OBJECTIVES OF APH:

 To define about APH.

 To list the causes of APH.
 To explain placenta previa, abruptio-placentae
& vasa previa
 To know the risk factors ,presentation, diagnosis
and management PP, AP ,& VP.
 To describe the nursing care and prevention of APH.
DEFINITION OF APH-
It is defined as bleeding from or into the genital tract
after 28th week of pregnancy but before the birth of
baby.
 CAUSES:
Placental bleeding(70%)
Unexplained or intermediate(25%)
Extraplacental causes(5%)
Causes Contd..
Placental bleeding Extra placental causes
 Placenta previa  Local cervical lesions
 Abruptio placentae  Cervical polyp
 Vasa previa  Carcinoma cervix
 Varicose vein
Local trauma
PLACENTA PREVIA:
DEFINITION: When
the placenta is
implanted partially or
completely over the
lower uterine segment is
called Placenta Previa.
Incidence
 About 1/3rd cases of APH
belongs to placenta previa
 0.5 -1%amongst hospital
deliveries
 80%cases found in
multiparous women
 Incidence is increased
beyond the age of 35 years
with high order
pregnancies
Etiology
Exact cause : unknown
following theories are postulated-
Dropping Down theory
Persistence of chorionic activity
Defective Decidua
Big surface area of the placenta
High Risk Factor
Multiparty
Maternal Age: >35 years
Race: Asian
Mother infertility treatment
Presence of uterine scar
Prior curettage
Prior placenta previa
Multiple pregnancy
Placental size abnormality
Smoking
Types or Degree
 Type -1. (low lying)
 Type -2.(marginal)
 Type -3. (incomplete or partial central)
 Type -4. (central or complete)
CONTD…
 Type 1. (Low lying):major part is attached to the
upper segment and only the lower margin encroaches
onto the lower segment but not up to the os.
 Type 2.(Marginal):Placenta reaches the margin of
the internal os but does not cover it.
 Type 3.(Incomplete or partial):Placenta covers the
internal os partially.
 Type 4.(Central or total):Placenta completely covers
the internal os even after it is fully dilated.
Clinical Features
 the only symptom of placenta previa is “painless vaginal
bleeding”.
 SIGNS:
Size of uterus : proportionate to period of gestation
Uterus :relaxed, soft and elastic without any localized edema
Malpresentation: breech or transverse or unstable lie
The head is floating
Vulval inspection: blood is bright red in colour
FETAL HEART SOUND :usually present unless major
separation.
Diagnosis Evaluation
 Placento-graphy
 Trans-abdominal
sonography
 Trans-vaginal sonography
 Trans-perineal
sonography
 Color Doppler : 3-D power
Doppler is the best
 MRI
Clinical Conformation
 Double setup examination
 Examination of the placenta following vaginal
delivery reveals-
 A tongue shaped comparatively thin segment of
placental tissues
 Rent on the membrane is situated on the margin of
the placenta
Abnormal attachment of the cord
Complication
Maternal Fetal
 Malpresentation Low birth weight
 EROM Fetal growth restriction
 Cord prolapse
Asphyxia
 Slow dilatation of cervix
 IPH Intra-uterine death
 Increased incidence of operative Birth injuries
interference Congenital malformation
 PPH
Fetal morbidity and mortality
During puerperium:
 Sepsis
 Sub-involution
 embolism
MANAGEMENT
 Prevention
 Immediate
Management
 Expectant
management
 Active management
 Nursing management
Prevention:
 Adequate antenatal care
Significance of warning
hemorrhage
AT HOME-
Put the patient on bed
Abdominal examination
Vaginal examination must
not be done
TRANSFER TO HOSPITAL-
Admission to hospital
IMMEDIATE ATTENTION
 To insure an adequate
blood supply to a women
and fetus place the
women immediately on
side lying position.
 A large bore IV cannula
is sited and infusion of
normal saline.
 Gentle abdominal
palpation
EXPECTANT MANAGEMENT
The expectant treatment is carried up to 37 weeks.
AIM: The aim is to continue pregnancy for fetal maturity
without compromising the maternal health.
INDICATIONS:
 No active bleeding
Patient stable haemo-dynamically
FHS- Good
CTG- reactive fetus
CONTD….
 Bed Rest
 Investigation: HB
estimation, blood grouping
and urine for protein
 Periodic Inspection: of
vulval pads and fetal
surveillance with USG at
interval of 2-3 weeks
 Supplementary hematinic
Use of tocolysis (MgSO4)
can be done.
ACTIVE MANAGEMENT
INDICATION:
 Bleeding occurs at or
after 37 weeks of
pregnancy
 Patient is in labor
 FHS-absent
 Gross fetal malformation
 Dead Fetus
CONTD….
ACTIVE MANAGEMENT:
Emergency cesarean delivery:
If maternal or fetal jeopardy is present after
stabilization of mother.
Vaginal delivery:
This may be attempted if the lower placental edge is
>2cm from the internal cervical Os.
NURSING CARE:
All maternal and fetal vital signs should be monitored.
 Assess amount and nature of bleeding.
The women should be grouped and cross-matched for
packed red blood loss.
Physical comfort and emotional support must be
provided.
 The lady must be assisted to rest in left lateral
position.
Observation must be made for any developing
complication.
ABRUPTIO PLACENTAE:
DEFINITION
It is one form of
antepartum hemorrhage
where the bleeding
occurs due to premature
separation of normally
situated placenta.
VARIETIES:
 Revealed: Following
separation of placenta
,blood insinuates
downwards between the
membranes and decidua.
 Concealed: Blood collects
behind separated placenta or
collected in between the
membranes and decidua.
Mixed: some parts of the
collects inside and a part is
expelled out.
CLASSIFICATION
 Grade 0: Asymptomatic –small retro placental clot
 Grade 1.(40%): External vaginal bleeding present. Uterine
tenderness and tetany may be present. No sign of maternal
shock or fetal distress is absent.
 Grade 2.(45%):External vaginal bleeding may or may not be
present.no sign of maternal shock, but fetal distress is
present.
 Grade 3.(15%):External bleeding may or may not be present.
Marked uterine tetany, a board like rigidity on
palpation.Persistant abdominal pain, maternal shock and fetal
distress are present. Coagulation may become evident in 30% of
cases.
INCIDENCE
 The overall incidence is about 1 in 100 deliveries.
 it is a significant cause of Perinatal mortality (15-
20%) and Maternal mortality (2-5%).
 It contributes nearly 30% of all cases and majority 60%
occur in third trimester of pregnancy.
RISK FACTOR
 Exact cause: Unknown
 Increased age and parity
 HYPERTENSION
 Trauma
 Sudden uterine compression
 Short cord
 Multiple Gestation
 Polyhydramnios
 Smoking
 Cocaine use
 Prior abruption
CLINICAL FEATURES
 Vaginal bleeding is usually
associated with abdominal
pain, uterine contractions,
tenderness and/or
irritability.
 Signs of hemorrhagic shock.
 May be faint and/or collapse.
 Consider concealed
abruption if abdominal or
back pain is present.
 Fetal moments are usually
absent unless it is an early
abruption or partial.
COMPLICATION
MATERNAL FETAL
Sensitization of Rh(-) mother  Prematurity
for fetal blood
 IUGR in chronic
Amniotic fluid embolism
Post partum hemorrhage abruption
Hypovolemic shock Hypoxic ischemic
DIC encephalopathy
Puerperal sepsis Cerebral palsy
Sheehan’s syndrome Fetal death
Maternal death
INVESTIGATION
Ultrasonography:
o Mainly to exclude placenta previa
o Can detect- Retro-placental
hematoma

CTG: Sinusoidal pattern, fetal

tachycardia or bradycardia
LABORATORY INVESTIGATION:
Investigation for consumptive
coagulopathy-platelet
count/BT/CT/PT/INR or APTT
Liver and Renal function tests.
MANAGEMENT
Small Abruption:
Conservative management depending upon gestational age.
Careful monitoring of fetal condition.
 Moderate or severe placental abruption:
 Restore blood loss
 Ideally measure central venous pressure(CPV)&adjust transfusion accordingly.
 Prevent coagulopathy
 Monitor urinary output
Delivery:
1.Cesarean section
2.Vaginal- If coagulopathy present
-If fetus is not compromised
-If fetus is dead
VASA PREVIA:
Fetal blood vessels from
placenta or umbilical cord
cross the internal os
beneath the baby.
Rupture of membrane
lead to damage of the fetal
vessels leading to
exsanguination and
death.
High fetal mortality(50-
75%)
RISK FACT0RS
 Eccentric (velamentous)
cord insertion
 Bilobed or succenturiate
lobe of placenta
 Multiple gestation
Placenta previa
 In vitro fertilization(IVF)
pregnancies
 History of uterine
surgery or D & C
CLINICAL FEATURES/DIAGNOSIS
 Moderate vaginal bleeding + fetal
distress
 Vessels may be palpable through
dilated cervix
 Vessels may be visible on
ultrasound (TV Color Doppler
ultrasound)
 Difficult to distinguish from
abruption
 Can look for fetal Hb (Kleihauer-
Betke test) or nucleated RBC’s in
shed blood
 Tachycardia or bradycardia in CTG
MANAGEMENT
 Urgent delivery
 Most of the time urgent
LSCS
 Neonatologist
involvement
 Aggressive resuscitation
of the baby with blood
transfusion following
delivery
APH PREVENTION:
 Adequate antenatal
care and monitor vital
signs.
 Antenatal diagnosis of
placental abnormalities.
 Significance of warning
hemorrhage.
 Family planning &
limitation of births.
NURSING DIAGNOSIS:
o Risk for impaired fetal Gas
exchange r/t Disruption of
Placental implantation.

o Active Blood Loss(Hemorrhage) r/t

Disrupted Placental Implantation.
o Fear r/t Threat to Maternal & Fetal
Survival Secondary to Excessive
Blood Loss.
o Activity intolerance r/t Enforced
Bed Rest .
o Altered Diversional Activity r/t
inability to Engage in Usual
Activities .
NURSING INTERVENTION:
 If continuation of the pregnancy is deemed safe for
patient and fetus administer magnesium sulphate.
 Obtain blood samples for complete blood count and
blood types and cross matching.
 Institute complete bed rest.
 If the patient is experiencing active bleeding
continuously , monitor her vital signs.
 Continuous monitoring of fetal and maternal health
status.
BIBLIOGRAPHY
 d.c. dutta textbook of obstetrics(9th edition).

 Annemma Jacob text book of midwifery and

gynecological nursing 4th edition.
Any Question