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2 min INTRODUCTION: Student teacher
introduces the
Antepartum haemorrhage or prepartum hemorrhage is genital bleeding
topic to the
during pregnancy from the 24th week (sometimes defined as from the
group with the
20th week) gestational age to term.
help of ppt.
It can be associated with reduced fetal birth weight.
In regard to treatment, it should be considered a medical emergency
(regardless of whether there is pain) and medical attention should be
sought immediately, as if it is left untreated it can lead to death of the
mother and/or fetus.

1 min Defines DEFINITION OF ANTEPARTUM HEMORRHAGE: Student teacher Define

antepartum It is defined as bleeding from or into the genital tract after the 28th week defines antepartum
hemorrhage. of pregnancy but before the birth of the baby (the first and second stage antepartum hemorrhage.
of labor are thus included). The 28th week is taken arbitrarily as the lower hemorrhage with
limit of fetal viability. The incidence is about 3% amongst hospital the help of ppt.
deliveries.
2 min Describes the CAUSES OF THE ANTEPARTUM HEMORRHAGE: Student teacher Enlist the causes
Causes of describes the of antepartum
antepartum APH causes of hemorrhage.
hemorrhage. antepartum
hemorrhage with
the help of ppt
Placental bleeding Unexplained (25%) extra placental
(70%) excluding placental - Implantation
Bleeding and local lesions bleed
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- cervical polyps
Placenta praevia - carcinoma of
Abruptio placenta Cervix
-cervical ectropion
- varicose vein
- local trauma

2 min Defines Abruptio DEFINITION OF ABRUPTIO PLACENTA: Student teacher Define abruptio
placenta It is one form of antepartum hemorrhage where the bleeding occurs due defines abruptio placenta.
to premature separation of normally situated placenta. Out of the various placenta with the
nomenclatures, abruptio placenta seems to be appropriate one. help of ppt.
5 min Explain about TYPE/ VARIETIES OF ABRUPTIO PLACENTA: Student teacher Describe the
the different (1) Revealed: Following separation of the placenta, the blood insinuates explains about types of the
type/ varieties downwards between the membranes and the decidua. Ultimately, the the different abruptio
of abruptio blood comes out of the cervical canal to be visible externally. This is the types/ varieties placenta.
placenta commonest type. of abruptio
(2) Concealed: The blood collects behind the separated placenta or placenta with the
collected in between the membranes and decidua. The collected blood is help of ppt.
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.
(3) 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.
Bleeding is almost always maternal. But placental tear may cause fetal
bleeding.
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1 min Discuss about INCIDENCE OF ABRUPTIO PLACENTA: Student teacher Confer the
the incidence of The overall incidence is about 1 in 200 deliveries. Depending on the extent discussed about incidence of the
the abruptio (partial or complete) and intensity of placental separation, it is a significant the incidence of abruptio
placenta cause of perinatal mortality (15–20%) and maternal mortality (2–5%). the abruptio placenta.
More and more cases of placental abruption are being diagnosed in the placenta with the
recent years. help of the ppt.
5 min Explain about ETIOLOGY OF THE ABRUPTIO PLACENTA: Student teacher Enlist the causes
the etiology of The prevalence is more with explains about of the abruptio
the abruptio (a) high birth order pregnancies with gravida 5 and above — three times the etiology of plcaenta.
placenta. more common than in first birth the abruptio
(b) advancing age of the mother placenta with the
(c) poor socio-economic condition help of ppt
(d) malnutrition
(e) Smoking (vaso-spasm).
 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
percent. 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 hematoma).
 Trauma: 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
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anaesthesia 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 attachment 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 labor 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.
 Placental anomaly: Circumvallate placenta.
 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 submucous 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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 Thrombophilias inherited or acquired have been associated with
increased risk of placental infarcts or abruption.
 Prior abruption: Risk of recurrence for a woman with previous
abruption varies between 5 to 17%.
5 min Describes about PATHOPHYSIOLOGY OF THE ABRUPTIO PLACENTA: Student teacher Elucidate the
the Depending upon the etiological factors, describes about Pathophysiology
Pathophysiology the of the abruptio
of the abruptio Premature placental separation is initiated by hemorrhage into the Pathophysiology placenta.
placenta. decidua basalis. of the abruptio
placenta with the
The collected blood (decidual hematoma) at the early phase hardly help of ppt.
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 (retroplacental hematoma).
The features of retroplacental 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.
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5 min Illustrate about CLINICAL FEATURES OF THE ABRUPTIO PLACENTA: Student teacher List down the
the clinical illustrated about clinical features
features of the the clinical of the abruptio
abruptio features with the placenta.
placenta. help of ppt.

5 min Explain COMPLICATIONS OF ABRUPTIO PLACENTA: Student teacher Describe about

regarding the explains about the maternal
complications of MATERNAL: In revealed type—maternal risk is proportionate to the visible the complication complications of
the abruptio blood loss and maternal death is rare. of the abruptio the abruptio
placenta. In concealed variety—The following complications may occur either singly placenta with the placenta.
or in combination. help of ppt.
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(1) Hemorrhage which is either totally concealed inside the uterus or
more commonly, part is revealed outside. There may be
intraperitoneal or broad ligament hematoma
(2) 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
(3) Blood coagulation disorders
(4) 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
(5) Postpartum hemorrhage due to — (a) atony of the uterus and (b)
increase in serum FDP
(6) 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 placenta than in placenta previa. This is due to the
presence of pre-existing placental pathology with poor functional reserve
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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.
5 min Explicate the PREVENTIVE MEASURES OF THE ABRUPTIO PLACENTA: Student teacher Describe the
preventive The prevention aims at— explicate the preventive
measures of the (1) elimination of the known factors likely to produce placental separation preventive measures of the
abruptio (2) correction of anemia during antenatal period so that the patient can measures of the abruptio
placenta. withstand blood loss and abruptio placenta.
(3) Prompt detection and institution of the therapy to minimise the grave placenta with the
complications namely shock, blood coagulation disorders and renal failure. help of ppt.
Prevention of known factors likely to cause placental separation are
 Early detection and effective therapy of pre-eclampsia and other
hypertensive disorders of pregnancy.
 Needle puncture during amniocentesis should be under ultrasound
guidance.
 Avoidance of trauma—especially forceful external cephalic version
under anaesthesia.
 To avoid sudden decompression of the uterus— in acute or chronic
hydramnios, amniocentesis is preferable to artificial rupture of the
membranes.
 To avoid supine hypotension the patient is advised to lie in the left
lateral position in the later months of pregnancy.
 Routine administration of folic acid from the early pregnancy — of
doubtful value.
5 min Describe about MANAGEMENT OF THE ABRUPTIO PLACENTA: Student teacher Explain the
the AT HOME: The patient is to be treated as outlined in placenta previa and describes about management of
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management of arrangement should be made to shift the patient to an equipped maternity the management the abruptio
the abruptio unit as early as possible. of the abruptio placenta.
placenta. IN THE HOSPITAL: Assessment of the case is to be done as regards: placenta with the
(a) amount of blood loss help of ppt.
(b) maturity of the fetus and
(c) whether the patient is in labor or not (usually labor starts)
(d) presence of any complication and
(e) Type and grade of placental abruption.

Emergency measures:
(i) Blood is sent for hemoglobin and hematocrit estimation,
coagulation profile (fibrinogen level, FDP, prothrombin time,
activated partial thromboplastin time and platelets), ABO and
Rh grouping and urine for detection of protein
(ii) Ringer’s solution drip is started with a wide bore cannula and
arrangement for blood transfusion is made for resuscitation.
Close monitoring of maternal and fetal condition is done.

Management options are:

(a) Immediate delivery
(b) Management of complications if there is any
(c)Expectant management (rare).

Definitive treatment (immediate delivery): The patient is in labor: Most

patients are in labor following a term pregnancy: The labor is accelerated
by low rupture of the membranes. Rupture of the membranes with escape
of liquor amnii accelerates labor and it increases the uterine tone also.
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Oxytocin drip may be started to accelerate labor when needed.

Vaginal delivery is favoured in cases with:

(i) Limited placental abruption
(ii) FHR tracing is reassuring
(iii) Facilities for continuous (electronic) fetal monitoring is
available
(iv) Prospect of vaginal delivery is soon or
(v) Placental abruption with a dead fetus.

The advantages of amniotomy are:

(a) Initiates myometrial contraction and labor process
(b) Expedites delivery
(c) Better compression of spiral artery to arrest hemorrhage
(d) Reduces entry of thromboplastin into maternal circulation and thereby
(e) Reduces the risk of renal cortical necrosis and DIC.

The patient is not in labor:

(i) Bleeding continues
(ii) > Grade I abruption :
Delivery either by
(A) Induction of labor or (B) Cesarean section.

(A) Induction of labor is done by low rupture of membranes. Oxytocin

may be added to expedite delivery. Labor usually starts soon in
majority of cases and delivery is completed quickly (4-6 hours).
Placenta with varying amount of retroplacental clot is expelled
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most often simultaneously with the delivery of the baby. Inj.
oxytocin 10.IU IV (slow) or IM or Inj. Methergin 0.2 mg IV is given
with the delivery of the baby to minimise postpartum blood loss.
Oxytocics should be used to improve the uterine tone along with
blood transfusion.
(B) Cesarean section: Indications are :
(a) Severe abruption with live fetus
(b) Amniotomy could not be done (unfavorable cervix)
(c) Prospect of immediate vaginal delivery despite amniotomy is
remote
(d) Amniotomy failed to control bleeding
(e) Amniotomy failed to arrest the process of abruption (rising
fundal height)
(f) Appearance of adverse features (fetal distress, falling fibrinogen
level, oliguria).
Anesthesia during cesarean section: Regional anesthesia is generally
avoided when there is significant hemorrhage. This is to avoid profound
and persistent hypotension Expectant management in a case of placental
abruption is an exception and not the rule. Cases where bleeding is slight
and has stopped (Grade I abruption), fetus reactive (CTG) and remote from
term, may be considered. The goal of expectant management is to prolong
the pregnancy with the hope of improving fetal maturity and survival.
Continuous electronic fetal monitoring is maintained. Patient should be
observed in the labor ward for 24-48 hours to ensure that no further
placental separation is occurring. Meanwhile betamethasone is given to
accelerate fetal lung maturity in the event preterm delivery has to be
contemplated. Further separation of placenta at any moment may cause
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fetal death or maternal complications. This is the major risk of
conservative management.
Management of complications : The major complications of placental
abruption are:
(a)Hemorrhagic shock.
(b) DIC.
(c) Renal failure and
(d) Uterine atony and postpartum hemorrhage.
Hypovolemia should be corrected early. Blood pressure may not be a
correct guide to assess shock, as it may be high due to severe degree of
vasospasm. Irrespective of the patient’s general condition, at least one
litre of blood transfusion should be the minimum when the diagnosis of
concealed accidental hemorrhage is made. The best guide to monitor the
patient is the use of central venous pressure (CVP), which is maintained at
10 cm of water. Hematocrit should be at least 30% and urinary output > 30
mL/h.
A. Hemorrhagic shock—Classification of obstetric hemorrhagic is based
upon volume deficit.
B. DIC—Release of tissue thromboplastin in placental abruption causes
consumptive coagulopathy. Diagnosis is based on the coagulation profile
assessment. Treatment is to restore the hematologic deficiency (fibrinogen
level > 150 mg/ dL), 1 unit (500 mL) of fresh blood contains 0.5 mL g of
fibrinogen and raises the fibrinogen level by 12.5 mg/dL. Platelet count
Increases by 10,000–15,000/cu mm to replenish the volume deficit and to
arrest the pathologic process (delivery).
Feto-maternal hemorrhage is common with traumatic variety of placental
abruption. To combat feto-maternal hemorrhage 300 μg of anti-D
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immunoglobulin is administered to all Rh-negative women. The amount of
fetal to maternal bleed is usually < 15 mL
5 min Describes about INDETERMINATE BLEEDING: Student teacher Describe about
the The exact cause of vaginal bleeding in late pregnancy is not clearly describes about the vasa previa.
indeterminate understood in few cases. The diagnosis of unclassified bleeding should be the
bleeding. made after exclusion of placenta previa, placental abruption and local indeterminate
causes. Rupture of vasa previa, marginal sinus hemorrhage, circumvallate bleeding with the
placenta, marked decidual reaction on endocervix or excessive show may help of ppt.
be a possible cause of such bleeding.

VASA PREVIA: The unsupported umbilical vessels in velamentous placenta,

lie below the presenting part and run across the cervical os. These vessels
are torn either spontaneously or during rupture of membranes.
Color-flow Doppler is helpful for antenatal diagnosis. Fetal mortality is high
(50%) due to fetal exsanguination. Detection of nucleated red blood cells
(Singer’s alkali denaturation test) or fetal hemoglobin is diagnostic.
Vaginal bleeding is often associated with fetal distress (tachycardia,
sinusoidal FHR tracing).
MANAGEMENT: Management depends on fetal gestational age, severity,
persistence or recurrence of bleeding, and the presumed cause of
bleeding.
A) Pregnancy > 37 weeks and bleeding recurrent — delivery is
recommended. The mode of delivery depends on the state of the fetus,
and other associated factors (cervix).
B) Expectant management can be done in selected cases for fetal maturity
similar to placenta previa. Fetal monitoring must be carefully done.
Intrapartum diagnosis of vasa previa, needs expeditious delivery. Neonatal
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blood transfusion may be needed.
10 min Explain about EXTRA PLACENTAL CONDITIONS OF ANTEPARTUM HEMORRHAGE: Student teacher Describe about
the extra explains about the extra
placental 1. IMPLANTATION BLEED the conditions of placental
conditions of A small vaginal bleed can occur when the blastocyst embed in the the antepartum conditions of
antepartum endometrium. This usually occurs 5-7 days after fertilization and if the hemorrhage with antepartum
hemorrhage. timing coincides with the expected menstruation this may cause confusion the help of ppt. hemorrhage.
over the dating of the pregnancy if the menstrual is used to estimate the
date of birth.
2. CERVICAL POLYPS
These are small, vascular, pedunculated growths on the cervix, which
consist of squamous or columnar epithelial cells over a core of connective
tissue rich with blood vessels. During pregnancy, the polyps may be a
cause of bleeding but require no treatment unless the bleeding is severe
or a smear test indicates malignancy.
3. CARCINOMA OF THE CERVIX
Carcinoma of the cervix is the most common gynaecological malignant
disease occurring in pregnancy with an estimated incidence of 1 in 2200
pregnancies .The condition presents with vaginal bleeding and increased
vaginal discharge. On speculum examination the appearance of the cervix
may lead to a suspicious of carcinoma, which is diagnosed following
colposcopy or a cervical biopsy.
The precursor to cervical cancer is cervical intraepithelial neoplasia (CIN),
which can be diagnosed from an abnormal papanicolaou (PAP) smear.
Where this is diagnosed at early stage, treatment can usually be
postponed for the duration of the pregnancy. The Pap smear is not
routinely carried out during pregnancy , but the midwife should ensure
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that pregnant women know about the National Health Service Screening
Programme(2013), recommending a smear 6 weeks postnatally if one has
not been carried out in the previous 3 years.

Treatment for cervical carcinoma in pregnancy will depend on the

gestation of the pregnancy and the stage of the disease, and full
explanations of treatments and their possible outcomes should be given to
the woman and her family. For carcinoma in the early stages, treatment
may be delayed until the end of the pregnancy, or a cone biopsy may be
performed under general anaesthetic to remove the affected tissue.
However there is risk of hemorrhage due to the increased vascularity of
the cervix of the cervix in the pregnancy, as well as the risk of miscarriage.
Where the disease is more advanced and the diagnosis made in early
pregnancy, the woman may be offered a termination of pregnancy in
order to receive the treatment, as the effects of chemotherapy and
radiotherapy on the fetus cannot be accurately predicted at the present
time. During the late second and third trimester the obstetric and
oncology teams will consider the optimal time for birth in order to achieve
the best outcomes for both mother and the baby.
4. CERVICAL ECTROPION
More commonly known as cervical erosion. The changes seen in cases of
cervical ectropion are as a physical response to hormonal changes that
occur in pregnancy. The number of columnar epithelial cells in the cervical
canal increase significantly under the influence of estrogen during
pregnancy to such an extent that they extend beyond to the vaginal
surface of the cervical os, giving it a dark red appearance. As this area is
vascular, and the cells form only a single layer, bleeding may occur either
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spontaneously or following sexual intercourse. Normally, no treatment is
required, and the ectropion reverts back to normal cervical cells during the
puerperium.

5 min Elucidate the NURSING MANAGEMENT OF ANTEPARTUM HEMORRHAGE: Student teacher List down the
nursing 1. ASSESSMENT: elucidates the points of nursing
management of Assess for the following clinical manifestation: nursing management of
the antepartum  Scant or profuse vaginal bleeding. management of antepartum
hemorrhage.  Uterine irritability, tenderness and rigidity. the antepartum hemorrhage.
 Abdominal pain that is intermittent or continuous. hemorrhage.
 Signs of maternal shock- hypotension, rapid pulse, dyspnoea
 Violent fetal activity followed by inactivity
 FHR- slow to absent
 Late deceleration noted in monitor strip
 May have blood stained amniotic fluid ( port wine stain)
2. ANALYSIS/ NURSING DIAGNOSIS:
 Risk for fetal injury
 Risk for infection
 Ineffective airway clearance
 Actual/ risk for aspiration
 Anxiety
 Anticipatory grieving
 Altered family process
 Actual/ risk for altered parenting
 Health seeking behaviour
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3. PLANNING:
 Promote safe care environment
 Monitor for presence of pre existing conditions.
 Assess maternal – fetal status and initiative emergency care
 Provide encouragement and support.
 Administer measures to treat shock and blood loss
4. IMPLEMENTATION:
 Monitor maternal and fetal vital signs.
 Treat shock symptoms
 Assess vital signs every 5-15 mins
 Administer oxygen by face mask at 7-10 L/min
 Increase IV flow rate
 Administer blood
 Monitor urinary output
 Monitor FHR continuously
 Observe for signs and symptoms of coagulation problems
 Measure abdominal girth
 Remain with woman
 Monitor labor pattern continuously if allowed to progress or
prepare for cessarean section.
5. EVALUATION
 The woman and her spouse understand the treatment plan
 The physiological status of the women and the fetus remains within
the normal limits.
 The women and her spouse verbalizes, decrease of anxiety and
feelings of support.
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 The women remain normotensive
 The hemoglobin and Hematocrit levels are within normal limits.

2 min Summarize the Summarization

topic. of the topic:
Antepartum
hemorrhage is
the 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. It is
dividing into
many types
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under which I’ve
covered abruptio
placenta, vasa
previa, and other
extra placental
conditions of
antepartum
hemorrhage.
2 min Conclusion of Conclusion of
the topic. the topic:
Antepartum
hemorrhage is a
serious life
threatening
condition which
la health care
professional
must be able to
identify in order
to prevent
serious
complications to
mother and
fetus.
 BIBLIOGRAPHY

 Jacob Annamma. A comprehensive textbook of midwifery; 2nd edition. New Delhi; Jaypee publishers/: Pp 311-315
 Datta D.C. Textbook of obstetrics 2010; 7th edition. New Delhi; New Central Book Agency/: Pp 241-259
 Dr.Sharma JB. A textbook of obstetrics; 1st edition. New Delhi; Avichal publishing company/: pp 222-224
 https://en.wikipedia.org/wiki/Antepartum_bleeding
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263934/
 HOLY FAMILY COLLEGE OF NURSING
LESSON PLAN
ON:
ANTEPARTUM
AND
POSTPARTUM HEMORRHAGE
{PANNEL DISCUSSION}

SUBMITTED TO: SUBMITTED BY:

MS.THERESIAMMA GEORGE NIDHI SHARMA

ASSISTANT PROFESSOR M.Sc. NURSING 1ST YEAR

HFCON HFCON