The two most clinically significant causes of bleeding in the second half of

pregnancy are: placenta previa and placentae

In placenta previa, the placenta isimplanted in the lower uterine segment rather

than the upper portion of the uterus

The placenta is implanted in the lower segment of the uterus or over the internal

cervical os.

Bleeding begins – may be either scanty or perfused

Placenta previa is categorized as being:

o Low lying – placenta is in the lower uterine segment but DOES NOT COVER

THE OS

o Partial – internal osis partially covered

o Marginal – edge of placenta is covered

o Complete – internal osis covered

CAUSE OF PLACENTA PREVIA IS UNKNOWN

Women at higher risk are:

Women of African descent

Women who have undergone prior C-section

Otherrisk factors:

High gravidity

High parity

Advanced maternal age

Previous miscarriage

Previousinduced abortion

Cigarette smoking

Male fetus

Fetal/Neonatal Implications

o Prognosisfor fetus depends on the extent of placenta previa

o Woman may be allowed to labor with: marginal and low-lying placenta previa

o Fetus may have changesin: FHR and meconium staining of the aminotic fluid -

FHR monitoring isimperative

o Porfuse bleeding: fetusis compromised and sufferssome hypoxia

o If nonreassuring fetal status occurs C-section is indicated

o Woman with complete or partial previa C-section because of high risk for

hemmoraging!!!

o Postpartum: blood sampling to check for anemia in the newborn

Clinical Therapy Expectant Management

Goal of medical care is to identify the cause of bleeding and to • Bed rest

provide treatment that will ensure birth of a mature newborn • Bathroom privileges as long as woman is not bleeding

• Transabdominal ultrasound scan to localized placenta • Performing no vaginal exams

• Until placenta previa isruled out: VAGINAL EXAMINATIONS • Monitoring blood loss, pain, and uterine contractility

ARE NEVER DONE WITH WOMAN WITH BLEEDING • Evaluating FHR with an external fetal monitor

o Examinersfingers can perforate placenta if • Monitoring maternal v/s

cervical dilation has occurred • Labs: H&H, Rh factor and urinalysis

o Once r/o then examiner can perform vaginal • IV (LR solution)

exam with speculum to determine cause of • 2 units of cross-matched blood available for transfusion

bleed • If frequent, recurrent or profuse bleeding persists or if fetal well-

• Differential diagnosis of placental or cervical bleeding takes being appearsthreatened a C-section is needed

careful consideration Clinical Signs

• Partial separation: painless bleeding • Most accurate diagnostic sign of placenta previa: PAINLESS,

• True placenta previa: may not demonstrate overt bleeding BRIGHT-RED VAGINAL BLEEDING

until labor begins • First bleeding episode is generally light,scanty

• Confusion between partial and true placental is an issue • If no vaginal examinations are performed it often subsides

when diagnosis spontaneously, however each subsequent hemorrhage is more

• Care of woman with painless late-gestational bleeding perfuse

depends on: • Uterusremainssoft

1. week of gestation during which the 1

st bleeding • If labor begins, the uterus relaxes during contractions

episode occurs • FHR remainsstable unless profuse hemorrhage and maternal

2. The amount of bleeding shock occur

• If pregnancy islessthan 37 weeks’, expectant management • Fetal presenting part is often unengaged and transverse lie is

is used to delay birth until about 37 weeks’ to allow the common

fetustime to mature

Nursing

Management

Prevent ortreat complications

• Nurse should assess blood loss, pain and uterine contractility (subjective and objective)

• Maternal V/S and the result of blood loss and urine test

• Monitor maternal vital signs every 15 min in the absence of hemorrhage and every 5 mins with active

hemorrhage

• Evaluate the FHR w/continuous external fetal monitoring

• Observe and verify family’s ability to cope with the anxiety associated with an unknown outcome

• Record, I&O’s, V/S, prepare whole-blood setup to be ready for IV infusion, establish IV site,

• Fluid volume deficit due to excessive blood loss

• Impaired gas exchange of fetusr/t decreased blood volume and maternal hypotension

• Anxiety related to concern for own personalstatus and baby’ssafety

• Check newborns Hgb, cell volume and erythrocyte count STAT and monitor it loosely, baby may require O2 and O

2. Abruptio Placentae

• Abruptio placentae - is the premature separation of a normally implanted placenta from the uterine wall