SEMINAR ON

Antepartum
hemorrhage and Post
partum hemorrhage

Submitted to Submitted By
Mrs. Lincy Jose Nice Mathew
Asso. Professor 2nd Year M. Sc Nursing
BM CON BM CON
Submitted On
15-05-13

INTRODUCTION

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 Bleeding is always a life threatening event. Obstetrics is "bloody business." Even though
hospitalization for delivery and the availability of blood for transfusion have dramatically reduced the
maternal mortality rate, death from hemorrhage still remains a leading cause of maternal mortality. In
countries with fewer resources, the contribution of hemorrhage to maternal mortality is more striking
(Jegasothy, 2002; Rahman and co-workers, 2002) than the developed countries. Indeed, hemorrhage
has been identified as the single most important cause of maternal death worldwide, accounting for
almost half of all postpartum deaths in developing countries (McCormick and colleagues, 2002).
Undoubtedly, there has been great improvement in mortality from hemorrhage with
modernization of obstetrics. For example, Sachs and associates (1987) reported that maternal deaths
from obstetrical hemorrhage in Massachusetts declined tenfold from the mid-1950s to the mid-1980s.
Slight vaginal bleeding is common during active labor. This "bloody show" is the
consequence of effacement and dilatation of the cervix, with tearing of small veins. Uterine bleeding
from a site above the cervix before delivery is cause for concern. The bleeding may be the
consequence of some separation of a placenta implanted in the immediate vicinity of the cervical
canal—placenta previa. It may come from separation of a placenta located elsewhere in the uterine
cavity—placental abruption. Rarely, the bleeding may be the consequence of velamentous insertion
of the umbilical cord with rupture and hemorrhage from a fetal blood vessel at the time of rupture of
the membranes—vasa previa.
The source of uterine bleeding that originates above the level of the cervix is not
always identified. In that circumstance, the bleeding typically begins with little or no other
symptomatology, and then stops, and at delivery no anatomical cause is identified. Almost always the
bleeding must have been the consequence of slight marginal separation of the placenta that did not
expand. The pregnancy in which such bleeding occurs remains at increased risk for a poor outcome
even though the bleeding soon stops and placenta previa appears to have been excluded by
sonography. Lipitz and colleagues (1991) studied 65 consecutive women who had uterine bleeding
between 14 and 26 weeks. Almost a fourth had placental abruption or previa. Total fetal loss
including abortions and perinatal deaths was 32 percent. Leung and colleagues (2001) found that
unexplained antepartum hemorrhage before 34 weeks was associated with a 62-percent risk of
delivery within one week when associated with uterine contractions and a 13-percent risk even in the
absence of contractions. For this reason, delivery should be considered in any woman at term with
unexplained vaginal bleeding.

ANTEPARTUM HEMORRHAGE

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It is defined as bleeding from or into the genital tract after the 28th week of pregnancy but before the
birth of the baby (the first and second stage of labor are thus included). The 28th week is taken
arbitrarily as the lower limit of fetal viability. The incidence is about 3% amongst hospital deliveries.
CAUSES
The causes of ante partum hemorrhage fall into the following categories. An average, the incidence of
placenta praevia, abruptio placentae and the indeterminate group is almost the same.
PLACENTA PREVIA
When the placenta is implanted partially or completely over the lower uterine segment (over and adjacent to
the internal os) it is called placenta praevia. The term praevia (L, in front of) denotes the position of the
placenta in relation to the presenting part.
INCIDENCE
About one-third cases of ante partum hemorrhage belong to placenta praevia. The incidence of placenta
praevia ranges from 0.5-1 % amongst hospital deliveries. In 80% cases, it is found to multiparous women.
The incidence is increased beyond the age of 35, with high birth order pregnancies and in multiple
pregnancy. Increased family planning acceptance with limitation and spacing of birth, lowers the incidence
of Placenta praevia.
ETIOLOGY
The exact cause of implantation of the placenta in the lower segment is not known. The following
theories are postulated.
 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. Failure of zona peIIucida to
disappear in time can be a hypothetical possibility. This explains the formation of central placenta
praevia.
 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 praevia.
 Defective decidua, results in spreading of the chorionic villi over a wide area in the uterine wall
to get no During this process, not only the placenta becomes membranous but encroaches onto
the lower segment. Such praevia may invade the underlying decidua or myometrium to cause
placenta accreta, increta or percreta
 Big surface area of the placenta as in twins may encroach onto the lower segment.

The high risk factors for placenta praevia are

 Multiparity

 Increased maternal age (>35 years )

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  History of previous caesarean section or any other scar in the uterus (myomectomy or
hysterotomy)

 Placental size and abnormality (succenturiate lobes).

 Smoking - causes placental hypertrophy to compensate carbon monoxide induced

hypoxaemia.

 Prior curettage.

TYPES OR DEGREES: - There are four types of placenta praevia depending upon the d extension of
placenta to the lower segment.

 Type - I (Low-lying): The major part of the placenta is attached to the upper segment and only
the margin encroaches onto the lower segment but not up to the os.

 Type - II (Marginal): The placenta reaches the margin of the internal os but does not cover it.
It can be in the anterior wall(2 a) , or in the posterior wall(2 b).

 Type - III (Incomplete or partial central) : The placenta covers the internal os partially (covers
the internal os when closed but does not entirely do so when fully dilated).
 Type - IV (Central or total) : The placenta completely covers the internal os even after it is
fully dilated.
Type III and IV constitute about one-third of the cases. For clinical purpose, the types are graded into mild
degree 'I (Type-I and II anterior) and major degree (Type-Il posterior, III and IV).

Dangerous placenta praevia is the name given to the type-II posterior placenta praevia. (1) Because of the
curved birth canal major thickness of the placenta (about 2.5 cm) overlies the sacral promontory, thereby
diminishing the anteroposterior diameter of the inlet and prevents engagement of the presenting part. This
hinders effective compression of the separated placenta to stop bleeding. (2) Placenta is more likely to be
compressed, if vaginal delivery is allowed. (3) More chance of cord compression or cord prolapse. The last
two may produce fetal anoxia or even death.

CAUSES OF BLEEDING:

As the placental growth slows down on later months and the lower segment progressively dilates the
inelastic placenta is sheared off the wall of the lower segment. This leads to opening up of uteroplacental
vessels and leads to an episode of bleeding. As it is a physiological phenomenon which leads to the
separation of the placenta, the bleeding is said to be inevitable.

The mechanisms of spontaneous s control of are (1) Thrombosis of the open sinuses (2)
Mechanical pressure by the presenting part (3) Placental infarction.
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Placental migration,

Ultrasonography at 17 weeks of gestation reveals placenta covering the internal os in about 10% of cases.
Repeat Ultrasonography at 37 weeks showed no placenta in the lower uterine segment in more than 90% of
cases. Lower uterine segment expands from 0.5 cm at 20 weeks to more than 5cm (10 fold) at term. The
term placental migration could be explained in two ways: (i) with the progressive increase in the length of
lower uterine segment, the lower placental edge relocates away from the cervical os (ii) Due trophotropism
(growth of trophoblastic tissue towards the fundus), there is resolution of placenta praevia.

CLNICAL FEATURES

SYMPTOMS

The only symptom of placenta praevia is vaginal bleeding. The classical features of bleeding in pIacenta
praevia are sudden onset, painless, apparently causeless and recurrent. In about 5% cases, it occurs - the first
time during labour, especially in primigravidae. In about one-third of cases, there is a history of “warning
hemorrhage" which is usually slight.

The bleeding is unrelated to activity and often occurs during sleep and the patient becomes frightened on
awakening to find herself in a pool of blood. The bleeding is unassociated with pain unless labour starts
simultaneously. Obvious causes for the placental separation such as trauma or hypertension are usually
absent. However, pre-eclampsia may complicate a case of placenta praevia. The first bout of bleeding is
usually not alarming but subsequent bouts may be heavier than the previous one due to separation of fresh
areas of placenta. , majority of cases, bleeding occurs before 38 weeks and earlier bleeding is more likely to
occur in major degrees. However, there may not be any bleeding in central placenta praevia until labour
starts. Asymptomatic cases may be detected by sonography or at the time of caesarean section.

SIGNS

General condition and anemia are proportionate to the visible blood loss. But in the tropics, the picture is
often confusing due to pre-existing anemia.

Abdominal examination

The uterus feels relaxed, soft and elastic without any localised area of tenderness.
 Persistence of Malpresentation like breech or transverse or unstable lie is more frequent.
There is increased frequency of twin pregnancy.
 The head is floating in contrast to the period of gestation. Persistent displacement of the fetal
head is suggestive. The head cannot be pushed down into the pelvis.
 Fetal heart sound is usually present, unless there is major separation of the placenta with the

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 patient exsanguinated condition. Slowing of the fetal heart rate on pressing the head down
into the pelvis w soon recovers promptly as the pressure is released is suggestive of the
presence of low lying place specially of posterior type (Stall worthy' s sign). But this sign is
not always significant because it may be due to fetal head compression even in an otherwise
normal case.

Vulval inspection
Only inspection is to be done to note whether the bleeding is still occurring or ceased, character of
the blood - bright red or dark coloured and the amount of blood loss - to be assess from the blood
stained clothings. In placenta praevia, the blood is bright red as the bleeding occurs from the
separated utero-placental sinuses close to the cervical opening and escapes out immediately.
Vaginal examination must not be done outside the operation theatre in the hospital, as it can provoke
separation of placenta with torrential hemorrhage and may be fatal. It should only be done prior to
termination of pregnancy in the operation theatre under anesthesia, keeping everything ready for
caesarean section.
CONFIRMATION OF DIAGNOSIS
DIAGNOSIS: Painless and recurrent vaginal bleeding in the second half of pregnancy should be
taken as placenta praevia unless proved otherwise. Ultrasonography is the initial procedure either to
confirm or to rule out diagnosis.
LOCALISATION OF PLACENTA CLINICAL
(PLACENTOGRAPHY)
Sonography •Magnetic resonance imaging (MRl) - By internal examination (double
Transabdominal ultrasound (TAS) set up examination)
Transvaginal ultrasound (TVS) - Direct visualisation during
Transperineal ultrasound caesarean section
Colour Doppler flow study - Examination of the placenta
following vaginal delivery

PLACENTOGRAPHY
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Sonography: Sonography is the diagnostic technique of choice. It provides the simplest, most precise and
safest method of placental localization.

In addition, it is helpful for assessing the fetal size and status. It also provides information pertaining to
maturity and well being of the fetus for guiding the management.

Transabdominal (TAS) : The accuracy after 30th week of gestation is about 98 percent. False positive
result may be due to full bladder or myometrial contractions. Poor imaging could be due to maternal obesity
and posteriorly situated placenta. The reasons for poor imaging in a posteriorly situated placenta are - (a)
acoustic shadow from the fetal presenting part may obscure the placental view, (b) there is no anatomical
landmark posteriorly (anteriorly uterovesical angle) below which placenta is defined as praevia (an arbitrary
distance of 5 cm from the internal os is considered as lower segment). As such, a positive case should be
subjected to repeat scan after emptying the bladder. Cases of placenta praevia detected in earlier weeks
should be subjected to repeat scan at 34 weeks or earlier for detection of placental migration

Transvaginal (TVS) : Transducer is inserted within the vagina without touching the cervix. The probe is
very close to the target area and higher frequencies could be used to get a superior resolution. It is safe,
obviates the discomfort of full bladder and is more accurate (virtually 100%) than TAS. Complete placenta
praevia diagnosed in the second trimester will persist into the third trimester in 26 per cent of cases, whereas
marginal placenta praevia with persist in only 2.5 per cent cases.
Transperineal (TPS) : This is well accepted by patients. Internal os is visualised in 97-100% of cases.
Colour doppler flow study: Prominent venous flow in the hypoechoic areas near the cervix is consistent
with the diagnosis of placenta praevia.
Magnetic Resonance Imaging (MRl) : It is a non invasive method without any risk of ionising radiation.
Quality of placental imaging is excellent. Limitations of MRI are: more time consuming, lack of portability
and the cost.
CLINICAL CONFIRMATION
Double set-up) : It examination (Vaginal examination is less frequently done these days. The indications
are : (i) Inconclusive USG report (ii) USG revealed type I placenta or (iii) USG facilities not available. It is
done in the operation theatre under anesthesia keeping everything ready for caesarean section. Palpation of
the placenta on the lower segment not only conclusively confirms the clinical diagnosis but also identifies its
degree.
COMPLICATIONS OF PLACENTA PRAEVIA
MATERNAL
DURING PREGNANCY:- Ante partum hemorrhage with varying degrees of shock is an inevitable
complication. The first bout of hemorrhage is seldom severe but torrential hemorrhage can easily be
provoked by injudicious internal examination. Co-existent placental abruption is about 10 per cent.

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  Malpresentation: There is increased incidence of breech presentation and transverse lie. The lie often
becomes unstable.
 Premature labour either spontaneous or induced is common,
 Death due to massive hemorrhage during the antepartum, Intrapartum or postpartum period.
Operative hazards, infection or embolism may also cause death.
DURING LABOUR
 Early rupture of the membranes.
 Cord prolapse due to abnormal attachment of the cord
 Slow dilation of the cervix due to the attachment of placenta on the lower segment.
 Intrapartum hemorrhage due to further separation of placenta with the dilation of the cervix
 Increased incidence of operative interference
 Post partum hemorrhage is due to
 Imperfect retraction of the lower uterine segment upon which the placenta is implanted
 Large surface area of placenta with atonic uterus due to pre-existing anaemia.
 Occasional association (15%) of morbidly adherent placenta (placenta accreta, increta,
percreta) on the lower segment. Often the placenta praevia and accreta is managed by
hysterectomy.
 Trauma to the cervix and lower segment because of extreme softness and vascularity.
 Retained placenta and increased incidence of manual removal add further hazard to the postpartum
shock. Increased incidence of retained placenta is due to : (1) increased surface area and (2) morbid
adhesion. The risk of placenta praevia being accreta in a woman with previous one caesarean section
is 10-20% and it rises to about 50% with two or more prior caesarean section.

DURING PUERPERIUM

 Sepsis is increased due to : (a) increased operative interference (b) placental site near to vagina and
(c) anaemia and devitalised state of the patient.
 Subinvolution
 Embolism.

FETAL COMPLICATIONS IN PLACENTA PRAEVIA

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  Low birth weight babies are quite common (15%) which may be the effect of preterm labour either
spontaneous or induced. Repeated small bouts of hemorrhage while carrying on the expectant
treatment can cause chronic placental insufficiency and fetal growth retardation.
 Asphyxia is common and it may be the effect of (a) early separation of placenta (b) compression of
the placenta or (c) compression of the cord.
 Intrauterine death is more related to severe degree or separation of placenta, with maternal
hypovolaemia and shock. Deaths are also due to cord accidents Birth injuries are more common due
to increased operative interference.
 Congenital malformation is three times more common in placenta praevia.

MANAGEMENT

PREVENTION

Placenta praevia is one of the inherent obstetric hazards and in majority the cause is unknown. Thus to
minimize the risks, the following guidelines are useful.

 Adequate antenatal care to improve the health status of women and correction of anemia.
 Antenatal diagnosis of low lying placenta at 20 weeks with routine ultra sound needs repeat ultra
sound examination at 34 weeks to confirm the diagnosis.
 Significance of "warning hemorrhage" should not be ignored.
 Colour flow Doppler USG in placenta praevia is indicated to detect any placenta accreta.

AT HOME

 The patient is immediately put to bed

 To assess the blood loss - (a) inspection clothings soaked with blood (b) To note the pulse, blood
pressure and degree of anemia
 Quick but abdominal examination to mark the height of the uterus, to auscultate the fetal heart sound
and to tenderness on the uterus
 Vaginal examination must not be done. Only inspection is done to see whether the bleeding is
present or absent and to put a sterile vulval pad.

TRANSFER TO HOSPITAL: Arrangement is made to shift the patient to an equipped hospital having
facilities of blood transfusion, emergency caesarean section and neonatal intensive care unit (N1CU). 'Flying
squad’ service is ideal for transfer of such type of patients. An intravenous dextrose-saline drip should be
started and is kept running during transport. Patient should be accompanied by two or three persons fit for
donation of blood, if necessary.

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ADMISSION TO HOSPITAL

All cases of APH, even if the bleeding is slight or absent by the time the patient reaches the hospital, should
be admitted. The reasons are: (1) All the cases of APH should be regarded due to placenta praevia unless
proved otherwise (2) The bleeding may recur sooner or later and none can when it recurs and how much she
will bleed.

TREATMENT ON ADMISSION

IMMEDIATE ATTENTION

Overall assessment of the case is quickly made as regards: (1) Amount of the blood loss by noting the
general condition, pallor, pulse rate and blood pressure (2) Blood samples are taken for group, cross
matching and estimation of hemoglobin (3) A large-bore IV cannula is sited and an infusion" normal saline
is started and compatible cross matched blood transfusion should be arranged (4) Gentle abdominal
palpation to ascertain any uterine tenderness and auscultation to note the fetal heart rate (5) Inspection of the
vulva to note the presence of any active bleeding.

Confirmation of diagnosis is made from the history, physical examination and with Sonographic
examination.

FORMULATION OF THE LINE OF TREATMENT:

The definitive treatment depends upon the duration of pregnancy, fetal and maternal status and extent of the
hemorrhage.

EXPECTANT TREATMENT:

Vital prerequisites:

 Availability of blood for transfusion whenever required

 Facilities for caesarean section should be available throughout 24 hours, should it prove necessary.

Selection of cases

Suitable cases for expectant management are

 Mother is in good health status hemoglobin > 10 gm%; haematocrit > 30%
 Duration of pregnancy is less than 37 weeks
 Active vaginal bleeding is absent
 Fetal well being is assured (USG).

Conduct of expectant treatment

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  Bed rest with bathroom privileges
 Investigations -like hemoglobin estimation, blood grouping and urine for protein are done
 Periodic inspection of the vulval pads and fetal surveillance with USG at interval of 2-3 weeks
 Supplementary haematinics should be given and the blood loss is replaced by adequate cross
matched blood transfusion, if the patient is anemic
 When the patient is allowed out of the bed (2-3 days after the bleeding stops), a gentle speculum
(Cusco's) examination is made to exclude local cervical and vaginal lesions for bleeding. However,
their presence does not negate placenta praevia
 Use of tocolysis (magnesium sulphate) can be done if vaginal bleeding is associated with uterine
contractions
 Use of cervical circlage to reduce bleeding and to prolong pregnancy is not helpful.
 Rh immunoglobin should be given to all Rh negative (unsensitised) women.

Active Management (Delivery)

The indications of definitive management (delivery) are:

 Bleeding occurs at or after 37 weeks of pregnancy

 Patient is in labour
 Patient is in exsanguinated state on admission
 Bleeding is continuing and of moderate degree
 Baby is dead or known to be congenitally deformed.

Definitive Management (Delivery)

Caesarean delivery is done for all women with sonographic evidence of placenta praevia where placental
edge is within 2 cm from the internal os. It is specially indicated if it is posterior or thick. Vaginal delivery
may be considered where placenta edge is dearly 2-3 cm away from the internal cervical os

Management of Placenta Previa

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 Algorithm for the management of placenta previa.

Nursing Management

Ensure the physiologic well-being of the client and fetus

 Take and record vital signs, assess bleeding, and maintain a perineal pad count. Weigh perineal pads
before and after use to estimate blood loss.
 Observe for shock, which is characterized by a rapid pulse, pallor, cold moist skin and a drop in
blood pressure
 Monitor the FHR
 Enforce strict bed rest to minimize risk to the fetus
 Observe for additional bleeding episodes.

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Provide client and family teaching

 Explain the condition and management options.

 To ensure an adequate blood supply to the mother and fetus, place the woman at bed rest in a side-
lying position.
 Anticipate the order for a sonogram to localize the placenta.
 If the condition of mother or fetus deteriorates, a cesarean birth will be required.
 Prepare the client for ambulation and discharge ( may be within 48 hours of last bleeding episode)
 Discuss the need to have transportation to the hospital available at all times.
 Instruct the client to return to the hospital if bleeding recurs and to avoid intercourse until after the
birth.
 Instruct the client on proper handwashing and toileting to prevent infection.

Address emotional and psychosocial needs

 Offer emotional support to facilitate the grieving process, if needed

 After birth of the newborn, provide frequent visits with the newborn so that the mother can be certain
of the infant’s condition

ABRUPTIO PLACENTAE

It is one form of antepartum haemorrhage where the bleeding occurs due to premature separation of
normally situated placenta.

VARITIES

REVEALED : Following separation of the placenta, the blood insinuates downwards between the
membranes and the decidua. Ultimately, the blood comes out of the cervical canal to be visible externally.
This is the commonest type.

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
presses on the lower segment. At times, the blood may percolate into the amniotic sac after rupturing the
membranes.. In any of the circumstances blood is not visible outside. This type is rare.

MIXED : In this type, some part of the blood collects inside (concealed) and a part is expelled out
(revealed). Usually one variety predominates over the other. This is quite common.

ETIOLOGY

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The exact cause of separation of a normally situated placenta remains obscure in majority of cases. The
prevalence is more with

 high birth order pregnancies with gravida 5 and above _three times more common than in first birth
 advancing age of the mother
 poor socio-economic condition
 malnutrition
 Smoking (vasospasm).
 Hypertension in pregnancy is the most important predisposing factor. Pre-eclampsia, gestational
hypertension and essential hypertension, all are associated with placental abruption. The association
of pre-eclampsia in abruptio placenta varies from 10-50 per cent. The mechanism of the placental
separation in pre-eclampsia is: Spasm of the vessels in the utero placental bed (decidual spiral artery)
anoxic endothelial damage rupture of vessels or extravasation of blood in the decidua basalis
(retroplacental haematoma).
 Traumatic separation of the placenta usually leads to its marginal separation with escape of blood
outside. The trauma may be due to : (i) Attempted external cephalic version specially under
anesthesia using great force (ii) Road traffic accidents or blow on the abdomen (iii) Needle puncture
at amniocentesis.
 Sudden uterine decompression: Sudden decompression of the uterus leads to diminished surface
area of the uterus adjacent to the placental attechment and results in separation of the placenta. This
may occur following (a) delivery of the first baby of twins (b) sudden escape of liquor amnii in
hydramnios 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 there 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 waveforms is
associated with placental abruption
 Folic acid deficiency - even without evidence of overt megaloblastic erythropoiesis this has been
observed to be associated.
 Uterine factor - Placenta implanted over a septum (Septate Uterus) or a sub mucous fibroid.
 Torsion of the uterus leads to increased venous pressure and rupture of the veins with separation of
the placenta.
 Cocaine abuse is associated with increased risk of transient hypertension, vasospasm and placental
abruption.

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  Prior abruption – risk of recurrence for a womenwith previous placental abruption varies between
5-17%

PATHOGENESIS:

Depending upon the etiological factors, premature placental separation is initiated by hemorrhage into the
decidua basalis. The collected blood (decidual hematoma) at the early phase hardly produces any morbid
pathological changes in the uterine wall or on the placenta. However, depending upon the extent of
pathology, there may be degeneration and necrosis of the decidua basalis as well as the placenta adjacent to
it.

Rupture of the basal plate may also occur, thus communicating the hematoma with the intervillous
space. The decidual hematoma may be small and self limited: the entity is evident only after the expulsion of
the placenta (retro placental hematoma).The features of retro placental hematoma are: (a) Depression found
on the maternal surface of the placenta with a clot which may be found firmly attached to the area (b) Areas
of infarction with varying degree of organization

If, however, a major spiral artery ruptures a big hematoma is formed. As the uterus remains distended by the
conceptus, it contract and therefore fails to compress the torn bleeding points.

It has to be remembered that absence of rhythmic uterine contractions plays a significant role for the blood
to remain concealed.

COUVELAIRE UTERUS (utero placental apoplexy): It is a pathological entity described by Couvelaire

and is met with in association with severe form of concealed abruptio placentae. There is massive
intravasation of blood into the uterine musculature up to the serous coat. The condition can only be
diagnosed on laparotomy

Naked eye features: The uterus is of dark port wine colour which may be patchy or diffuse. It tends to occur
initially on the cornu before spreading to other areas, more specially over the placental site. Sub peritoneal
petechial hemorrhages are found under the uterine peritoneum and may extend into the broad ligament.
There may be free blood in the peritoneal cavity or broad ligament hematoma.

CLINICAL CLASSIFICATION: Depending upon the degree of placental abruption and its clinical
effects, the cases are graded as follows:

GRADE 0

 Clinical features may be absent.

 The diagnosis is made after inspection of placenta following delivery

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GRADE 1

 Vaginal bleeding is slight

 Uterus: irritable, tenderness may be minimal or absent
 Maternal BP and fibrinogen levels unaffected
 FHS is good.

GRADE 2

 Vaginal bleeding mild to moderate

 Uterine tenderness is always present
 Maternal pulse increased and BP is maintained
 Fibrinogen level may be decreased
 Shock is absent
 Fetal distress or even fetal death occurs.

GRADE 3

 Bleeding is moderate to severe or may be concealed

 Uterine tenderness is marked
 Shock is pronounced
 Fetal death is the rule
 Associated coagulation defect or anuria may complicate.

Diagnosis

When a woman presents with late pregnancy bleeding, the primary task of a clinician is to exclude placenta
previa or abruptio placentae, or rarely a vasa previa.

In spite of advances in ultrasonography and now the recent introduction of magnetic resonance imaging
(MRI), the diagnosis of abruptio placentae remains essentially clinical. The clinical triad of vaginal
bleeding, abdominal pain and uterine tenderness constitute the main diagnostic criteria for placental
abruption. However, a woman with abruptio placentae may not always typically present with all the three
features. In the early stages, abruptio placentae may even be asymptomatic. It is important to have a high
degree of suspicion and subsequent close surveillance in any pregnant woman with any of the above three
diagnostic features in late pregnancy, particularly when she has any of the high risk factors for abruptio
placentae.

Vaginal Bleeding

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The majority of women (nearly 80%) with abruptio placentae present with bleeding per vaginum of varying
degree. The amount of bleeding however is not necessarily indicative of the severity of abruption. This may
be either a revealed or a mixed type of accidental hemorrhage. In concealed accidental hemorrhage, there is
no vaginal bleeding.

Uterine Tenderness

This may be localized or generalized. Usually, the area of tenderness corresponds to the site of placental
abruption. In case of a posterior placenta, the uterine tenderness may be absent.

Uterine Contractions

The majority of cases of placental abruption have uterine activity. Uterine contractions are typically of hign
frequency and low amplitude type and may not be clearly demonstrated due to uterine hypertonus.

Other clinical findings such as maternal hypovolemic shock out of proportion to the external blood loss and
evidence of fetal distress are additional signs in the diagnosis of abruptio placentae.

The diagnosis of abruptio placentae may not be clinically evident immediately and some period of
observation may be necessary before the diagnosis becomes apparent. For instance, the abruption and fetal
distress may not be apparent until 24 to 48 hours after sustaining abdominal trauma.

When the clinical picture is not clear, ultrasonography can be useful. However, unlike placenta previa where
ultrasound can exclude the condition with very high accuracy, abruptio placentae may not be excluded on
the basis of ultrasound alone. There may be a false positive diagnosis as well. Conditions such as thick pla-
centa fibroids, chorioangioma, molar change, or ever. a normal retroplacentaI anechoic area form the
differennai diagnosis. Depending on its evolution, the retroplacenta, bleed and clot may be anechoic,
hypoechoic, echoic or hyperechoic on ultrasound, so also will there be change in the size of the clot while
the other conditions will show the same ultrasound image.

Recently, magnetic resonance imaging has been used to diagnose placenta praevia and may be useful in the
diagnosis of abruptio placentae. However, it has not been conclusively shown to be superior to ultrasound
besides being less readily available and much more expensive.

Management

Principles of Management

 Early diagnosis and assessment of the severity of abruption.

 Prompt hospital admission and close observation.
 General measures to stabilize the general condition of the patient.

17
  Appropriate investigations and work-up.
 Keeping adequate blood and blood products ready for transfusion.
 Correct timing and method of delivery.
 Fetal monitoring.
 Timely diagnosis and appropriate treatment of complications.

A lady with late pregnancy bleeding should be hospitalized. Correct diagnosis of the cause of ante partum
bleeding should be made by clinical means and, in addition if necessary, by ultrasound. In case of abruptio
placentae, the severity of the condition should be assessed clinically though this may not always be easy.
Both the mother and the fetus should be brought under immediate close observation.

General Measures

Evaluation of the maternal general condition is made by recording the vital parameters and looking for signs
of blood loss. Abdominal examination is made and vaginal blood loss is estimated. Maternal urine output is
charted and watched for hematuria.

An intravenous line is established and appropriate fluids (normal saline, Ringer's solution) given through a
wide bore cannula. Plasma expanders may be started in case of significant hypovolemia while blood is being
made ready for transfusion. Maternal general condition must be monitored closely and kept stable.

Investigations and Work-up

When the clinical presentation is not clear, ultrasound examination should be carried out to made correct
diagnosis and it may help in assessing the size of the retroplacental clot and the extent of placental
separation.

Maternal blood should be sent for hemoglobin and hematocrit estimation, grouping and cross matching.
Baseline renal function studies and electrolytes should be done. Coagulation studies, such as bleeding time,
clotting time, serum fibrinogen, platelet count, prothrombin time (PT) and partial thromboplastin time (PTT)
should be assessed. However, in a mild abruption, observation of clot formation in a test-tube within 4-8
minutes and observation of clot retraction and clot stability in 30 minutes is a simple and adequate bedside
test.

Timing and Method of Delivery

The following factors determine the obstetric management in a case of abruptio placentae - gestational age,
severity of abruption, maternal general condition, presence of any maternal complications, viability of fetus
and foetal health status and cervical status.

18
Once the maternal condition is stabilized, the most important therapeutic goal is to have an appropriate plan
for effecting delivery of the fetus. (definitive treatment)

If the gestational age and foetal maturity is compatible with a reasonable chance for neonatal survival, then
the plan should be to deliver the baby soon. This gestational age may be taken as 32 weeks and estimated
foetal weight to be 1500 gm. However, one has to take into consideration the level of neonatal care
available, and the survival rates for preterm babies.

If the fetus is very premature with poor chance for extrauterine survival, then an expectant and
conservative approach may be adopted when the abruption is mild. In these cases selective tocolysis may
be helpful in prolonging the duration of pregnancy as long as there is no progression in the process of
abruption.12 Steroids may be given to improve the foetal pulmonary maturity. If the placental abruption is of
moderate to severe nature, then the delivery has to be effected irrespective of gestational age and foetal
condition, in the maternal interest.

The choice of method of delivery, either vaginal or cesarean section, depends on the maternal condition,
cervical dilatation, inducability of cervix, and the fetal condition. If the patient is already in labor with
anticipated good progress, vaginal delivery should be attempted when there are no signs of fetal distress and
no further progression of abruption. In selected cases when the cervix os very ripe, induction of labor may
be carried out and progress of labor monitored very carefully. Amniotomy is known to help uniformly in
cases of abruption as it not only reduces the intrauterine pressure and possibility of myometrial extravasation
of the bleed but also helps in augmenting labor. An oxytocin drip may be started selectively to augment
labor.

Vaginal delivery should be carried out if the fetus is too premature, or already dead, or the maternal
condition contraindicates abdominal delivery. However, several studies have shown that timely cesarean
section in appropriately selected cases has reduced perinatal mortality and morbidity as well as maternal
mortality and morbidity. Thus, in the presence of excessive bleeding and an undilated cervix a cesarean
section should be performed before fetal distress sets in. Obviously, if there are signs of fetal distress and
vaginal delivery is not imminent, then timely cesarean section should be performed.

Fetal Monitoring

Since placental abruption is known to produce fetal distress suddenly and rapidly, constant or at least
frequent fetal heart rate monitoring should be performed. Electronic fetal monitoring is advisable.
Ultrasound may also be used effectively to monitor the fetal biophysical profile besides assessing the extent
of placental separation.

COMPLICATIONS OF ABRUPTIO PLACENTAE

19
MATERNAL: In revealed type - maternal risk is proportionate to the visible blood loss and maternal death
is rare.

In concealed variety - The following complications may occur either singly or in combination

 Haemorrhage which is either totally concealed inside the uterus or more commonly, part is revealed
outside the uterus. There may be intra-peritoneal or broad ligament haematoma
 Shock may be out of proportion to the blood loss. Release of thromboplastin into the maternal
circulation results in DIC or there may be amniotic fluid embolism
 Blood coagulation disorders
 Oliguria and anuria due to (a) hypovolemia (b) serotonin liberated from the damaged uterine muscle
producing renal ischemia and (c) Acute tubular necrosis However, a severe case may lead to (d)
cortical necrosis and renal failure
 Postpartum haemorrhage due to(a) atony of the uterus and (b) increase in serum FDP
 Puerperal sepsis.

The complicating factors those are responsible for increased maternal death varies from 2-8%. However,
with better understanding in the management of shock, coagulation failure and renal failure, maternal death
has been reduced markedly. Some cases who manage to survive may develop features of ischemic pituitary
necrosis. There is failure of lactation (Sheehan's syndrome) later on.

FETAL: In revealed type, the fetal death is to the extent of 25-30%. In concealed type, however, the fetal
death is appreciably high, ranging from 50-100%. The deaths are due to prematurity and anoxia due to
placental separation. With same degree of placental separation, the fetus is put to more risk in abruptio
placentae than in placenta previa. This is due to the presence of pre-existing placental pathology with poor
functional reserve in the former, in contrast to almost normal placental functions in the latter. Risk of
recurrence in subsequent pregnancy is about tenfold with high perinatal mortality.

Prevention, Early Diagnosis and Treatment of Complications

Prevention aims at

 Elimination of known factors likely to produce placental separation

 Correction of anemia during antenatal period so that the patient can withstand blood loss
 Prompt detection and institution of the therapy to minimise the grave complications likely to arise
out of placental separationnamely shock, blood coagulation disorders and renal failure

Placental abruption is known to produce serious maternal morbidity from life-threatening complications.
With proper and timely management, these problems may be averted.

20
  Hemorrhagic shock: Maternal hypovolemia and blood loss must be replaced soon. Intravenous fluids
and plasma expanders are to be started but it is the most important to give adequate fresh blood trans-
fusion as soon as possible.
 Disseminated intravascular coagulation syndromes can be defined as the formation of fibrin deposits
within the microcirculation, occurring in definite clinical situations like, abruptio placentae, amniotic
fluid embolism, etc. Their biological counterpart is a consumption coagulopathy. The clinical
profiler of DIC have been known for decades, are multiform and range from latency to over helming
hemorrhagic diathesis, including also characteristic but rare situations, such as purpura fulminans,
acral cyanosis and pictures resembling thrombotic thrombocytopenic purpura or hemolytic-uremic
syndrome. Biological tests of DIC show consumption coagulopathy, displayed on standard
hemostasis sheet, e.g. low platelets, low fibrinogen, along with signs of paracoagulation and/ or of
secondary fibrinolysis (fibrinogen degradation products (FDP). New tests have recently been
introduced D-dimers are specific and sensible, antithrombin-III, protein C, and alpha 2-antiplasmin
also can sometimes be useful. Fibrin deposits may be nonocclusive, and indeed they are swiftly
removed by a secondary fibrinolysis. Except in very rare situations, such as those leading to a
cortical renal necrosis, and perhaps in some ARDS, there is little evidence relating DIC to organ
failure syndromes.
 Renal cortical necrosis/ tubular necrosis. These problems occur due to ischemic damage to the
kidneys following severe hypovolemic shock and DIC. While renal tubular necrosis produces
reversible renal shut down, renal cortical necrosis produces permanent renal failure. These conditior
s have to be managed very aggressively.
 Postpartum hemorrhage: This may occur particularly in case of 'Couvelaire uterus'. Usually PPH can
be managed effectively by the use of oxytocics 15-methvl prostaglandin F. In rare cases, an obstetric
hysterectomy may be required.
 Noncardiogenic pulmonary edema.

Perinatal Mortality and Morbidity

Placental abruption is associated with high perinatal mortality ranging from 25 to 50 percent. In moderate to
severe grades of abruptio placentae, the reported perinatal mortality ranges from nearly 60 to 80 percent."
The causes of perinatal death due to abruption are fetal anoxia, neonatal prematurity and fetal bleeding.

Placental abruption is also associated with significant perinatal morbidity. There is a higher incidence of
congenital malformations, intrauterine growth retardation, and neonatal intracranial lesions in the form of
periventricular and intraventricular hemorrhage

Maternal Mortality

21
Moderate to severe degree of abruptio placentae is associated with significant maternal mortality is
particularly when complications are present and timely appropriate management is not executed

INDETERMINATE BLEEDING

It includes collective group of entities where a confident diagnosis of placenta previa or abruptio placentae
cannot be made, nor there any local lesion to account for the bleeding. Marginal sinus haemorrhage,
circumvellate placenta, excessive show may be the cause of bleeding. The possibility of ruptured vasa previa
or marked decidual reaction on endocervix may also be the causes.

Nursing Management:

1. Continuous evaluate maternal and fetal physiologic status, particularly:

 Vital Signs

 Bleeding

 Electronic fetal and maternal monitoring tracings

 Signs of shock – rapid pulse, cold and moist skin, decrease in blood pressure

 Decreasing urine output

 Never perform a vaginal or rectal examination or take any action that would stimulate
uterine activity.

2. Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped
with bed rest, emergency cesarean delivery may be indicated.

3. Provide appropriate management.

 On admission, place the woman on bed rest in a lateral position to prevent pressure on the
vena cava.

 Insert a large gauge intravenous catheter into a large vein for fluid replacement. Obtain a
blood sample for fibrinogen level.

 Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes.
Administer oxygen to the mother by mask.

 Prepare for cesarean section, which is the method of choice for the birth

4. Provide client and family teaching.

22
 5. Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent
of the separation, amount of fetal hypoxia and amount of bleeding.

NURSING DIAGNOSES

1. Deficient fluid volume related to excessive fluid and electrolyte loss as evidenced by hypotension,
increased pulse rate, decreased concentrated urine, and change in mental status.
2. Ineffective uteroplacental tissue perfusion related to separation of placenta as evidenced by change in
fetal heart rate and fetal activity.
3. Fear regarding self , fetus and outcome of pregnancy
4. Risk for maternal injury related to tissue hypoxia and anemia.
5. Acute pain related to placental abruption.

POST PARTUM HEMORRHAGE

Definition

Any amount of bleeding from or into the genital tract following birth of the baby up to the end of the
puerperium which adversely affects the general condition of the patient evidenced by rise in pulse rate and
falling B.P is called PPH.

The average blood loss following vaginal delivery, caesarean delivery and caesarean hysterectomy is
500ml, 1000ml, and 1500 ml respectively.

Depending upon the amount of blood loss, PPH can be 1. Minor (<1L), 2. Major (>1L) or 3. Severe (>2L).

Incidence

The incidence is about 4-6% of all deliveries.

Types

Primary
Secondary

Primary

Haemorrhage occurs within 24hrs following the birth of the baby. In the majority, haemorrhage occurs
within two hours following delivery. These are of two types:

Third stage haemorrhage------bleeding occurs before expulsion of placenta

True Postpartum haemorrhage-----Bleeding occurs subsequent to expulsion of placenta.

23
Secondary:

Haemorrhage occurs beyond 24 hours and within puerperium, also called delayed or late puerperial
haemorrhage.

PRIMARY POSTPARTUM HAEMORRHAGE

Causes

1. Atonic uterus: Atonicity of the uterus is the commonest cause of PPH. With the seperation of the
placenta, the uterine sinuses which are torn, cannot be compressed effectively due to imperfect
contraction and retraction of the uterine musculature and bleeding continues. The following are the
conditions which often interfere with the retraction of the uterus as a whole and of the placental site
in the particular.

 Grand multipara- Inadequate retraction and frequent adherent placenta contribute to it.
Associated anaemia may also probably play a role.
 Over-distension of the uterus-as in multiple pregnancy, hydramnios and large baby. Imperfect
retraction and a large placental site are responsible for excessive bleeding.
 Malnutrition and anemia-Even slight amount of blood loss may develop clinical
manifestations of PPH.
 Antepartum haemorrhage
 Prolonged labour- Poor retraction, infection (amnionitis), dehydration and analgesic drugs
used during labour are the responsible factors.
 Anaesthesia- It is the depth of anaesthesia and also the anaesthetic agents (ether, halothane
or cyclopropane) which cause atonicity.
 Initiation or augmentation of delivery by oxytocin- Post-delivery uterine atonicity is
likely unless the oxytocin is continued for at least one hour following delivery.
 Persistent uterine distension - Retention of partially separated placenta or bits of placenta
or blood clots interfere with effective retraction.
 Malformation of the uterus- Implantation of the placenta in the uterine septum of a septate
uterus or in the cornual region of a bicornuate uterus may cause excessive bleeding.
 Uterine fibroid causes imperfect retraction mechanically.
 Mismanaged third stage of labour - This includes: (a) Too rapid delivery of the baby
preventing the uterine wall to adapt to the diminishing contents. (b) Premature attempt to
deliver the placenta before it is separated. (c) Kneading and fiddling the uterus. (d) Pulling
the cord. All these produce irregular uterine contractions leading to partial separation of

24
 placenta and haemorrhage. (e) Manual separation of the placenta increases blood loss during
caesarean delivery.
 Constriction ring _ Hour-glass contraction formed in the upper segment across the partially
separated placenta or at the junction of the upper and lower segment with the fully separated
placenta trapped in the upper segment may produce excessive bleeding.
 Precipitate labour: In rapid delivery, separation of the placenta occurs following the birth
of the baby. Bleeding continues before the onset of uterine retraction. Bleeding may be due
to genital tract trauma

2. Traumatic (20%) : Trauma to the genital tract usually occurs following operative delivery;
even after spontaneous delivery. Blood loss from the episiotomy wound is often
underestimated. Similarly blood loss in caesarean section amounting to 800-1000 ml is most
often ignored. Trauma involves usually the cervix, vagina, perineum (episiotomy wound and
lacerations), para-urethral region and rarely, rupture of the uterus occurs. The bleeding is
usually revealed but can rarely be concealed (vulvo-vaginal or broad ligament haematoma).
3. Combination of atonic and traumatic causes.
4. Blood coagulation disorders, acquired or congenital: Blood dyscrasias or blood coagulation
disorders are less common causes of postpartum haemorrhage. The blood coagulopathy may
be due to diminished procoagulants (washout phenomenon) or increased fibrinolytic activity.
The firmly retracted uterus can usually prevent bleeding even if serious disorders of clotting
mechanism are present. The conditions where such disorders may occur are abruptio
placentae, jaundice in pregnancy, thrombocytopenic purpura, HELLP syndrome or in IUD.

Diagnosis and clinical effects:

In the majority, the vaginal bleeding is visible outside, as a slow trickle. Rarely, the
bleeding is totally concealed either as vulvo-vaginal or broad ligament haematoma. The effect of blood
loss depends on - (a) Pre-delivery haemoglobin level, (b) degree of pregnancy induced hypervolemia and
(c) speed at which blood loss occurs. Alteration of pulse, blood pressure and pulse pressure appears only
after class 2 haemorrhage (20-25% loss of blood volume). On occasion, blood loss is so rapid and brisk
that death may occur within a few minutes.
State of uterus, as felt per abdomen, gives a reliable clue as regards the cause of
bleeding. In traumatic haemorrhage, the uterus is found well contracted. In atonic haemorrhage, the
uterus is found flabby and becomes hard on massaging. However, both the atonic and traumatic cause
may co-exist. Even following massive blood loss from the injured area, a state of low general condition
can make the uterus atonic.
25
PROGNOSIS :

Postpartum haemorrhage is one of the life threatening emergencies. It is one of the major causes
of maternal deaths both in the developing and developed countries. Prevalence of malnutrition and
anaemia, inadequate antenatal and intranatal care and lack of blood transfusion facilities, substandard
care are some of the important contributing factors. There is also increased morbidity. These include
shock, transfusion reaction, puerperal sepsis, failing lactation, pulmonary embolism, thrombosis and
thrombophlebitis. Late sequelae includes Sheehan's syndrome (selective hypopituitarism) or rarely
diabetes insipidus.

Sheehan Syndrome

Severe intrapartum or early postpartum hemorrhage is on rare occasions followed by pituitary failure
or Sheehan syndrome. The classical case is characterized by failure of lactation, amenorrhea, breast atrophy,
loss of pubic and axillary hair, hypothyroidism, and adrenal cortical insufficiency. The exact pathogenesis is
not well understood, because such endocrine abnormalities do not develop in most women who hemorrhage
severely. In some but not all instances of Sheehan syndrome, varying degrees of anterior pituitary necrosis
with impaired secretion of one or more trophic hormones account for the endocrine abnormalities. The
anterior pituitary of some women who develop hypopituitarism after puerperal hemorrhage does respond to
various releasing hormones, which at the least implies impaired hypothalamic function. Moreover,
Whitehead (1963) identified specific atrophic changes in hypothalamic nuclei histologically in some cases.
Lactation after delivery usually, but not always, excludes extensive pituitary necrosis. In some women,
failure to lactate may not be followed until many years later by other symptoms of pituitary insufficiency. In
the series reported by Ammini and Mathur (1994), the average duration of onset of symptoms was 5 years.

The incidence of Sheehan syndrome was originally estimated to be 1 per 10,000 deliveries (Sheehan
and Murdoch, 1938). It appears to be even less common today (Kovacs, 2003). Bakiri and colleagues (1991)
used computed tomography to study 54 women with documented Sheehan syndrome. In all of these, the
appearance of the pituitary was abnormal and the sella turcica was either totally or partially empty.

PREVENTION

Postpartum haemorrhage cannot always be prevented. However, the incidence and specially its
magnitude can be reduced substantially by assessing the risk factors and following the guidelines as
mentioned below

However, most cases of PPH have no identifiable risk factors.

I Antenatal

26
♦ Improvement of the health status of the woman and to keep the haemoglobin level normal (> 10 g/dl) so
that the patient can withstand some amount of the blood loss.
♦ High risk patients who are likely to develop postpartum haemorrhage (such as twins, hydramnios, grand
multipara, AFH, history of previous PPH, severe anaemia) are to be screened and delivered in a well
equipped hospital.

♦ Blood grouping should be done for all women so that no time is wasted during emergency.

♦ Placental localisation must be done in all women with previous caesarean delivery by USG or MRI to
detect placenta accreta or percreta .

♦ Women with morbid adherent placenta are at high risk of PPH. Such a case should be delivered by a
senior obstetrician. Availability of blood and or blood products must be ensured before hand.

II Intranatal

♦ Active management of the third stage, for all women in labour should be a routine as it reduces PPH by
60%.
♦ Cases with induced or augmented labour by oxytocin, the infusion should be continued for at least one
hour after the delivery.
♦ Women delivered by caesarean section, Oxytocin 5IU slow IV is to be given to reduce blood loss.
Carbetocin (long acting oxytocin) 100 ug is very useful to prevent PPH.
♦ Exploration of the utero-vaginal canal for evidence of trauma following difficult labour or instrumental
delivery.
♦ Observation for about two hours after delivery to make sure that the uterus is hard and well contracted
before sending her to ward.
♦ Expert obstetric anaesthetist is needed when the delivery is conducted under general anaesthesia. Local
or epidural anaesthesia is preferable to general anaesthesia, in forceps, ventouse or breech delivery.
♦ During caesarean section spontaneous separation and delivery of the placenta reduces blood loss (30%).
♦ Examination of the placenta and membranes should be a routine so as to detect at the earliest any
missing part.

All said and done, it is the intelligent anticipation, skilled supervision, prompt detection and effective
institution of therapy that can prevent a normal case from undergoing disastrous consequences.

MANAGEMENT OF THIRD STAGE BLEEDING

The principles in the management are :

♦ To empty the uterus of its contents and to make it contract.

♦ To replace the blood. On occasion, patient may be in shock. In that case patient is managed for shock
27
first.

♦ To ensure effective haemostasis in traumatic bleeding.

STEPS OF MANAGEMENT : ♦ Placental site bleeding ♦ Traumatic bleeding

Placental site bleeding

— To palpate the fundus and massage the uterus to make it hard. The massage is to be done by placing four
fingers behind the uterus and thumb in front. However, if bleeding continues even after the uterus becomes
hard, suggests, the presence of genital tract injury.

— To start crystalloid solution (Normal saline or Ringer's solution) with oxytocin (1 L with 20 units) at
60 drops per minute and to arrange for blood transfusion if necessary.
— Oxytocin 10 units IM or methergin 0.2 mg is given intravenously.
— To catheterise the bladder.
— To give antibiotics (Ampicillin 2 g and Metronidazole 500 mg IV).
— Placental expulsion

During this procedure, if features of placental separation are evident, expression of the placenta is to
be done either by fundal pressure or controlled cord traction method. If the placenta is not separated, manual
removal of placenta under general anaesthesia is to be done. However, if the patient is in shock, she is
resuscitated first before undertaking manual removal. If the patient is delivered under general anaesthesia,
quick manual removal of the placenta solves the problem. In cases where oxytocin 10 units is given IM. with
the delivery of the anterior shoulder, manual removal is done promptly when two attempts of controlled cord
traction fail. Crede's expression of the placenta is abandoned as it is not only ineffective, but produces shock
and rarely inversion.

Management of traumatic bleeding

The uterovaginal canal is to be explored under general anaesthesia after the placenta is expelled and
haemostatic sutures are placed on the offending sites.

STEPS OF MANUAL REMOVAL OF PLACENTA

Step-I: The operation is done under general anaesthesia. In extreme urgency where anaesthetist is not
available, the operation may have to be done under deep sedation with 10 mg diazepam given intravenously.
The patient is placed in lithotomy position. With all aseptic measures, the bladder is catheterised.

Step-II: One hand is introduced into the uterus after smearing with the antiseptic solution in cone shaped
manner following the cord, which is made taut by the other hand . While introducing the hand, the labia are

28
separated by the fingers of the other hand. The fingers of the uterine hand should locate the margin of the
placenta.

Step-III: Counter pressure on the uterine fundus is applied by the other hand placed over the abdomen. The
abdominal hand should steady the fundus and guide the movements of the fingers inside the uterine cavity
till the placenta is completely separated.

Step-IV: As soon as the placental margin is reached, the fingers are insinuated between the placenta and the
uterine wall with the back of the hand in contact with the uterine wall. The placenta is gradually separated
with a sideways slicing movement of the fingers, until whole of the placenta is separated.

Step-V: When the placenta is completely separated, it is extracted by traction of the cord by
the other hand. The uterine hand is still inside the uterus for exploration of the cavity to be sure
that nothing is left behind.

Step—VI: Intravenous methergin 0.2 mg is given and the uterine hand is gradually removed while massaging
the uterus by the external hand to make it hard. After the completion of manual removal, inspection of the
cervicovaginal canal is to be made to exclude any injury.

Step-VII: The placenta and membranes are inspected for completeness and be sure that the uterus remains
hard and contracted.

Difficulties:

(1) Hour-glass contraction leading to difficulty in introducing the hand

(2) Morbid adherent placenta which may cause difficulty in getting to the plane of cleavage of placental
separation. In such a case placenta is removed gently in fragments using an ovum forceps.

MANAGEMENT OF UNFORESEEN COMPIICATIONS DURING MANUAL REMOVAL

(i) Hour-glass contraction — The placenta, either unseparated or separated — partially or completely, may
be trapped by a localised contraction of circular muscles of the uterus. This may be situated at the junction of
the lower and upper segment or may be placed in one cornu. Administration of any oxytocic, specially
ergometrine in the active management of third stage or undue irritability of the uterus by premature attempts to
express the placenta is the important cause. The diagnosis is only made during attempted manual removal.

Management: The ring should be made to relax by deepening the plane of anaesthesia (halothane is useful in
these cases), then the cone shaped hand is introduced and the separation of the placenta is preferably done
from above downwards to minimise bleeding.

29
(ii) Morbid adherent placenta — In majority, the diagnosis is made only during attempted manual removal.
On rare occasion, however, no cleavage between the placenta and the uterine wall is made possible and the
diagnosis of a total placenta accreta is certain.

Complications:

(1) Haemorrhage due to incomplete removal

(2) Shock

(3) Injury to the uterus

(4) Infection

(5) Inversion (rare)

(6) Subinvolution

(7) Thrombophlebitis

(8) Embolism. In such cases placenta is removed in fragments using an ovum forceps or a flushing curette.

MANAGEMENT OF TRUE POSTPARTUM HAEMORRHAGE

PRINCIPLES : Simultaneous approach

• Communication ♦ Resuscitation
• Monitoring and ♦ Arrest of bleeding

It is essential in all cases of major PPH (blood loss > 1000ml or clinical shock). (RCOG - 2009).

30
MANAGEMENT

Immediate Measures are to be taken by the attending Medical Officer /Midwife.

• Call for extra help — involve the obstetric registrar (Senior

Staff) on call.

• Put in two large bore (14 gauge) intravenous cannulas.

• Keep patient flat and warm.

• Send blood for group, cross matching, diagnostic tests and

ask for 2 units (at least) of blood.

• Infuse rapidly 2 litres of normal saline (crystalloids) or

plasma substitutes like haemaccel (colloids), an urea linked gelatin, to re-expand the vascular bed. It does
not interfere with cross matching.

• Give oxygen by mask 10-15 L/min.

• Start 20 units of oxytocin in 1L of normal saline IV at the

rate of 60 drops per minute. Transfuse blood as soon as possible.

• One Midwife should be assigned to monitor the following —

(i) Pulse

(ii) Blood pressure

(iii) Respiratory rate and oxymeter

(iv) Type and amount of fluids the patient has received

(v) Urine ouput (continuous catheterisation)

(vi) Drugs-type, dose and time

(vii) Central venous pressure (when sited).

ACTUAL MANAGEMENT

Atonic ♦ Traumatic ♦ Retained tissues ♦ Coagulopathy

The first step is to control the fundus and to note the feel of the uterus. If the uterus is flabby, the bleeding is
likely to be from the atonic uterus. If the uterus is firm and contracted, the bleeding is likely of traumatic
origin.

Atonic uterus:

31
Step—I:

(a) Massage the uterus to make it hard and express the blood clot

(b) Methergin 0.2 mg is given intravenously

(c) Inj oxytocin drip is started (10 units in 500 ml of normal saline) at the rate of 40-60 drops per minute

(d) Foley catheter to keep bladder empty and to monitor urine output

(e) To examine the expelled placenta and membranes, for evidence of missing cotyledon or piece of
membranes. If the uterus fails to contract, proceed to the next step.

Step—II:

The uterus is to be explored under general anaesthesia. Simultaneous inspection of the cervix, vagina
specially the paraurethral region is to be done to exclude co-existent bleeding sites from the injured area. In
refractory cases:

• Inj. 15 methyl PGF2tt 250 |i.g IM in the deltoid muscle every 15 minutes (up to maximum of 2 mg).

OR

• Misoprostol (PGEi) 1000 \ig per rectum is effective.

• When uterine atony is due to tocolytic drugs, calcium gluconate (1 g IV slowly) should be given to
neutralise the calcium blocking effect of these drugs.

Step—III: Uterine massage and bimanual compression.

Procedures :

(a) The whole hand is introduced into the vagina in cone shaped fashion after separating the labia with the
fingers of the other hand

(b) The vaginal hand is clenched into a fist with the back of the hand directed posteriorly and the knuckles in
the anterior fornix

(c) The other hand is placed over the abdomen behind the uterus to make it anteverted

(d) The uterus is firmly squeezed between the two hands . It may be necessary to continue the compression for a
prolonged period until the tone of the uterus is regained. This is evidenced by absence of bleeding if the
compression is released.

During the period, the resuscitative measures are to be continued. If, in spite of therapy, the uterus remains
refractory and the bleeding continues, the possibility of blood coagulation disorders should be kept in mind
32
and massive fresh whole blood transfusion should be given until specific measures can be employed.
However, with oxytocics and blood transfusion, almost all cases respond well. Uterine contraction and
retraction regain and bleeding stops. But in rare cases, when the uterus fails to contract, the following may
be Med desperately as an alternative to hysterectomy.

Step — IV: Uterine tamponade

(i) Tight intrauterine packing done uniformly under general anaesthesia.

Procedure: A 5 metres long strip of gauze, 8 cm wide folded twice is required. The gauze should be soaked in
antiseptic cream before introduction. The gauze is placed high up and packed into the fundal area first while
the uterus is steadied by the external hand. Gradually, the rest of the cavity is packed so that no empty space
is left behind. A separate pack is used to fill the vagina. An abdominal binder is placed. Intrauterine
plugging acts not only by stimulating uterine contraction but exerts direct haemostatic pressure (tamponade
effect) to the open uterine sinuses. Antibiotic should be given and the plug should be removed after 24
hours.

Intrauterine packing is useful in a case of uncontrolled postpartum haemorrhage where other methods have
failed and the patient is being prepared for transport to a tertiary care centre.

(ii) Balloon tamponade : Tamponade using various types of hydrostatic balloon catheter has mostly replaced
uterine packing. Mechanism of action is similar to uterine packing. Foley catheter, Bakri balloon, Condom
catheter or Sengstaken-Blakemore tube is inserted into the uterine cavity and the balloon is inflated with
normal saline (200-500 mL). It is kept for 4-6 hours. It is successful in atonic PPH. This can avoid
hysterectomy in 78% cases.

Step V: Surgical methods to control PPH are many.

(a) Ligation of uterine arteries — the ascending branch of the uterine artery is ligated at the lateral border
between upper and lower uterine segment. The suture (No.l chromic) is passed into the myometrium 2 cm
medial to the artery. In atonic haemorrhage bilateral ligation is effective in about 75% of cases.
(b) Ligation of the ovarian and uterine artery anastomosis if bleeding continues, is done just below the
ovarian ligament. Rarely temporary occlusion of the ovarian vessels at the infundibulopelvic ligament may
be done by rubber sleeved clamps.
(c) Ligation of anterior division of internal iliac artery (unilateral or bilateral) — reduces the distal
blood flow. It helps stable clot formation by reducing the pulse pressure up to 85%. Due to extensive
collateral circulation, there is no pelvic tissue necrosis. Bilateral ligation (not division) can avoid
hysterectomy in about 50% of the cases.
(d) B-Lynch compression suture and multiple square sutures : Both these surgical methods work by

33
tamponade (like bimanual compression) of the uterus. Success rate is about 80% and it can avoid hysterectomy.
(e) Angiographic arterial embolisation (bleeding vessel) under fluoroscopy can be done using gel foam.
Success rate is more than 90% and it avoids hysterectomy.

Step VI: Hysterectomy — rarely uterus fails to contract and bleeding continues in spite of the above
measures. Hysterectomy has to be considered involving a second consultant. Decision of hysterectomy
should be taken earlier in a parous woman. Depending on the case it may be subtotal or total.

Recombinant Activated Factor VII

This vitamin K–dependent protein has been licensed by the Food and Drug Administration for
treatment of bleeding in individuals with hemophilia, acquired antibodies to components of the intrinsic
pathway, and congenital factor VII deficiency. Other clinicians have explored its usefulness for the control
of hemorrhage due to other causes, including traumatic and surgical bleeding (Branch and Rodgers, 2003).
Bouwmeester and associates (2003) described the successful use of recombinant activated factor VII for the
treatment of intractable hemorrhage in a woman with uterine atony and vaginal lacerations who did not
respond to uterotonic drugs, suturing, ligation of the internal iliac arteries, subtotal hysterectomy, packing of
the pelvis, and blood and component transfusions. Although this therapy looks promising, thrombotic
complications have been reported, and additional study clearly is needed (Siegel and associates, 2004).

TRAUMATIC PPH : The trauma to the perineum, vagina and the cervix is to be searched under good light by
speculum examination and haemostasis is achieved by appropriate catgut sutures. The repair is done under
general anaesthesia, if necessary.

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35
SECONDARY POSTPARTUM HAEMORRHAGE

CAUSES : The bleeding usually occurs between 8th to 14th day of delivery.

The causes of late postpartum haemorrhage are :

(1) Retained bits of cotyledon or membranes (commonest)

(2) Infection and separation of slough over a deep cervico-vaginal laceration

(3) Endometritis and subinvolution of the placental site — due to delayed healing process

(4) Secondary haemorrhage from caesarean section wound usually occur between 10-14 days. It is probably
due to —

(a) separation of slough exposing a bleeding vessel or

(b) from granulation tissue

(5) Withdrawal bleeding following oestrogen therapy for suppression of lactation

(6) Other rare causes are: chorion-epithelioma — occurs usually beyond 4 weeks of delivery; carcinoma cervix;
placental polyp; infected fibroid or fibroid polyp and puerperal inversion of uterus.

DIAGNOSIS :

The bleeding is bright red and of varying amount. Rarely it may be brisk. Varying degree of anaemia and
evidences of sepsis are present. Internal examination reveals evidences of sepsis, subinvolution of the uterus
and often a patulous cervical os. Ultrasonography is useful in detecting the bits of placenta inside the uterine
cavity.

MANAGEMENT

Principles :

• To assess the amount of blood loss and to replace it (transfusion).

• To find out the cause and to take appropriate steps to rectify it.

Supportive therapy :

(1) Blood transfusion, if necessary

(2) To administer methergin 0.2 mg intramuscularly, if the bleeding is uterine in origin

(3) To administer antibiotics as a routine.

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Conservative : If the bleeding is slight and no apparent cause is detected, a careful watch for a period of 24
hours or so is done in the hospital.

Active treatment: As the commonest cause is due to retained bits of cotyledon or membranes, it is preferable
to explore the uterus urgently under general anaesthesia. One should not ignore the small amount of
bleeding; as unexpected alarming haemorrhage may follow sooner or later. The products are removed by
ovum forceps. Gentle curettage is done by using flushing curette. Methergin 0.2 mg is given
intramuscularly. The materials removed are to be sent for histological examination.

Presence of bleeding from the sloughing wound of cervico-vaginal canal should be controlled by
haemostatic sutures. Secondary haemorrhage following caesarean section may at times require laparotomy.
The bleeding from uterine wound can be controlled by haemostatic sutures; may rarely require ligation of
the internal iliac artery or may end in hysterectomy.

NURSING MANAGEMENT

Nursing Assessment

 Assess maternal history for etiology of previous postpartum hemorrhage (eg, rapid or prolonged
labor, uterine distention [macrosomia, polyhydramnios, or multiple gestation], use of tocolytics or
halogenated anesthesia, operative birth, high parity, chorioamnionitis/intra-amniotic infection, placental
abnormalities, or previous uterine surgery).
 Assess blood loss; evaluate presence of clots; note number of pads saturated in 1 hour or shorter time
frame if applicable. Note that a saturated pad contains about 25 to 50 mL of blood.
 Assess vital signs every 15 minutes, especially mean arterial pressure (MAP). Assess intake and
output.
 Assess for hypotension, tachycardia, change in respiratory rate, decrease in urine output, and change
in mental status—may indicate hypovolemic shock.
 Assess location and firmness of uterine fundus.
 Percuss and palpate for bladder distention, which may interfere with contracting of the uterus.
 Inspect for intactness of any perineal repair.

NURSING ALERT

Normal vital signs are not an indication that the woman is not in shock. Traditional signs of hypovolemic
shock are not evident until approximately 15% to 20% of total maternal blood volume is lost.

Nursing Diagnoses

37
 Anxiety related to unexpected blood loss and uncertainty of outcome
 Deficient Fluid Volume related to blood loss
 Risk for Infection related to blood loss and vaginal examinations

Nursing Interventions

Decreasing Anxiety

 Maintain a quiet and calm atmosphere; provide emotional support.

 Provide information about the situation and explain everything as it is done; answer questions that
the woman and her family ask.
 Encourage the presence of a support person.

Maintaining Fluid Volume

 Maintain or start a large-bore I.V. line if vaginal bleeding becomes heavy. Use lactated Ringer's
solution or plasma expanders (try to maintain urine output at more than 30 mL/hour).
 Monitor and maintain accurate intake and output; use of Foley catheter provides accurate output
measurements.
 Make sure that crossmatched blood is available.
 Provide additional oxygen by face mask; monitor oxygen saturation with pulse oximetry.
 Administer oxytocin, methergine, carboprost tromethamine or Prostin alpha, I.V. fluids, and blood
products at prescribed rate.
 Apply correct uterine massage (use only enough force to effect contraction or expulsion of the clots).
 Monitor CBC for anemia.
 Dilatation and curettage (may be needed for late postpartum hemorrhage)

NURSING ALERT

Avoid Trendelenburg's position for shock because it interferes with the cardiac and respiratory function by
increasing pressure on the chemoreceptor and baroreceptors, which ultimately decreases lung expansion.
The best thing to do is elevate the legs 20 to 30 degrees.

Preventing Infection

 Maintain aseptic technique.

 Evaluate for symptoms of infection, chilling, and elevated temperature, changes in WBC, uterine
tenderness, and odor of lochia.

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 Administer antibiotics as prescribed.
 Maintain adequate rest and proper nutrition

Patient Education and Health Maintenance

 Educate the woman about the cause of the hemorrhage.

 Teach the woman the importance of eating a balanced diet and taking vitamin supplements.
 Advise the woman that she may feel tired and fatigued and to schedule daily rest periods.
 Teach woman and family signs and symptoms of hemorrhage to watch for during the puerperium.
 Ensure woman has emergency procedures and numbers readily available.
 Advise the woman to notify her health care provider of increased bleeding or other changes in her
status.

Evaluation: Expected Outcomes

 Verbalizes concerns about her well-being

 Vital signs stable, urine output adequate, hematocrit stable
 Remains afebrile, WBC count within normal limits

CONCLUSION

Bleeding in any situation is a life threatening complication. When it is related to pregnancy it

creates a threat to the life of the mother and to the baby. Medical personnel should have adequate knowledge
regarding the situation which will be helpful for making life saving interventions. The medical technology is
now a day so advanced that lot of measures is there to avoid the complications. Pregnancy is a precious
event of the life. So by avoiding the complications it will be made happier.

REFERENCES

1. D C Dutta “Textbook Of Obstetrics” 7 th Edition 2012, Jaypee brothers medical publishers pvt
ltd New Delhi Pp218-245
2. Williams obstetrics 22nd edition mc grew hills publications chapter 35
3. Bobak . Lowdermilk . Jenson, ‘Maternity Nursing’, 4th edition, Mosby publications, St. Louis,
Missori, page no: 123-171
4. K Park, “Park’s Textbook of Preventive and Social Medicine”, 19th edition, Banarsidas Bhanot
publications, 2007, page no : 263-266
5. Lowdermilk, Perry, ‘Maternity and women’s health care’,9 th edition, Mosby publications, St. Louis,
page no: 433-446

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 6. Shirish S. Sheth, “Essentials of Obstetrics” ist edition, Jaypee publishers, Newdelhi,2004, page
no:102-107

Net reference

www.ncbi.nlm.nih.gov › ... › Am J Public Health › v.78(10); Oct 1988

wiki.answers.com › ... › Jobs › Professions › Accountants

www.jstor.org/stable/25335214

journals.lww.com › Home › Collections

en.wikipedia.org/wiki/Midwifery

www.plannedparenthood.org/pacific-southwest/ - United States

en.wikipedia.org/wiki/Prenatal_diagnosis

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