the end of the session, students will be able to gain in depth knowledge about antepartum hemorrhage and its management. Specific objectives : At the end of the session the group will be able to :

- Define antepartum haemorrhage - Understand the causes of antepartum haemorrhage - Classify the antepartum hemorrhage - Define the abruptio placenta - List the etiology of abruptio placenta - Expain the effects of abruptio placenta - Enumerate the clinical features of abruptio placenta - Describe the treatment of abruptio placenta - Discuss about the nursing care of abruptio placenta - Define the placenta praevia - List the etiology of placenta praevia

- Explain the effects of placenta praevia - List the types of placenta praevia - Explain the clinical features of placenta praevia - Describe treatment of placenta praevia - Discuss the nursing management of placenta praevia - Expain the levels of prevention of antepartum hemorrhage - Discuss the differences between placenta praevia and abruptio placenta - Discuss about research studies and case scenario related to antepartum
hemorrhage

ANTEPARTUM HEMORRHAGE INTRODUCTION Antepartum bleeding or hemorrhage is bleeding from vagina that takes place after 24th week of gestation. It occurs 2-5% of all cases. In the absence of pregnancy, uterus receives 1% of the hearts output. This increases dramatically to approximately about 20% of out put in the third trimester. As such uterine bleeding which can occur due to various causes can be substantial during pregnancy, leading to profound blood loss and hemodynamic instability. It is one of the most significant cause of maternal death during the third trimester. Severe antepartum hemorrhage causes causes still birth and neonatal death and also if bleeding is severe, it may accompany by shock. Disseminated intravascular coagulopathy. And the mother may die or will be left with permanent illness. DEFINITION Antepartum hemorrhage is defined as bleeding from or into the genital tract after 28th week of pregnancy but before birth of the baby. - Dutta Antepartum hemorrhage is also called prepartum hemorrhage, is bleeding from the vagina during pregnancy from 20-24 weeks of gestation. - Encyclopedia INCIDENCE Antepartum hemorrhage affects 3-5% of all pregnancies. It is 3 times more common in multiparous than in primiparous women.

According to confidential enquiry into maternal and child health ( CEMACH) ( 2005), the mortality rate due to obstetric hemorrhage was 0.66 per 1,00,000 maternities. ETIOLOGY The antepartum hemorrhage is mainly caused by following 1. Placental bleeding (75%) : which includes abruption placenta (35%) and placenta praevia (35%) 2. Unexplained cause is about 25% or its indeterminate ( excluding placental bleeding and local lesions 3. Extra placental causes (5%) Local cervico vaginal lesions: Cervical polp Carcinoma of cervix Varicose veins Local trauma CLASSIFICATION OF ANTEPARTUM HEMORRHAGE Antepartum hemorrhage is classified according to the site of placenta. 1. Accidental hemorrhage or abruption placenta is bleeding from the premature separation of the placenta situated in the upper uterine segment 2. Antepartum hemorrhage due to placenta praevia or unavoidable antepartum hemorrhage is bleeding from a placenta situated partially or wholly in the lower uterine segment 3. Unclassified antepartum hemorrhage in which group of patients. There is neither evidence of placenta praevia nor of accidental hemorrhage. The

cause of bleeding may not determined even after the delivery. Usually such bleeding may be due to incidental findings such as cervical erosion, vascular ulcerated polyps and rarely carcinoma of cervix. ABRUPTIO PLACENTA INTRODUCTION Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 2040% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. The heart rate of the fetus can be associated with the severity DEFINITION It is one form of antepartum hemorrhage where the bleeding occurs due to premature separation of normally situated placenta. - Dutta Abruption placenta or premature separation of placenta or ablation placentae or placental abruption is a premature separation of normally implanted placenta from the uterus after 20 week of gestation The term abruption means to tear apart and term accidental implies separation as a result of trauma but does not occur spontaneously.

INCIDENCE Abruption placenta occurs in 0.4 to 1.5% of all pregnancies, incidence peaks at 24 to 26 weeks of gestation ETIOLOGY The exact cause of a placental abruption may be remains abscure ( unknown). Direct causes are rare. But include Hypertension in pregnancy is the most important predisposing factor, pre eclampsia, gestational hypertension and essential hypertension, all are associated with abruptio placenta. The mechanism of the placental separation in pre eclampsia is spasm of vessels in the utero placental bed ( decidual spiral artery) leads to anoxic endothelial dmage leads to rupture of vessels or extravasation of blood in the deciduas basalis ( retro placental hematoma) Trauma traumatic separation of the placenta usually leads to its

marginal separation with escape of blood outside. The trauma may be due to a) Attempted external cephalic version specially under anesthesia using great force b) Road traffic accidents or blow on the abdomen c) Needle puncture at aminocentesis Sudden uterine decompression :- sudden decompression of the uterus to diminished surface area of the uterus adjacent to the placental

attachment and results in separation of placenta. This may occur in following: a) Delivery of the first baby of twins b) Sudden escape of liquor amnii in hydraminos and c) Premature rupture of membranes Short cord, either relative or absolute, can bring about placental separation during labour by mechanical pull. Supine hypotension syndrome:- In this condition which occurs in pregnancy ther is passive. Engorgement of the uterine and placental vessels resulting in rupture and extravasation of the blood. Sick placenta:- Poor placentation evidenced by abnormal uterine artery Doppler wave forms is associated with placental abruption. Folic acid deficiency:-deficiency of folic acid without evidence of overt megaloblastic erythropoiesis has been blamed to cause of separation of placenta. Torsion of the uterus:leads to increased venous pressure and rupture of the veins with separationof the placenta. Cocaine abuse: is associated with increased risk of treatment hypertension and placental abruption. Thrombophilias: Inherited or acquired have been associated with increased risk of placental infarcts or abruption. Risk factors:The prevalenceis more with a) High birth order pregnancies is gravida 5 and above three times more common than in first birth

b) Advancing age of the mother c) Poor socio economic condition d) Malnutrition e) Smoking and alcohol abuse (drinking more than 14 alcohol drinks/week in pregnancy) f) A tendency of recurrence in subsequent pregnancies is ten fold g) Diabetes h) Uterine fibroids i) Poly hydraminos j) Chorio amnionitis/vasculitis k) Blood cloting disorders CLASSIFICATION: I. The most common classification of abruption placenta according to type and severity is 3types1. Revealed : Following separation of the placenta, the blood insinuates downwards between the membranes and decidua. Ultimately the blood comes out of the cervical canal to be visible externally. This is the commonest type. 2. Concealed : The blood collects behind the separated placenta or collected in between the membranes and decidua. The collected blood is prevented from coming out of the cervix by the presenting part, which passes on the lower segment. At times, the blood may percodates into the amniotic sac after rupturing the membranes. In any of the circumstances blood is not visible outside. This type is rare.

3. Mixed : In this type, some part of the blood collects inside ( concealed) and a part is expelled ( revealed) usually one variety predominates over the other. This type is quite common II. DEGREES Abruption placenta is also divided into three degrees 1. Mild Abruptio placenta In this condition the placenta separates from centre of the placenta 2. Moderate abruption placenta In this placenta passess between fetal membranes and uterine wall and escapes vaginally . it can develop abruptly. It can progress from mild to extensive separation with external hemorrhage. 3. Severe abruption placenta Here almost total separation leads to possible fetal cardiac distress III. PAGE S CLASSIFICATION Pages classified abruptio placenta into four grades Grade 0 : clinically unrecognized before delivery and diagnosis made after examination of placenta Grade 1 : These show external bleeding only or mild tetany but no evidence of maternal shock.

Grade 2 : There is uterine tetany usually with uterine tenderness possible with external bleeding, fetal distress or death but with no evidence of shock Grade 3 : There is maternal shock or coagulation defects with uterine tetany or intrauterine death of fetus. Grade 0 and 1 is revealed hemorrhage, and grade II is concealed and grade II & III is mixed type CLINICAL TYPES

Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta.

Class 1: mild and represents approximately 48% of all cases. Characteristics include the following:

No vaginal bleeding to mild vaginal bleeding Slightly tender uterus Normal maternal BP and heart rate No coagulopathy No fetal distress

Class 2: moderate and represents approximately 27% of all cases. Characteristics include the following:

No vaginal bleeding to moderate vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress Hypofibrinogenemia (i.e., 50250 mg/dL)

Class 3: severe and represents approximately 24% of all cases. Characteristics include the following:

No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia (i.e., <150 mg/dL) Coagulopathy Fetal death When bleeding is entirely concealed the blood may collect in any

one of the following situations Behind the placenta as a large retroplacental clot. Between the membranes and uterine wall separating the membranes from uterine wall It may collect behind the presenting part The blood may occasionally extravasate into the uterine musculature, tearing and injuring the tissues badly. The extravasated blood may be visible as bluish ecchymosis scattered throught the uterine musculature. Because of disorganization of uterine musculature the uterus loses its tone and distends easily with blood. This is called apoplexy of ( couvelaire uterus). These patients also have fibrinogen deficiency due to failure of blood clotting mechanism

PATHOPHYSIOLOGY Predisposing factors Trauma Pregnancy Hypertension Use of drugs like cocaine Smoking At placental bed contain distended blood vessels Ruptured blood vessels and causing separation Partial separation Detached peripheral portion mild to moderate vaginal bleeding detached central portion mild to moderate concealed bleeding blood at peripheral portion DIC massive vaginal bleeding ( concealed ) maternal shock fetal death death complete separation

decreased platelet decreased fibrinogen increased fibrin

progressive separation fetal distress

fluid enters into muscle fibres

PATHOLOGICAL CHANGES Premature placental separation is initiated by hemorrhage into the deciduas basalis. This produces following pathological changes Degeneration and necrosis the decidual basalis as well as placenta adjacent to it Rupture of basal plate thus communicating hematoma with in tervillous space Evidences of retroplacental hematoma by depression at maternal surface and areas of infarction Formation of a big hematoma Failure to contract and compress the turn bleeding points Absence of rhythmic uterine contractions Couvelaire uterus Its a pathological entity first delivered by couvelaire and is met within association with severe form of concealed abruption placenta . there is massive intravasation of blood into uterine musculature upto serous coat. It can diagnosed on laprotomy. Features : dark pot wine colour, patchy or diffuse, sub peritoneal petechial hemorrhage , free blood in peritoneum and broad ligament.

Changes in Other Organs: Fibrin note in the hepatic sinusoids Acute cortical necrosis or acute tubular necrosis Intrarenal vasospasm Shock, proteinuria due to renal anoxia Proteinuria due to preeclampsia Overt hypo fibrino genemia Blood coagulopathy is due to excess consumption of plasma fibrinogen due to disseminated intravascular coagulopathy and retro placental bleeding CLINICAL FEATURES: The clinical features depend on degree of separation of placenta, speed at which separation occurs and amount of blood concealed inside the uterine cavity. Revealed Mixed, Concealed

features predominant Symptoms Abdominal discomfort or The client seized with pain followed by vaginal acute intense pain on bleeding (slight) abdomen followed by

slight vaginal bleeding, pain continuous.

Character of bleeding

Continuous dark colour

Continuous, dark colour or blood stained serous discharge

General Condition

Proportionately loss, shock is absent

blood Shock which

is is

pronounced, out to of the

proportionate visible blood loss

Pallor

Related with visible blood Pallor is usually severe loss and out of proportionate to visible blood loss

Features preeclampsia

of May be absent

Either

pre-existing

or

appear for first time.

Proportionate Uterine height

to

the May be disproportionately enlarged and globular.

period of gestation.

Localised Uterine Feel

tenderness, Uterus is tense, tender and

contractions frequent and rigid. local amplitude

Can be identified easily. Fetal parts Usually present. Fetal heart sounds Normal

Difficult to make out.

Usually absent.

Usually diminished

Urine out put

INVESTIGATIONS: Ultra sonography : Retro placental mass could be seen in 20-25 % of cases LABORATORY Blood: HB % Low value proportionate Makedly lower out of to the blood loss proportionate loss Coagulation profile Usually unchanged - Clotting time to blood

increases more than 6 min. - Low fibrinogen

level less than 150 mg/dl. - Low platelet count - Increased partial

thromboplastin time and fibrin

degradation products

Urine for protein

May be absent

Usually present

Confusion diagnosis

With placenta praevia Withheld

With Acute obstetricalsurgical

vaginal gynocological

examination.

complication.

DIFFERENTIAL DIAGNOSIS: Placenta praevia Rupture uterus Rectus Sheath hematoma Apendicular or interstinal perforation Twisted ovarian tumor Volvulus Acute hydramnios Tonic uterine contractions PROGNOSIS: The prognosis of mother & baby depends on the clinical types (revealed, concealed, mixed), degree of placental separation, the interval between separation of placenta and delivery of baby and efficacy of treatment. Bleeding in placental obruption is almost always maternal. Fetal bleeding is only observed with traumatic variety of placental abruption. COMPLICATIONS: 1. Maternal a. In revealed type-maternal risk is proportionate to visible blood loss. Maternal death is rare. b. In concealed type

- Hemorrhage leads to intra peritoneal or braod ligament hematoma - Shock due to release of thromboplastin in maternal circulation - Blood coagulation disorders for example disseminated intravascular coagulopathy - Oliguria and anuria due to hypovolemia - Post partum hemorrhage due to atony of uterus - Puerperal sepsis - Ischemic pituitary necrosis - Sheehans syndrome 2. Fetal Prematurity Anoxia Fetal death in revealed ( 25-30%) and in concealed type (50-100%) MANAGEMENT Treatment at home Arrangement should be made to shift the patient to an equipped maternity unit as early as possible In the hospital 1. In revealed type: Assess the case for amount of blood loss, maturity of fetus whether the client is in labour or not Preliminaries

1. Blood is sent for haemoglobin, coagulation profile, ABO and Rh typing and also test for detection of protein 2. Ringer lactate drip is started with a wide bored cannula and arrangement for blood transfusion is to be made 3. Close m9onitoring of fetal and maternal condition

Definitive Treatment: The patient is in labour: The labour is accelerated by low rupture of membranes to escape of liquor amnii and to increase uterine tone which allows separated placenta to be compressed between fetal bulk and uterine wall, oxytocin drip may be started to accelerate labour. The patient is not in labour: Pregnancy 37 weeks or more ; Induction of labour is done by low rupture of membrane with or without oxytocin or Caesarean section is preformed if there is appearance of fetal distress, when amniotomy fails and associated with complicating factors. Pregnancy less than 37 weeks; a. Bleeding moderate to severe and continuing low rupture of membrane is effective, oxytocin dripp may be added. And rarely caesarean section is performed

b. Bleeding slight or slopped means patient put on conservative treatment, close observation of mother and carefull fetal monitoring with continuous tocograph. II. Mixed or Concealed type: A. Preacautions: 1. Rapid management is critical 2. Fetal death occurs in upto 30% within 2hr. 3. Dont delay the management for ultrasound conformation. a. Ultrasound is unreliable for diagnosis. b. Placental abruption is clinical diagnosis. B. Indications: 1. Brisk bleeding. 2. Unstable vital signs. 3. Fetal distress 4. Grade II and III placental abruption. C. Immediate interventions: 1. Oxygen 2. Trendelenberg position 3. Obtain immediate intravenous access. a. Two large bore IV (16-18 gauze) b. Initiate isotonic crystalloid bolus normal saline, ringer lactate. 4. Blood transfusion atleast one litre minimum in concealed type to prevent complications. 5. Call for immediate obstetric and neonatal support. 6. Delivery within 20 min if there is fetal distress.

7. Caesarean section unless iminant vaginal delivary by induction. If the cervix is unfavourable early caesarean section is performed. If the progress of labour is delayed (6-8 hr). Late caesarean section is performed especially in case of couvelerie uterus. 8. Anti D game globulin if maternal blood is Rh negative. D. Monitoring: 1. Orthostatic blood pressure and pulse 2. Monitor intake & output. 3. Maintain urine output over 30 cc/hr. 4. Monitor HB or hematocrit q 1-2hr - Maintain HB more than 10 g/dl or heamatocrit more than 30%. - In fusion of packed RBC as needed. 5. Monitor Coagulation studies - Transfusion of fresh frozen plasma as needed - Platelet transfusion as needed NURSING MANAGEMENT: Nursing Diagnosis: Impaired gas exchange to fetus related to insufficient oxygen supply secondary to premature separation of placenta Pain related to concealed bleeding secondary to premature separation of placenta. Risk for fluid volume deficit related to bleeding. Powerlessness related to disease condition. Fear related to perceived threat to fetal survival. Nursing Interventions:

- Monitor maternal vital signs - Monitor fetal heart rate - Monitor uterine contractions and vaginal bleeding - Vaginal delivary depends on degree and timing of separation of placenta in labour - Caeserean delivery indicated for moderate to severe placental separation. - Evaluate maternal laboratory values - Replace fluid and electrolyte and if required transfuse blood - Provide emotional support assess the client condition and determine the extent of bleeding frequently - Check fundal height every 30 min. As if the level of fundal height increases suspects abruptio placenta. - Count the no. Of pads that the client uses, weighing them as necessary to measure amount of blood loss. - Maintain IO chart - Encourage woman to verbalise her feelings - Keep all equipments ready for caesarean delivery. - Council the client and help her by developing effective coping stratergies.

PLACENTA PRAEVIA
INTRODUCTION Placenta praevia (placenta previa AE) is

an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal bleeding). It affects approximately 0.5% of all labours. Placenta praevia is hypothesized to be related to abnormal vascularisation of the endometrium caused by scarring or atrophy from previous trauma, surgery, or infection. In the last trimester of pregnancy the isthmus of the uterus unfolds and forms the lower segment. In a normal pregnancy the placenta does not overlie it, so there is no bleeding. If the placenta does overlie the lower segment, as is the case with placenta praevia, it may shear off and a small section may bleed. DEFINITION: When the placenta is implanted partially or completely over the lower uterine segment is called Placenta Praevia. The term praevia denoted the position of placenta in relation to the internal os. INCIDENCE: About 1/3 of antepartum hemorrhage belongs to placenta praevia. The incidence of placenta praevia ranges from 0.5 to 1 % among hospital deliveries.

- In 80% of cases it is found in multi parous women. - The incidence also increases beyond the age 35, - with high birth order pregnancies and - In multiple pregnancy. - Increased family planning acceptance and limitation of births lowers incidence of placenta praevia. ETIOLOGY: The Exact cause is unknown. The following theories are postulated. Dropping down theory: According to this theory fertilized ovum drops down from upper uterine segment to lower uterine segment and gets implanted there itself due to poor decidual reaction. Persistant chorionic activity: Persistent chirionic activity in deciduas capsularis and its development into capsular placenta comes in contact with deciduas vera of lower uterine segment. That inturn leads to placenta praevia Increased surface area of placenta The surface area of the placenta as big as in case of multiple pregnancy. Then placenta encroach into lower uterine segment Defect in decidua Due to defect in the deciduas chorionic villi unable to get nourishment. So for nourishment it spreads over wide area of uterine wall which further leads to encroachment of placenta onto lower uterine segment.

Predisposing factors of placenta The main predisposing factors of placenta praevia includes Frequent smoking leads to hypertrophoid placenta Multiparity and increased maternal age increases the incidence of placenta praevia Abnormality of shape and size of the placenta that is big size placenta and succenturiate placenta History of praevious caesarean section, scar in uterus due to hysterectomy and myomectomy TYPES OR DEGREES OF PLACENTA PRAEVIA Depending on the degree of extension of placenta to the lower uterine segment, it is divided into four types 1. Type I ( low lying) The major part of the placenta is attached to the upper segment and only the lower margin encroaches onto the lower segment but not upto the os 2. Type II ( Marginal ) The placenta reaches the margin of the internal os but does not cover it 3. Type III (incomplete or partial) the placenta covers the internal os

partially ( covers the internal os when it closed but it does not entirely do so when fully dilated 4. Type IV ( complete or central or total ) The placenta completely covers the internal os even after it is fully dilated

For clinical purpose the types of placenta praevia graded into two types . that are 1. Mild degree As per above classification the type I and II anterior comes under first category 2. Major degree Type II posterior, type III and type IV are considered as major degree Type II posterior considered as dangerous placenta praevia because of curved birth canal the major thickness of placenta lies on sacraln promontory which compress placenta, cord and prevents engagement of fetal head PATHOPHYSIOLOGY As the placental growth slows down in later months The lower uterine segment progressively dilates The inelastic placenta is shared off the wall of lower uterine segment Opening up of uteroplacental vessels leads to episodes of bleeding However the separation of placenta provoked by trauma including vaginal examination, coital act, external version Inevitable bleeding

PATHOLOGICAL ANATOMY Placenta: The placenta may be large or thin. There is often tongue shaped extension from the main placenta mass. Extensive areas of degeneration with infarction, calcification may be evident. The placenta may be morbidly attached due to poor decidual reaction Umbilical cord: The cord may be attached to the margin or into membranes. The insertion of the cord may be closed to the internal os gives rise to vasa praevia . which may rupture along with rupture of membranes Lower uterine segment Due to increased vascularity the lower uterine segment and the cervix become soft and more friable CLINICAL FEATURES The most characteristic feature is painless and apparentaly sudden onset, causeless and recurrent vaginal bleeding. In about 1/3 of the cases there is a history of warning hemorrhage usually slight Symptoms - Vaginal bleeding - Sudden onset - Painless bleeding - Recurrent - Unrelated activity

Signs - Size of the uterus according to the period of gestation - Uterus feels relaxed, soft, elastic and tenderness - Malpresentation - Floating head - Presence of fetal heart rate in mild cases DIAGNOSIS History collection Abdominal examination : The presenting part felt like soft boggy through the brim in case of major degree Vulval inspection : Is done to note the colour and amount of bleeding Vaginal examination must be not be done Placentography usually performed to detect localisation of placenta and the relationship between margin of placenta in relation to the internal os Colour Doppler flow study to note the venous flow in the hyperechoic areas Magnetic resonance image to see the quality of placental image excellence Double set up of examination ( vaginal examination) is done to by keeping everything ready for caesarean section in operation theatre Differential diagnosis - Abruption placenta - Vasa praevia - Local cervical lesion - Circumvallate placenta

COMPLICATIONS 1. Maternal a. During pregnancy - Antepartum hemorrhage - Malpresentation - Premature labour b. During labour - Early rupture of membranes - Cord prolapsed - Slow dilatation - Intrapartum hemorrhage - Increased operative deliveries - Post partum hemorrhage - Retained placenta c. Puerperium - 15th day of puerperium may be incidence of sepsis 2. Fetal - Low birth weight baby - Asphyxia - Intrauterine death - Birth injuries - Congenital malformation PROGNOSIS Due to increased maternal death are reduced by early diagnosis, prompt treatment and use of antibiotics

TREATMENT At home Patient immediately put on bed Assess the blood loss Quick but gentle abdominal examination should be done Vaginal examination must not be done Transfer client to hospital Immediate attention Assess the amount of blood loss Blood samples are taken for grouping Start IV normal saline Gentle abdomen and inspection of vulva Expectant treatment - Availability of blood for transfusion - Facilities for cesearean section for 24 hours - Bed rest to reduce fatigue - Investigation for typing and grouping - Supplemental hematinics to maintain blood volumwe - A gentle speculum examination done once bleeding stops If the mother is in more than 37 weeks termination of pregnancy is done

- Steroid therapy given for maturity of placenta Definitive treatment

Definitive treatment should be instituted soosn after hospitalization or following expected treatment resolves into: 1. Vaginal examination in operation theatre followed by low rupture of membranes or caesarean section 2. Caesarean section without internal examination 1. Vaginal examination : Double setup examination should be done in the operation theatre keeping everything ready for caesarean section Contra indications for vaginal examination : - Patient in exsanguinated state - Diagnosed cases of major degree placenta praevia - Associated with complicating factors like elderly primi, malpresentation etc a. Low rupture of memebranes: Induce the labour by low rupture of membranes using long kochers forceos in lesser degree of placenta praevia. The finger in inserted to exclude the cord prolapsed . amniotomy helps to initiation of labour and there by encourages descent of the head. This inturn presses on the separated placenta and controls the bleeding. Oxytocin drip may be started . if amniotomy fails to stop bleeding and initiation of labour caesarean section is performed. Precautions during vaginal delivery All possible steps taken to restore blood volume Methergin 2.5mg should be given intramuscularly. Proper examination of cervix following delivery Checking the babys haemoglobin level Indications for Caesarean Section:

1. Major degree placenta praevia 2. Lesser degree placenta praevia where amniotomy fails. 3. Complicating factors associated with lesser degree of placenta praevia. 2. Caesarean section without internal examination in conditions where the vaginal examination is contraindicated . Alternative therapies to treat placenta previa

Generally low placenta becomes alright on its own. But incase, you want to have a natural childbirth or a home birth, it is best to ensure that the problem has been resolved. Here are some ways through which can help yourself. Low placenta finds its cure by three techniques. The first and most prevalent method to treat low placenta is rest. Doctors all over the world suggest complete bed rest to pregnant women suffering from placenta previa. In case of bleeding one is advised to put two pillows under ones legs, knees onwards. Doctors also suggest women to restrict their movements to the minimum, getting up only to eat and visit the toilet. Often eating well and resting allows the baby to grow as the months proceed and the baby itself pushes the placenta away from the cervix while fixing its head. Acupuncture is another method, quite prevalent in china, to help cure placenta previa. The acupuncture practitioners have key puncture points where they insert needles to help the placenta move away from the opening of the uterus. Du 20 is one such point, located at the top of the head, known to cure this problem. Traditional Chinese medicines also have a cure for placenta previa. However, the herbs used are generally not disclosed by the practitioners. They

although pay visits at your home also to help those how can not get up from their bed or travel. Nettles are one herb known to help during excessive bleeding or spotting during pregnancy. It is a rich source of Vit-K.

Certain

things

to

be

kept

in

mind

Vaginal examinations are not done on women suffering from low placenta during pregnancy. In case of low placenta problem, avoid intercourse completely during the course of your pregnancy. Exerting exercise or movement should be completely avoided. Any kind of bleeding to spotting should not be overlooked and should be brought to the doctors notice immediately.

NURSING MANAGEMENT: Nursing Diagnosis: Decreased cardiac output related to excessive blood loss Fluid volume deficit related to severe blood loss Altered peripheral tissue perfusion related to hypovolemia Risk for injury related to decreased placental perfusion. Anxiety & fear related to treatment regimen. Altered family process related to hospitalization. Anticipatory grieving related to actual or perceived threat to self, pregnancy or infant.

Expected outcomes of Care: Expected outcomes for the woman experiencing palcenta praevia may include the following. The woman will; Verbalise understanding of her condition and its management. Identify and use available support systems. Demonstrate compliance with prescribed activity limitations. Develop no complications related to bleeding. Carry the pregnancy to term or near term. Give birth to a healthy new born. Plan of care and interventions: Assess for amount of bleeding, fetal condition Encourage mother for adequate rest Closely monitor the woman Weigh the pads to know the amount of bleeding one gram represents the one ml of blood. Ultra sonography done for every 2-3 weeks. Monitor fetal conditions by cardio tocograph. No vaginal or rectal examinations are performed. Place the woman on pelvic rest. Assess for signs of hypovolemic shock. Make referral if necessary. If the mother is in term and persistant bleeding delivery by caesarean section is indicated. Vaginal birth can be attempted for woman with minimal bleeding.

Monitor vital signs frequently. Assess for signs of fetal hypoxia by continuous monitoring. Observe fundus contractions after delivery Provide emotional support for client and her family. Allow the mother to express her feelings. Then provide spiritual support. Educate the woman about home management including bedrest, watching for spotting or bleeding, close followup with health care provider. Advice the mother to lie on left lateral position. Provide and teach perineal hygiene to decrease the risk of infection. PREVENTION The prevention mainly aims at : - Elimination of known factors that likely to cause antepartum hemorrhage - Correction of anemia during antenatal period so that patient can withstand blood loss - Prompt detection and institution of therapyto minimise grave complications likely to arise out of antepartum hemorrhage like shock, blood coagulation disorders and renal failure Primordial prevention Adequate antenatal care to improve the health status of women Correction of anemia to withstand for blood loss Family planning and limitation of births reduce the incidence of antepartum hemorrhage Routine administration of folic acid from the early pregnancy

Avoid drinking, smoking, or using recreational drugs during pregnancy Recognizing and managing conditions in the mother such as diabetes and high blood pressure also decrease the risk of placental abruption Primary prevention Prevention, early detection and effective therapy of pre eclampsia and other hypertensive disorders during pregnancy Avoidance of trauma specially forceful external cephalic version under anesthesia Avoid supine hypotesion syndrome the patient is adviced to lie in the left lateral position in the later months of pregnancy Needle puncture during amniocentesis should be under the ultrasound guidance Significance of warning hemorrhage should not be ignored or underestimated Antenatal diagnosis of low lying placenta at 20 weeks with routine ultrasound needs repeat ultrasound examination at 34 weeks to conform the diagnosis. Secondary prevention Hospitalization Amniocentesis is preferable for artificial rupture of membranes Avoid sudden decompression of of the uterus in acute or chronic hydramnios Administer Intravenous fuids with a large bore needle Avoid vaginal examination

Either induction of labour or caesarean section performed based on period of gestation and severity of disease condition Maintainence of normal fluid volume Teriary prevention Immediate Hospitalization Resuscitation Blood transfusion Caesarean section irrespective of gestational age Differences between placenta praevia abruption placenta

Placenta Praevia Clinical Features: Nature of Bleeding a. Painless, apparently causeless, recurrent. b. Bleeding revealed always

Abruptio Placenta

a. Painful, attributed preeclampsia trauma. b. Revealed, concealed mixed

often to or

and

Character of Blood:

Bright red

Dark coloured.

General condition and Proportionate to visible anemia blood loss

Out of proportionate to visible blood loss in concealed type.

Features of preeclampsia Not relevant

Present cases.

in

1/3

of

Abdominal examination Height of the uterus Proportionate height. May disproportionately enlarged type. in concealed be

Feel of uterus

Soft and relaxed.

May be tensed, tender, and rigid.

Mal presentation

Common

Unrelated

Fetal heart sounds

Usually present.

Usually absent.

Placentography.

Placenta segment.

in

lower Placenta segment.

in

upper

Vaginal examination.

Placenta felt at lower Placenta not felt at lower uterine segment uterine segment but there is presence of blood clots.

RESEARCH STUDIES Fouzia sheikh,fcps. 2. Sabreena abbas khokhar,mbbs 3. Pushpa sirichand,mcps, dgo, fcps 4. Raheela bilal shaikh,mbbs 1. A study of antepartum hemorrhage:mat ernal and p erinatal outcome OBJECTIVE: To determine the maternal and perinatal complications in patients presented with antepartum hemorrhage (APH) at a tertiary care hospital so that a preventive strategy can be made to optimize fetomaternal outcome. METHODOLOGY: This prospective descriptive study was conducted from September 2007 to august 2008 at Department of Gynaecology and Obstetrics unit II, Liaquat University Hospital, Hyderabad, Sindh, Pakistan. A total of 195 diagnosed cases of antepartum hemorrhage were included in the study after obtaining informed consent. RESULTS: The incidence of APH was 5.4%. maternal and perinatal morbidity was very high with increased rates of caeserian section ( 57.1% ), postpartum hemorrhage ( 19%),

need of blood transfusion ( 77.4% ), shock ( 6.66% ), peripartum hysterectomy ( 1%), preterm delivery ( 79.16% ) and maternal and perinatal mortality ( 3% and 49.7% respectively ). CONCLUSION: It was concluded that APH does stand out as a serious condition with manifestation of significant maternal and perinatal morbidity and mortality. These complications can be reduced by provision of antenatal care to every woman at their doorsteps and provision of family planning services to reduce family size hence complications Journal of obstetrics and gynaecology the journal of the Institute of Obstetrics and Gynaecology (2000)

2. Comparision study of maternal and neonatal outcome with placenta praevia and antepartum hemorrhage. We set out to assess the maternal and neonatal outcomes of women with placenta praevia and antepartum haemorrhage (APH) between 1991 and 1997, compared with woman with a diagnosed placenta praevia who did not bleed. The demographic data, maternal and perinatal outcomes of 159 women with antepartum haemorrhage were compared with 93 women without antepartum haemorrhage in a retrospective study. Women with antepartum haemorrhage had the diagnosis of placenta praevia confirmed at an earlier gestation. More women with antepartum haemorrhage received antenatal steroids and tocolytic agents, and had emergency caesarean sections. The majority of women with bleeding had an emergency caesarean section for antepartum haemorrhage and more delivered early because of fetal distress.

There were more preterm deliveries in women with antepartum haemorrhage. The mean birth weight was 2.69 kg in the women with antepartum haemorrhage and 3.06 kg in those without. More infants in the bleeding group had a low Apgar score at the first minute, respiratory distress syndrome, and admission to special baby care and neonatal intensive care unit. It is concluded that there is an increased risk of premature delivery in women with antepartum haemorrhage and placenta praevia. Aggressive management, tocolysis and cervical cerclage should be explored further to improve the perinatal outcome. Women without antepartum haemorrhage can be managed on an outpatient basis.

SUMMARY: So far we have discussed about antepartum hemorrhage and its etiology and classification. Then placental abruption its definition, etiology, types, effects on mother and fetus, clinical features, prevention and medical and nursing management. Then we also dealt about placenta praevia its definition etiology, varieties clinical features and its management.

CONCLTION: Antepartum hemorrhage is bleeding from genital tract after 28 weeks of pregnancy and before delivery. It is quiet common and most dangerous, acute condtion during pregnancy. And it is one of the leading causes of maternal mortablity and morbidity. So as a mid wife we should know about antepartum hemorrhage and its management to provide adequate and intime care for mother with antepartum hemorrhage to deliver healthy baby from healthy mother.

BIBLIOGRAPHY Books : 1. Boback teals (1995) maternity nursing ( 4th edition) Philadelphia , Mosby publications ; page no 364-368 2. D.C dutta (2006) Text book of obstetrics (6th edition) new Delhi, new central book agency ; page no. 243-261 3. Myles (1992) Text book of midwives (11th edition) Calcutta, Longman groups pvt ltd ; page no. 4. Annama Jacob (2002) Text book of comprehensive midwifery (2 nd edition) new Delhi , jaypee brothers pvt ltd ; page no. 115-119 5. B.T Basavanthappa (2005) Text book of reproductive and midwifery health (1st edition) new delhi, jaypee brothers medical publishers pvt ltd: page no :520-530 6. Neelam kumara (2007) maternity Nursing (1st edition), banglore, page no: 328-338

Journals 1. Journal of nurse midwifery (2004) jan-feb (44),vol.1 page no. 6 2. Journal of nursing research and midwifery (2006) November, vol 18, page no. 20-22 3. An international journal of obstetrics and gynecology 4. (2007) vol. 109, march ; page no. 44-56

5. International journal of nursing studies (2008) vol. 54, September ; page no. 535-538

Web site 1. http:// www.medicinet.com 2. http:// www.medplus.com 3. http:// www.wilkipedia.com

SEMINAR ON ANTEPARTUM HEMORRHAGE