College of Health Sciences

School of Nursing & Midwifery

Maternity & RH track
Advanced maternity and reproductive health nursing practice II

By: Hana Bekele

[Link]: GSR/0039/14
Submitted to: Semerya B. (Assistant Professor, PhD candidate)

October, 2023
AA, Ethiopia
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Presentation outline

Over view of information about APH

 Case presentation
 Midwifery care process
 Antepartum hemorrhage
• Bleeding from the genital tract after 28 weeks up to delivery of the fetus(last fetus
in case of multiple pregnancies) is known to be antepartum hemorrhage.

• Causes of APH can be both Placental and non-placental.

• Placental causes includes: placenta Previa, placental Abruption and vasa Previa/
circumvallate placenta in rare cases

• Non – placental causes like Heavy show, ruptured uterus, bleeding diathesis. The
other Local causes i.e. Cervicitis, cervical Ca, cervical polyp, vaginal & vulvar
pathologies
Incidence

• Antepartum hemorrhage occurs in approximately 2% of pregnancies.

• A study shows that prevalence of APH was 3.4%, Abruptio placenta(69.5%) and
placenta previa(28.2%) accounts majorly and other causes(2.3%)

• Incidence of antepartum hemorrhage in Ethiopia is 3.8% where abruptio placenta

(46.5%) and placenta previa(33.3%) are the major causes.
 1. Abruptio Placenta
• is premature separation of normally situated placenta occurring after 28 th wks of
pregnancy.

Risk factors: The cause is not always clear but it is associated with

• PIH(The most common cause of sever hypertension) .

• Poor socioeconomic condition & malnutrition.

• Previous abruption

• Fall or blow on the abdomen, Trauma

• Attempt external cephalic version

Types

Based on Blood lost from Abruption: classified in to three

1. Revealed: Following separation of placenta the blood is downwards between

the membranes and decidua
Blood comes out the cervical canal to the visible externally.

This is commonest type.

Complications are fewer.

Retro placental clot is NOT formed.

 DIC may occur.

Types . .
2. Concealed:
Blood is collected behind the separated placenta or collected in between the
membranes or deciduas.
The collected blood is prevented from coming out of the lower segment.

This type is rare.

3. Mixed:
Some of the part of the blood is collected inside (concealed) and some part is
expelled (revealed).
This type is very rare.
Types . . .
Based on Degree of abruption

1. Mild Separation
• Placenta Separation and bleeding are slight

• Mother and fetus are in good condition.

• Placental separation of about 1/6th

2. Moderate Separation
• Placental separation of about 1/4th

• The mother will be shocked

• The fetus may be dead of alive

 Types. . .
3. Severe Separation
Is an acute obstetric emergency
At least 2/3rd of the placenta has been detached.
The fetus will almost certainly died.
The woman will have severe abdominal pain
The uterus will have board like consistency
Complications

• Hemorrhagic shock (acute kidney injury, congestive heart failure),

• DIC
• Utero-placental insufficiency that may lead to IUGR, fetal distress or IUFD.
• PPH due to DIC. Inj. Renal Failure as a result of Hypovolaemia
• Pituitary necrosis (Sheehan’s Syndrome) due to severe Hypotension.
Prevention:
Prevention and early detection and effective therapy of PIH.
Avoidance of trauma - especially forceful ECV under anesthesia.
Routine administration of folic acid supplement from early stage of pregnancy
Management
• Resuscitate and stabilize on arrival, and admit the patient
• Assess maternal and fetal wellbeing
• Prepare cross matched blood (at least 2 units)
Expectant management:
• If patient is <37 weeks, patient in stable condition and reassuring fetal condition

• Give dexamethasone 6 mg IM BID or Betamethasone 12 mg IM every 24 hours

for 48 hours if GA< 37 weeks
• Anti D 300µg IM if Rh negative and not sensitized
• Closely monitor maternal and fetal conditions
Management . . .

Immediate delivery:
• Gestational age is >37 weeks/,
• deranged vital signs, heavy bleeding, NRFHRP, IUFD, malformed fetus,
• established labor
• Mode of delivery: Vaginal delivery is preferred.
• Cervical ripening and induction of labor, amniotomy
• Emergency cesarean section: For severe bleeding endangering maternal life,
NRFHR or other Obstetrics indications
Nursing Care
• Follow vital sign (Bp, pulse, respiration taken frequently.
• If Pyrexia is present, temperature may be recorded every 1 or 2hrs.
• Urine output is accurately assessed by the insertion of an indwelling catheter.
• Urine should be send to lab for protein.
• Fluid intake must be recorded accurately to assess the fluid balance.
• Fundal height and abdomen girth are measured hourly.
• If fetus is alive, the FHR should be monitored continuously
2. Placenta previa

• Placenta previa is defined as implantation of placental tissue over the lower

uterine segment which is used to be the isthmus before pregnancy.

• It is one of the leading placental cause of Antepartum hemorrhage.

• The overall reported incidence of placenta previa at delivery is 1 in 200 births.
 Cont. . .
The exact causes of placenta previa are not known however, it is frequently
associated with:

A. Endometrial scaring that can result from: Previous placenta Previa, C/S,
Increased parity or Closely spaced pregnancies

B. Impended endometrial vascularization (inadequate blood supply) can be

due to Hypertension, Diabetes mellitus, Uterine tumor, Smoking, Advanced
maternal age, Drug addiction

C. Increased placental mass; Multiple pregnancy, Syphilis infection, Maternal

smoking
Clinical Manifestations

• Placenta previa typically presents as painless vaginal bleeding in the second or

third trimester.

• Vaginal bleeding is sudden onset, painless, and causeless.

• 70% to 80% of patients with placenta previa will have at least one bleeding
episode
 Classification

 Type II placenta previa /Marginalis

Type I/ low lying Placenta previa
• The edge of the placenta is at the margin of
• Majority of the placenta is in the internal os.
the upper uterine segment
• The placenta is partially located in the LUS
• Vaginal delivery is possible
near the internal cervical os
• Blood loss is mild.
• Vaginal delivery is possible particularly if
• Mother and fetus are in good
the placenta is anterior.
health condition.
• Blood loss is moderate.

• Mother & fetus condition is varying.

 Classification. . .
Type III-Placenta previa/Partialis Type IV-placenta previa/totalis

• the internal OS is partially covered by • The placenta is located centrally

placenta over the internal os.
• The placenta is located over the • Vaginal delivery should not be
internal os but not centrally. considered.
• Vaginal delivery is inappropriate. • Blood loss is very severe.

• Blood loss is severe, particularly

when lower segment stretches and
cervix begins effacement and dilates.
 Classification. . .

A. Type iv/ totalis b. type iii/ partialis c. type ii/ marginalis d. type i/ low lying
Risk factors

 Advanced maternal age

 Multiparty

 Multifetal gestations

 Prior uterine surgery and prior cesarean delivery

 Previous placenta Previa(2-3% chance of developing pp again)

 Cigarette smoking and cocaine use(smokers are about 2 times more likely than non
smokers)
Diagnosis
 Vaginal bleeding: bright red, painless and recurrent.

 Ultrasound (trans abdominal or trans vaginal): for placental location

and fetal wellbeing assessment.
Management
General principles

 Admit all patient with APH at time of diagnosis.

 Resuscitation and stabilize based on clinical condition.

 Closely monitor maternal and fetal conditions

 HCT, BG & Rh, cross-match at least two units of blood

 Vaginal & rectal examinations are absolutely contraindicated as it aggravates or

initiates the bleeding.
Management . . .

 Decide on conservative management versus immediate delivery

 Serial sonography - to assess placental location and fetal growth

 Avoidance coitus and activity restrictions

 Counseling about labor symptoms and vaginal bleeding

 Prevent and treat maternal anemia, and early medical attention if any vaginal
bleeding occurs.
Management . . .

 Management depends on:-

o Amount of bleeding

o Gestational age

o Fetal and maternal condition

o Degree of the placenta

 Types of management: Conservative and Active

Conservative management

If GA < 37 weeks & patient in stable condition and reassuring fetal condition

• Give dexamethasone 6 mg IM BID or Betamethasone 12 mg IM every 24

hours for 48 hours if GA < 37 weeks
• Anti D 300µg IM if Rh negative and not sensitized

• Closely monitor maternal and fetal conditions with APH chart

• Prevent and treat anemia

Indications for immediate delivery:

• If bleeding continues / excessive bleeding,

• Term pregnancy Gestational age is >37 weeks

• deranged vital signs / Non-reassuring FHR pattern,

• IUFD, fetal growth restriction, lethal congenital anomaly of the fetus,

• Gross fetal congenital malformation , established labor

• In absence of any of the above conservative management is instituted till an

indication comes to picture
Patient history

Date: 23/10/2023 MRN: IC 256988

Full Name : Bethelhem Sultan Age : 33yrs

 Sex : Female

Marital status : Married

 Educational status : Degree

Nationality: Ethiopian

Religion: Orthodox
History cont …

• This is Bethelhem Sultan a 33 years old G-II P-I (alive via C/S) mother who
doesn’t remember her LNMP but claimed to be amennorhic for the past 7 months
and Gestational age is 29 + 3 weeks from early U/S. She had ANC follow up at
private clinic where she took iron supplementation and 2 doses of TT vaccine.

• Currently, she is referred from private clinic after incidental finding of placenta
previa on U/S. She is admitted to D6 ward with the assessment of MG + Early
preterm + placenta previa + previous c/s scar

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History cont . . .

• C/C: referred from private clinic mentioning the placenta precedes the fetus

• Past obstetric history: she is multigravida mother,

-she has 1 alive male child

-1 c/s delivery for an indication of fetal macrosomia & the

outcome was 3.8 kg.

-Otherwise, she has no history of previous placenta previa,

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 History …
• Past medical & surgical history; she has no History of known medical problem
hypertension, DM, heart disease and Asthma.

• Past gynecologic history

o She has no history of STI and HIV/AIDS

o She has no History of abortion

o She has no History of operations such as FGM ,cervical cerclage

• Family history

She has no family history of chronic disease(hypertension, DM, heart disease)

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Physical examination

G.A- well looking

Vital Sign: - BP- 100/75mm/Hg PR- 84 bpm RR- 18bpm T°- 36.4 ℃

HEENT-Head- no scar on the head, hair is smooth and evenly distributed,

-Eye- pink conjunctiva

-Ear- no discharge and other abnormality

-Nose- no discharge and other abnormality

-Throat- no gum bleeding no laceration of mucosa

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History cont . . .
• Chest& Cardio vascular system- No abnormality detected

• Abdomen

Inspection: There is c/s scar and striae gravida

Palpation – 30 week sized gravid uterus

• Longitudinal lie

• breech presentation

Auscultation - FHB-146 beat/minute

• Genito-urinary (GUT)– no vaginal bleeding

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Laboratory investigations Obstetric Ultrasound
• Single intrauterine pregnancy
• Hgb- 11g/dl
• Breech presentation
• Hct- 33.5 % • EFW- 1800 gm
• BG and RH- O+ • Placenta covers cervical os

• VDRL- NR ,

• PICT- NR

• HBsAg- NR

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Summary of Subjective and Objective data
Subjective data Objective data

• Unknown LNMP • Vital signs BP- 100/75 mmHg PR=84bpm,

• Have ANC follow up RR=18 b/min T°- 36.4 ℃
• Took Iron supplement and TT • Abdomen - C/S scar, 30wk sized gravid ux
Vaccine FHB - 146
• GUS- no vaginal bleeding

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Investigation of record for pertinent finding

[Link]. Investigation Result

1 11g/dl
Hemoglobin
2 Blood group and RH O+

3 VDRL Non reactive

4 Non reactive
PICT
5 Non reactive
HBsAg
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 Diagnosis

Name- Bethelhem Sultan Age- 33 MRN-IC 256988 Ward-D6

Date No. Problem Diagnosis Signature

02/10/2023 01 Risk of vaginal bleeding Antepartum hemorrhage

02 Early preterm pregnancy 29+3 weeks

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 Midwifery care and management plan
Name- Bethelhem Sultan Age- 33 MRN-IC 256988 Ward-D6

No Proble Signatur
Date Expected Outcome Care & management plan
. m e
02/10/2023 01 bleedi • Expectant management
ng
• Reduce risk of bleeding plan of APH ( administer
• The patient will exhibit corticosteroid, reduce risk
stable vital signs of bleeding and prevent
anemia)
02 Early • Feto-maternal condition • Follow feto-maternal
preter will remain stable condition closely
m

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 Implementation
Name- Bethelhem Sultan Age- 33 MRN-IC 256988 Ward-D6
Date No. problem Implementations
02/10/2023 01 Risk for vaginal
• Advice on bed rest and activity
bleeding
restriction
• Give FeSo4 325g PO daily
• Check maternal vital sign and abdominal
tenderness
02 Early preterm
• Administer dexamethasone 6mg IM
• Check maternal vital signs and FHB

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 Evaluation

Name- Bethelhem Sultan Age- 33 MRN-IC 256988 Ward-D6

Date No Midwifery Diagnosis Evaluation

01 Risk for vaginal • Patient admitted and follow fetal

03/10/2023
bleeding kicks with kick chart
• there is no vaginal bleeding
• She has started FeSo4 325 mg PO
daily
02 Early preterm • She take her 2nd dose of
dexamethasone
• Fetomaternal condition is stable
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Progress Note (SOAP)
• Patient vital signs were assessed and remain stable.

• Excessive blood loss is excluded and expectant management of APH was started.

• Activities restricted, patient took bed rest and there is no bleeding

• She has started to take corticosteroid (dexamethasone 6mg, 4 dose over 48 hours.

• She has started to take FeSo4 325mg PO daily

• Feto-maternal condition is assessed and patient and fetus are in stable condition.

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 Progress Note (SOAP)…

• S: No bleeding compliant

• O: Bp-100/75mmhg PR- 85 bpm RR-20 T°-36.7

• A: placenta previa + early preterm pregnancy

• P: Expectant management.(follow vital sign, FHB, and kick chart advice bed rest )

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Thank you!
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