ANTEPARTUM

HEMORRHAGE
PREPARED BY:
MS. SUMA C M
1ST YEAR M.SC (N)
RCON
 INTRODUCTION

 Antepartum hemorrhage refers to bleeding from the genital tract that occurs after 20 weeks of

pregnancy and before the onset of labour. It is a significant obstetric complication and a

leading cause of maternal and perinatal morbidity and mortality. The condition requires

prompt diagnosis and management to prevent adverse outcomes for both the mother and

fetus.
 DEFINITION
 Antepartum hemorrhage (APH) is defined as bleeding from the genital tract after 28 th week of
pregnancy and before the birth of the baby.

Incidence
 1 in 250 in India.
 One third of all APH occur due to placesta previa
 Causes

The exact cause is unknown.

The following theories are
postulated;
* Dropping down theory.
* Multiple pregnancies.
* Defective decidua.
 Risk factors

High risk factors 0f placenta previa are;

* Increased maternal age (> 35 years).
* Multiparity.
* Previous cesearean section Or scar on
the uterus.
* smoking.
* Prior curettage.
 Types or Degree
* Type I (loco lying) :
The lower margin of the Placenta lies in the lower segment.
* Type II anterior:
it means placenta is implanted at the anterior call of the uterus.
* Type II posterior:
It means placenta is implanted at the posterior or back wall of the
uterus.
* Tye III (complete or partial or central:
The placenta covers the internal or when closed, but not when fully
dilated.
* Tye IV (central /complete) :
The placenta completely covers the internal OS even when the cervix is
 Signs & Symptoms

* Painless vaginal bleeding in the 3rd trimester of

pregnancy.
* Bright vaginal bleeding.
• The bleeding can be scanty at first and then
become more profuse and gradually increases with
the placental separation.
 Puerperium
* Sepsis
* Increased operative interference.
• Embolism.

 fetal.
* Low birth weight babies.
* Asphyxia.
* Intrauterine death.
* Birth injuries.
* Congenital malformations.
 Management

 Prevention

* To improve the health status of woman and correction of anemia, adequate antenatal care
is required.
• Antenatal diagnosis of low- lying placenta with repeat ultrasound.

 Home management

* Put the Patient to bed rest.

* Assess the blood loss.
* Quick but, gentle abdominal examination.
• Vaginal examination must not be done.

 Management at hospital

* If the gestational age is early, an attempt is made to prolong the pregnancy with the
intention of optimizing the neonatal outcome.
* Blood replacement therapy or iron therapy.
 Nursing Role

Instruct the mother for bed rest, no strunous exercise or sexual intercourse for the rest of
the pregnancy until baby is ready for delivery..
If woman isexperiencing bleeding:
* Assess baseline vital signs, especially BP.
* Assess fetal heart sound.
*No abdominal manipulation.
* Assist the woman in a side lying position.
* start blood transfusion.
Contractions causing bleed
* Nurse should be ordered to give tocolytics (drugs to stop contractions).
bruptio Placenta

efinition: The premature separation of a normally situated placenta after 28 weeks of gestation and before b

aby is called abruptio placenta.

pes/Varities

Revealed: It is the most common type. In this, following separation of the placenta, the blood escape dow

between the membranes and decidua. Ultimately, blood comes out of the cervical canal to be visible exte

Concealed: This type is rare. The blood collects behind the separated placenta or between the membrane

decidua. As a result, the blood cannot comes out of the cervical canal and cannot be visible externally.

Mixed: In this type some portion of the blood collects inside (concealed) and a portion is expelled out (rev
 Causes of abruptio
previa
The exact cause is unknown, but several factors have been considered as
causes:
* Spasm of the uterine vessels followed by pooling of blood into the
choriodecidual space
* Malnutrition
* Folic acid deficiency
* Traction of short cord
•Trauma from external cephalic version (ECV)
•High birth order, i.e. gravida >5
* Advancing age of mother
* Poor socioeconomic condition
•Smoking
* Major congenital malformations
Clinical Classification-Grading of Abruptio Placenta
Depending upon the degree of placental abruption and its clinical effects, the cases are graded as f
* Grade 0: Clinical features are absent. The diagnosis is made after inspection of placenta following
• Grade 1: External bleeding is slight. Uterus → irritable, tenderness may or may not be present. Sh
FHS is good.
•Grade 2: External bleeding → Mild to moderate uterine tenderness is always present. shock → abse
or fetal death occurs.
• Grade 3: Bleeding → Moderate to severe. Uterine tenderness → marked. Shock → pronounced feta
Coagulation defect/anuria may complicate.
Signs and Symptoms
* Small to moderate amount of bright or dark red vaginal bleeding.
Acute abdominal pain associated with vaginal bleeding.
Uterine tenderness and high uterine tonicity often describe as 'board like abdomen'.
•Increased size of uterus in case of concealed hemorrhage.
.Failure of uterus to relax between contractions.
. Fetal heart sound absent with concealed/mixed type.
* Urine output usually diminished.
Diagnosis
Ultrasonography: To visualize the location of the placenta and presence of clots or hematoma
Coagulation profile: To rule out disseminated intravascular coagulopathy (DIC)
* Clotting time.
* Bleeding time.
* Fibrinogen level.
* Platelet count.
* Prothrombin (PT) and partial prothrombin time (aPTT).
* Fibrin degradation products.
Urine test: For albumin.
Renal function test.
Management
Prevention: The following guidelines may be helpful in prevention of abruptio placenta:
• Prevention, early detection and effective therapy of preeclampsia and other hypertensive disorders
• pregnancy.
Needle puncture during amniocentesis should be done under ultrasound guidance.
* Avoidance of trauma: Specially forceful external cephalic version under anesthesia.
• To avoid sudden decompression of the uterus: In acute or chronic hydramnios, amniocentesis is pre
rupture of membranes.
• To avoid supine hypotension, the patient is advised to lie in the left lateral position in the later mon
to avoid vena caval compression.
Routine administration of folic acid from early pregnancy of doubtful value.
Home: In case of abruptio placenta, it is not possible to treat the patient at home, so arrangement is m
to an equipped maternity unit as early as possible.
 Conclusion

After writing this lesson plan, we have discussed about the introduction, definition, types
causes, risk factors,
signs ana symptoms, diagnosis, management and nurses role of antepartum hemorrhage
I hope that patient
and family members gained some knowledge about antepartum hemorrhage and they
apply these measure
in their health.
 Bibliography

1.SANDEEP KAUR, TEXTBOOK OF MIDWIFERY AND OBSTETRICAL NURSING, CBS PUBLISHERS ANO DISTRIB
IST EDITION, PAGE NO.: 272-274.
2. SANDEEP KAUR, TEXTBOOK OF MIDNIFERY ANO GYNEOCOLOGICAL NURSING, CBS PUBRISHERS AND
DISTRIBUTORS, 2NO EDITION, PAGE NO: 221 - 225.
3. NIMA BHASKAR, TEXTBOOK OF MIDWIFERY ANO OBSTETRICAL NURSING, EMMESS MEDICAL PUBLISHER
BRO EDITION, PAGE NO: 337- 341.