SPECIFIC CONTENT TIME AV AIDS TEACHER/ EVALUATION

OBJECTIVES LEARNER
ACTIVITY
To define ANTE PARTUM HEMORRHAGE:- 2min PPT and Lecture What is
APH. black board cum APH?
DEFINITION:- discussion

 It is defined as bleeding from or into the genital tract after

the 28th week of pregnancy but before the birth of the baby.

CAUSES:-
To enumerate 3min PPT explanation What are the
causes of 1. Placental bleeding (70%):- causes of
APH. APH?
i. Placenta previa (30%)
ii. Abruptio placenta (30%)
2. Unexplained (25%) or indeterminate
3. Extra placental causes (5%):-
i. Cervical polyp
ii. Carcinoma cervix
iii. Varicose vein
iv. Local trauma
To explain 1) PLACENTA PREVIA:- 20mi What is
placenta n Lecture placenta
previa. DEFINITION:- PPT cum previa?
explanation
 When the placenta is implanted partially or completely over
the lower uterine segment (over and adjacent to the internal
os) is called placenta previa.

INCIDENCE:-

 About one-third cases of antepartum hemorrhage belong to

placenta previa.
 The incidence of placenta previa ranges from 0.5 to 1%
amongst hospital deliveries.
 In 80% cases, it is found in multiparous women.

ETIOLOGY:-

 The exact cause of implantation of the placenta in the lower

segment is not known.
 The following theories are postulated.
1. Dropping down theory:-
 The fertilized ovum drops down and is implanted in the
lower segment.
 Poor decidual reaction in the upper uterine segment may
be the cause.
 This explains the formation of central placenta previa.
2. Persistence of chorionic activity:-
 Persistence of chorionic activity in the decidua
capsularis and its subsequent development into capsular
placenta which comes in contact with decidua vera of the
lower segment can explain the formation of lesser
degrees of placenta previa.
3. Defective decidua:-
 This results in spreading of the chorionic villi over a
wide area in the uterine wall to get nourishment. During
this process, not only placenta becomes membranous but
encroaches into the lower segment.
 4. Big surface area of the placenta:-
 Big surface area of the placenta as in twins may
encroach onto the lower segment.

HIGH-RISK FACTORS FOR PLACENTA PREVIA:-

 Multiparity
 Maternal age: >35years-4-fold increase
 Race: Asian women
 Infertility treatment
 Presence of uterine scar: caesarean section,
myomectomy
 Prior curettage
 Prior placenta previa
 Multiple pregnancy
 Succenturiate lobes, big placenta
 Smoking
TYPES OR DEGREES:-

There are four types placenta previa depending upon the degree of
extension of placenta to the lower segment.

1. Type I (low-lynig):-
 The major part of the placenta is attached to the upper
segment and only the lower margin encroaches onto
the lower segment but not up to 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 central):-
 The placenta covers the internal os partially.
4. Type IV (Central or complete):-
 The placenta covers the internal os even after it is
fully dilated.
CLINICAL FEATURES:-

SYMPTOMS:-

 Vaginal bleeding (sudden onset, painless, apparently

causeless and recurrent).
SIGNS:-

 General condition and anemia are probably

proportionate to the visible blood loss.
Abdominal examination:-

 The size of uterus is proportionate to the period of

gestation.
 The uterus feels relaxed, soft and elastic without any
localized area of tenderness.
 Persistence of malpresentation like bridge or
transverse or unstable lie is more frequent. There is
also increased frequency of twin pregnancy.
 Head is floating in contrast to the period of gestation.
Persistent displacement of the fetal head is very
 suggestive.
 Fetal heart sound is usually present unless there is
major separation of the placenta with the patient in
exsanguinated condition.
Vulval inspection:-

 Only inspection is to be done to not whether the bleeding is

still occurring or has ceased, character of blood- bright red
or dark colored and the amount of blood loss- to be assessed
from the blood stained clothing.
 In placenta previa, the blood is bright red as the bleeding
occurs from the separated uteroplacental sinuses close to the
cervical opening and escapes out immediately.

DIAGNOSTIC EVALUATION:-

 Ultrasonography
  TAS
 TVS
 TPS
 MRI

COMPLICATIONS:-

DURING PREGNANCY:-

 Antepartum hemorrhage:-
 Malpresentation
 Premature labor either spontaneous or induced
 Early rupture of the membranes
 Slow dilatation of the cervix
 Intrapartum hemorrhage
 Postpartum hemorrhage:-
 Imperfect retraction of the lower utensil upon which
the placenta is implanted
 Large surface area of placenta with atonic uterus with
 preexisting anemia
 Trauma to the cervix and lower uterine segment
 Death due to massive hemorrhage
 Retained placenta

DURING PUERPERIUM:-

 Sepsis
 Subinvolution
 Embolism

FETAL COMPLICATIONS:-

 Low birth weight babies

 preterm labour
 fetal growth restriction
 asphyxia
 Intrauterine death
  Birth injuries
 Congenital malformation

MEDICAL MANAGEMENT:

 Bed Rest: Bed rest may be recommended to reduce the risk

of bleeding.
 Avoidance of Intercourse: Sexual intercourse and activities
that may increase the risk of bleeding should be avoided.
 Close Monitoring: Regular check-ups with a healthcare
provider, including ultrasounds to monitor the position of
the placenta and the baby's growth.
 Hospitalization: In severe cases or if bleeding occurs,
hospitalization may be necessary for closer monitoring and
immediate medical intervention if needed.
 Corticosteroids: If there's a risk of preterm delivery due to
placenta previa, corticosteroids may be administered to help
accelerate the development of the baby's lungs.
  Blood Transfusion: In cases of severe bleeding, blood
transfusions may be required to replace lost blood and
stabilize the mother's condition.

SURGICAL MANAGEMENT:

 Cesarean Section: In the majority of cases of placenta

previa, a cesarean section is performed to minimize the risk
of bleeding during delivery. This is typically scheduled
before the due date to avoid the risk of spontaneous labor
and potential heavy bleeding.
 Placenta Removal: In cases where the placenta is firmly
adherent to the uterine wall (placenta accreta, increta, or
percreta), surgical removal of the placenta may be
necessary. This procedure may involve a hysterectomy
(removal of the uterus) if the bleeding cannot be controlled
and poses a significant risk to the mother's life.
 Selective Embolization: In cases of severe bleeding,
selective embolization of the uterine arteries may be
 performed to help control the bleeding by blocking the
blood supply to the placenta.
 Compression Sutures: In some cases, compression sutures
may be placed on the uterus to help control bleeding during
a cesarean section or to manage bleeding in cases of
placenta accreta.

NURSING MANAGEMENT:-

1. Assessment:

 Conduct a thorough assessment of the patient's history,

including any previous pregnancies, surgeries, or medical
conditions.
 Monitor vital signs regularly, paying close attention to signs
of hemorrhage such as tachycardia and hypotension.
 Assess the patient's level of pain, if any, and any vaginal
bleeding.
2. Education and Counseling:

 Educate the patient about placenta previa, its causes,

symptoms, and potential complications.
 Provide information about the importance of avoiding
activities that may trigger bleeding, such as intercourse and
heavy lifting.
 Discuss signs and symptoms of preterm labor or
hemorrhage that require immediate medical attention.
 Address any concerns or fears the patient may have about
the condition or the delivery process.

3. Monitoring and Observation:

 Monitor for any signs of vaginal bleeding, abdominal pain,

or contractions.
 Assess fetal well-being through regular fetal heart rate
 monitoring and ultrasound examinations.
 Monitor for signs of preterm labor, such as cervical changes
or regular contractions.

4. Emotional Support:

 Provide emotional support to the patient and her family, as

placenta previa can be a stressful and anxiety-provoking
condition.
 Encourage open communication and provide a supportive
environment for the patient to express her concerns and
fears.

5. Preparation for Delivery:

 Educate the patient about the possibility of a cesarean

section delivery and what to expect during and after the
procedure.
 Assist in preparing the patient for delivery, including
 arranging for hospital admission and ensuring that she
understands any preoperative instructions.

6. Preventing Complications:

 Monitor for signs of hemorrhage and be prepared to initiate

emergency interventions if bleeding occurs.
 Administer medications as prescribed, such as
corticosteroids to promote fetal lung maturity in the event of
preterm delivery.

7. Collaboration with Healthcare Team:

 Collaborate with obstetricians, midwives, and other

members of the healthcare team to ensure comprehensive
care for the patient.
 Communicate any changes in the patient's condition or any
 concerns promptly to the healthcare provider.

2) PLACENTAL ABRUPTION (ABRUPTIO

PLACENTAE)

INTRODUCTION:-

 It is a serious obstetric complication characterized by the

To describe
placenta premature separation of the placenta from the uterine wall,
abrutio. 20mi lecture cum
leading to potential complications for both mother and
n discussion What is
fetus. PPT placenta
abruptio?

DEFINITION:

Placental abruption is defined as the early detachment of the

placenta from the uterine wall before the onset of labor, which can
compromise fetal oxygenation and lead to significant maternal
bleeding. The condition varies in severity and can have critical
consequences if not managed promptly.
TYPES:

1. Complete Placental Abruption: The entire placenta is

separated from the uterine wall, often resulting in severe
bleeding and a high risk of fetal and maternal complications.
This is the most severe form and usually requires urgent
delivery.
2. Partial Placental Abruption: Only a portion of the
placenta detaches from the uterine wall. The severity of
symptoms and complications depends on the extent of the
detachment. This type can sometimes be managed more
conservatively, depending on the fetal and maternal
condition.

CAUSES:

 Trauma: Blunt abdominal trauma, such as from a fall or

accident, can lead to placental abruption.
 Hypertension: Chronic hypertension or pregnancy-induced
 hypertension (pre-eclampsia) can damage the placental
blood vessels, increasing the risk of abruption.
 Multiple Gestations: Pregnancies with twins or more
increase the risk due to the increased uterine distention.
 Smoking: Tobacco use is a significant risk factor associated
with placental abruption.
 Cocaine Use: Cocaine or other illicit drug use during
pregnancy greatly increases the risk of placental abruption.
 Previous History: A history of placental abruption in
previous pregnancies increases the likelihood of recurrence.
 Premature Rupture of Membranes: Early rupture of the
amniotic sac can lead to a higher risk of abruption.
 Uterine Overdistension: Conditions like polyhydramnios
(excess amniotic fluid) can stretch the uterus and increase
the risk.

SIGNS AND SYMPTOMS:

 Vaginal Bleeding: The bleeding may be external or

 concealed (behind the placenta). It can vary from light to
severe and may be accompanied by clots. Concealed
bleeding might not be visible but can lead to abdominal pain
and uterine tenderness.
 Abdominal Pain: Sudden, severe pain in the abdomen,
often described as crampy or persistent. The pain can be
localized or diffuse.
 Uterine Tenderness: The uterus may feel hard and tender
on palpation. Contractions may be frequent and painful.
 Decreased Fetal Movements: The fetus may show reduced
movement or signs of distress, including abnormal heart rate
patterns.
 Signs of Shock: Maternal signs may include pallor, rapid
pulse, low blood pressure, and dizziness, indicating
significant blood loss.

DIAGNOSTIC EVALUATIONS:

 Clinical Examination: Includes assessing maternal vital

 signs, abdominal tenderness, uterine tone, and fetal heart
rate.
 Ultrasound: Although useful, ultrasound may not always
detect placental abruption, especially if the bleeding is
concealed. It helps in identifying the location of the placenta
and assessing fetal well-being.
 Fetal Monitoring: Electronic fetal monitoring assesses fetal
heart rate and patterns to detect signs of fetal distress.
 Laboratory Tests:
o Complete Blood Count (CBC): To evaluate the
extent of blood loss and detect anemia.
o Blood Typing and Crossmatching: To prepare for
potential blood transfusions.
o Coagulation Profile: To check for signs of
disseminated intravascular coagulation (DIC), a
potential complication of severe abruption.
MANAGEMENT:

Medical Management:

 Stabilization: Immediate attention to stabilize the mother,

which includes intravenous fluids and possibly blood
transfusions to manage blood loss.
 Medication: Medications may be administered to manage
blood pressure or treat any associated conditions such as
pre-eclampsia. Pain relief and tocolytics (to prevent
premature labor) might be used if delivery is not imminent
and if it is deemed safe.
 Monitoring: Continuous monitoring of maternal vital signs,
fetal heart rate, and uterine contractions.

Surgical Management:

 Delivery: The primary treatment is delivery. The mode of

delivery depends on the gestational age, maternal condition,
 and fetal status:
o Cesarean Section: Often required in cases of severe
abruption, fetal distress, or when rapid delivery is
necessary.
o Vaginal Delivery: May be considered if the
abruption is mild, the fetus is stable, and there are no
other contraindications.

Nursing Management:

 Monitoring: Regular assessment of maternal vital signs,

fetal heart rate, uterine tone, and bleeding. Monitor for any
signs of worsening condition or complications.
 Support: Provide emotional support to the mother and
family, explaining the condition, interventions, and potential
outcomes. Offer reassurance and address concerns.
 Preparation for Delivery: Ensure all necessary equipment
 and personnel are available for possible emergency delivery.
Prepare for potential blood transfusions and other
interventions.
 Postpartum Care: Monitor for postpartum hemorrhage,
assess uterine tone, and support the mother’s recovery.
Educate the mother on recognizing signs of complications
and provide guidance on future pregnancies.

Bibliography:-
1. Dc Dutta “Textbook of Obstetrics”, 9th edition Published by
Jaypee Publishers, New Dehli. Page no. 108-116

2. Nima Bhaskar “Textbook of Midwifery and Obstetrical

Nursing”, 2nd edition Published by EMMESS Medical
Publishers. Page no.-88-91.

3. https://www.ncbi.nim.nih.gov

4. https://www.healthline.com
5. https://shideshare.com