Crisanta Grace Oponda, RN

Maternal hemorrhagic disorders are bleeding

conditions that can occur during pregnancy or
after childbirth. They can be caused by a
number of factors, including bleeding disorders,
placental abnormalities, and uterine atony.
1. ANTEPARTUM HEMORRHAGE
[Link] HEMORRHAGE
[Link] DISORDER
1. FIRST TRIMESTER BLEEDING
a. Abortion
b. Ectopic Pregnancy
c. Fetal Demise
[Link] TRIMESTER BLEEDING
a. H. Mole
b. Premature Cervical
Dilatation
[Link] TRIMESTER BLEEDING
a. Placental Anomalies
• preffered to be called spontaneous
miscarriages
• medical term for interruption of a
pregnancy before a fetus is viable.
• Early miscarriages happens before week 16
• late miscarriages happens between 16-20
weeks
• Abnormal fetal development due to teratogenic
factor or chromosomal aberration
• immunologic factor
• implantation abnormalities due to inadequate
endometrial formation
• ingestion of alcohol
• urinary tract infections
• systemic infections - rubella, syphilis, poliomyelitis,
cytomegalovirus, toxoplasmosis
1. SPONTANEOUS ABORTION
a. Threatened
b. inevitable
c. complete
d. incomplete
e. missed
f. habitual
[Link] ABORTION
a. therapeutic abortion
b. illegal abortion
1. THREATENED ABORTION
a. CAUSE:
i. Unknown;
ii. possible chromosomal or uterine abnormalities
b. ASSESSMENT:
i. (+) mild uterine contraction,
ii. (+) vaginal bleeding - only scant and usually bright red,
iii. (+) CLOSED CERVIX
c. DIAGNOSTIC TEST:
i. UTZ of viable pregnancy,
ii. HCG testing
1. THREATENED ABORTION
MANAGEMENT:
a. CBR,
b. No coitus for 2 weeks,
c. progesterone medications,
d. avoid strenuous activity for 24 to 48 hours,
e. avoid using tampons to halt bleeding
f. instruct WOF passage of products of conception
2. INEVITABLE ABORTION
a. CAUSE: unknown but possibly poor placental
attachment
b. ASSESSMENT:
i. (+) moderate to severe uterine contraction
ii. (+) moderate to heavy vaginal bleeding
iii. (+) open cervix
c. DIAGNOSTIC TEST
i. blood test - HCG
ii. pelvic exam
iii. UTZ
2. INEVITABLE ABORTION
MANAGEMENT
a. D&C
b. Rhogam
c. save any tissue fragments passed
d. emotional support
3. COMPLETE ABORTION
a. CAUSE: unknown but possibly chromosomal or uterine
abnormality
b. ASSESSMENT
i. Ok uterus
ii. (+) open cervix
iii. all products of conception are expelled
iv. (+) vaginal spotting and cramping
c. DIAGNOSTIC TEST
MANAGEMENT
i. blood test
a. Emotional support
ii. UTZ
b. supportive care
iii. pelvic examination
4. INCOMPLETE ABORTION
a. CAUSE: unknown but possibly chromosomal or uterine
abnormality
b. ASSESSMENT
i. not all products of conception are expelled
ii. not ok uterus and cervix
iii. (+) vaginal spotting and cramping
c. DIAGNOSTIC TEST
i. blood test
ii. UTZ
iii. Pelvic examination
4. INCOMPLETE ABORTION
MANAGEMENT
a. D&C
b. suction curretage
c. Rhogam
5. MISSED ABORTION
a. CAUSE: unknown
b. ASSESSMENT
i. all products of conception are retained
ii. not ok uterus, cervix, & fetus
c. DIAGNOSTIC TEST
i. UTZ
ii. Blood test
5. MISSED ABORTION
MANAGEMENT
a. D&C
b. Antibiotic Therapy
c. Rhogam
d. WOF for symptoms of DIC
e. If pregnancy is over 14 weeks, labor is induced by a
prostaglandin suppository (Cytotec)
f. Emotional support
g. supportive care
6. HABITUAL ABORTION/ RECURRENT PREGNANCY LOSS
a. CAUSE:
i. defective spermatozoa or ova
ii. endocrine factors
iii. deviation of the uterus
iv. resistance to uetine artery blood flow
v. uterine infections or chorioamnionitis
vi. autoimmune disorders
6. HABITUAL ABORTION/ RECURRENT PREGNANCY LOSS
a. ASSESSMENT
i. 3 or more consecutive pregnancies resulted in
abortion which is usually related to incompetent
cervix
b. DIAGNOSTIC TEST MANAGEMENT
i. UTZ 1. McDonald Operation
ii. psychogenic [Link] procedure
iii. co-morbidity
1. THERAPEUTIC INDUCED ABORTION
a. Medical Intervention
b. Ensures the life of the mother especially if there are
bioethical issues involved.
c. It has a two-fold effect which opts for the choice of
lesser evil.
[Link] INDUCED ABORTION
a. Unwanted termination of the pregnancy
b. the mother’s and the fetal life is at stake
c. not premitted by the law in the Philippines
• The termination of the pregnancy after the age of
viability

• ANTENATAL DEMISE - occurs before labor

• INTRAPARTUM DEMISE - occurs after onset of
labor
• Idiopathic
• Antiphospholipid Antibody Syndrome (APAS)
• Maternal Diabetes
• Maternal Trauma
• Severe maternal isoimmunization
• Fetal aneuploidy
• Fetal Infection
• MACERATED BABY - soft body of the dead baby
within 1-2 weeks
• MUMMIFICATION - leather like body that is
more than 2 weeks
• LITHOPEDION - stone hard body
• implantation occured outside the uterine cavity.
• extrauterine implantation
• 90% of such pregnancy is a tubal pregnancy
• 80% occurs in ampullar portion
• 12% occur in isthmus
• 8% are interstitial or fimbrial
• TUBAL IMPLANTATION - most
common
• OVARIAN IMPLANTATION
• CERVICAL IMPLANTATION - Rare
• ABDOMINAL IMPLANTATION - Most
dangerous
• UNRUPTURED ECTOPIC PREGNANCY
⚬ Missed Period
⚬ Abd pain w/n 3-5 weeks of amenorrhea
⚬ scanty, dark brown vaginal bleeding
⚬ vague discomfort
• RUPTURED ECTOPIC PREGNANCY
⚬ Sudden, sharp, knifelike, unilateral severe pain
⚬ Kehr’s sign
⚬ (+) Cullen’s sign
⚬ syncope
• Termination of pregnancy
• Exploratory Laparotomy
• Fluid Replacement
• Administration of Methotrexate
• Testing for HCG Titer
• RhoGam
• Salphingostomy/Salphigectomy
• Combat Shock
• Abnormal proliferation and the degeneration of the
trophoblastic villi.
• “bunch of grapes”
• gestation anomaly of the placenta
• incidence is approx 1 in every 1500 pregnancies.
• Below 17 and above 35 years old pregnancies
• Low CHON Diet
• Previous [Link]
• COMPLETE MOLE
⚬ occurs when a sperm fertilizes an empty egg, resulting in a
placenta with no fetal development and only paternal DNA
• PARTIAL MOLE
⚬ happens when two sperm fertilize a normal egg, leading to
some fetal development and a mix of maternal and
paternal DNA
• Pelvic examination
• serum HCG level monitoring
⚬ assessed every 4 weeks for 6-12 months
⚬ after 6 months if HCG levels are already negative, patient is
theoretically free from the risk of malignancy.
• Suction curettage
• instruct the patient not to get pregnant for 1 year to allow HCG
to decrease
• Prophylaxis: Methotrexate
• If metastasis occur: Dactinomycin
• hysterectomy
• previously termed as incompetent cervix
• it is a rare condition when a cervix dilates prematurely and
therefore cannot hold a fetus until term
• it occurs about 1% of women
• commonly occurs at approximately week 20 of pregnancy
• increased maternal age
• congenital structural defects
• trauma to the cervix

• dilation is usually painless

• first symptoms include show
• increased pelvic pressure
• PROM
• uterine contraction
• Early sonogram

• Cervical cerclage
⚬ McDonald Procedure
⚬ Shirodocar Procedure
 A condition which placenta is implanted abnormally in the lower
part of the uterus, is the most common cause of painless bleeding
in the third trimester of pregnancy.
• presence of scars and tumors in the uterine lining
• multigravida
• presence of fibroids
• previous cesarean section
• increasing maternal age
• cigarette smoking
• previous previa
• prior curettage
• PAINLESS BRIGHT RED BLEEDING beginning in the 7th month
• engagement usually has not occured
• fetal distress
• presentation of placenta

• UTZ
⚬ less than 30% blockage possible for NSD
⚬ more than 30% blockage candidate for CS
• Blood test
• APT or Kleihauer Betke test
• secure consent
• Place patient in a side lying position
• No coitus, No IE, No Enema
• CBR S BRP
• prepare to induce labor if cervix is ripe or dilated
• IV Fluids
• place patient in NPO for possible CS
• prepare for double set-up
• estimate the present blood loss
Premature separation of a normally implanted placenta. This
occurs in about 10 out of 1000 pregnancies and it can lead to
extensive bleeding reason why it is the most frequent cause of
perinatal death.
• Preeclampsia and hypertensive disorders
• illicit drug use
• trauma
• history of placenta abruptio
• multigravida
• increase maternal age
• cigarette smoting
• short umbilical cord
• chorioamnionitis
• sharp, stabbing pain high in the uterine fundus as the initial
separation occurs
• DARK RED PAINFUL VAGINAL BLEEDING
• Concealed bleeding - rigid board like abdomen
• moderate to severe abd pain
• drop in coagulation factors
• hyperactivity then cessation of fetal movement
• Disseminated Intravascular Coagulation (DIR)
• Couvelaire uterus / uteroplacental apoplexy

• Emergency CS
• Vaginal Delivery
• Conservative in-hospital observation
• secure consent
• Place patient in a side lying position
• No coitus, No IE, No Enema
• IV Fluids
• Blood typing and cross matching for possible blood transfusion
• Monitor FHT and maternal VS for shock
• Measure blood loss
• Strict I&O
• Report signs and symptoms of DIC
• Restrict from doing any abdominal, pelvic, and vaginal
examination
• a condition that occurs when the uterus
doesn't contract enough after childbirth, which
can lead to heavy bleeding. It's the most
common cause of postpartum hemorrhage,
which can be life-threatening
• Deep anesthesia or analgesia
labor initiated and assisted with an oxytocin
agent
high parity or maternal age of 35 above
• previous uterine surgery
• prolonged and difficult labor
• chorioamnionitis or endometritis
• secondary maternal illness
⚬ history of PPH
⚬ prolonged magnesium sulfate or other
tocolytic
• Administration of Uterotonics
⚬ Oxytocin
⚬ Carboprost tromethamine
⚬ Methargine
⚬ Misoprostol (Cytotec)
• Fundal massage
• elevate lower extremities
• CBR S BRP
• Empty bladder - offer bedpan or assist the patient to the
bathroom every 4 hours
• strictly monitor VS
• Blood replacement
Small lacerations or tears of the birth canal are
common and may be considered a normal
consequence of childbearing. large lacerations,
can be a source of infection or hemorrhage.
• Dystocia or precipitate labor
• primigravida
• macrosomia
• with the use of lithotomy position and instruments (e.g. forceps,
vacuum extraction)

• CERVICAL LACERATION
• VAGINAL LACERATION
• PERINEAL LACERATION
⚬ 1st degree - damages skin area
⚬ 2nd degree - includes muscles and bulbocavernosus
⚬ 3rd degree - includes external anal sphincter
⚬ 4th degree - anal mucosa
• Proper perineal care
• avoid streinous activity
• cold compress in first 24-48 hours
• warm compress in next 72 hours
• check any discharge
• use bed commode
• usage of droplight in the perineal area
• Suturing
• high fiber diet
• stool softener as prescribed
• patient with 3rd and 4th degree laceration should not have an
enema or renal suppository
• pieces of the placenta that remain
in the uterus after giving birth
• this happens when placenta
doesn’t detach entirely
• Previous cesarean birth
• in vitro fertilization
• succenturiate placenta
• placenta accreta
• D&C
• Observe the color of lochia
• methotrexate
 It is the prolapse of the fundus of the
uterus through the cervix so that the
uterus turns inside out with either birth of
the fetus or delivery of the placenta
• Traction of umbilical cord
• fundal push
• precipitate labor

• Inverted fundus
• Total inversion
• Never attempt to replace an inversion
• Never remove the placenta
• discontinue oxytocin
• replace fluids
• administer oxygen
• OB will manually replace the fundus
• after replacement, resume oxytocin
• Antibiotic therapy
• Possible CS in the future
it is a rare but serious condition that causes abnormal
blood clotting throughout the body's blood vessels
• Abruptio placenta
• gestational hypertension
• amniotic fluid embolism
• placenta retention
• septic abortion

• Bruising
• IV site bleeding
• Bleeding
• Administration of Heparin
• Blood Transfusion
• Resolving the underlying insult
• WOF bleeding
• Strictly monitor VS
• Monitor coagulation level
• incomplete return of the uterus to its pre-pregnant size and shape.
• can be a result from a small retained placental fragments, a mild
endometritis, and other problems

• Methergine
• Antibiotics
• Increased fluid intake
• Promote Voiding
• collection of blood in the subcutaneous
layer of tissue of the perineum
• hematomas are likely to occur after
rapid, spontaneous births and in women
in perineal varicosities.
• Precipitate labor
• perineal varicosities
• episiorrhapy

• Cold compress
• pain reliever
• check for discharge, color, smell, and circulation
• Maternal and Child Nursing 8th Edition by Adele
Pillitteri