CON, Adesh University
• The placenta is implanted partially or
completely over the lower uterine segment
(over or adjacent to the internal os ) it is called
• In Placenta Praevia the placenta is implanted
in the lower uterine segment such that is
completely or partially cover the cervix or is
close enough to the cervix to cause bleeding
when the cervix dilated or the lower uterine
(Hull and Resnik, 2009)
• In 80% cases it is found in multiparous
• The incidence is increased beyond the age of
35, with high birth order pregnancies and in
• The incidences approximately 4-5 per
• Increased maternal age
• Higher altitude
• History of previous scar in the uterus.
There are four types of placenta praevia
depending upon the degree of extension of
placenta to the lower segment.
• Type 1 (Low lying)
• Type 2 (Marginal)
• Type 3 ( Incomplete or partial central )
• Type 4 ( Central or total)
Type 1 (Low lying) :
The major part of placenta is attached to
the upper segment and only the lower
margin encroaches onto the lower
segment but not to the os.
Type 2 (Marginal) :
The placenta reaches
the margin of internal
os but does not cover
Type 3 ( Incomplete or partial central ) :
The placenta covers the internal os partially
( cover the internal os when closed but does
not entirely do so when fully dilated)
Type 4 ( Central or total) :
The placenta completely covers the internal
os even after it is fully dilated.
• sudden in onset, painless
• revealed bleeding (fresh blood)
• Bright red or dark colored
• Unrelated to activity
• General condition and anaemia are
proportionate to the visible blood loss
Abdominal examination: the size of the uterus
• Uterus feels relaxed and soft.
• The head is floating in contrast to the period of
• Fetal heart sound is usually present.
• Vaginal inspection:
Placenta is felt on the lower segment.
Complications of Placenta Praevia:
• During Pregnancy
• During labour
2. Fetal complications
• Antepartum haemorrhage
• Premature labour
• Early rupture of membranes
• Cord prolapse
• Slow dilatation of the cervix
• Intrapartum haemorrhage
To minimize the risks , the following guidelines are
• Adequate antenatal care
• Significance of warning haemorrhage
At Home –
• Put the patient on bed .
• Abdominal examination
• Vaginal examination must not be done.
Transfer To Hospital
• Admission To Hospital
• To ensure an adequate blood supply to a
women and fetus place the women
immediately on bed rest in a side lying
• A large bore IV cannula is cited and
infusion of normal saline
• Gentle abdominal palpation
Scheme Of Management
All APH patients are to be admitted
General and abdominal examination
Clinical assessment of blood loss
Resuscitation if necessary
Localisation of placenta
• Expectant management Active interference
The expectant treatment is carried upto 37 weeks.
Aim: The aim is to continue pregnancy for fetal
maturity without compromising the maternal
• No active bleeding
• Patient stable haemo-dynamically
• FHS- good
• CTG- reactive fetus
• Bed rest
• Periodic inspection of vulvul pads
• Supplementary haematinics if patient is
• Use of tocolytics.
• Rh immunoglobulins to all Rh negative
• Bleeding occurs at or after 37 weeks of
• Patient is in labour
• FHS- absent
• Gross fetal malformation
• Dead fetus
Vaginal delivery Caesarean delivery
Placental edge is within 2 cm from the
internal os: in this case no internal
examination is performed and caesarean
section is considered as the best choice.
Placental edge is 2-3 cm away from the internal cervical os:
Internal examination in OT
ARM with or without oxytocin
Satisfactory progress of labour bleeding continues
& no labour initiation
vaginal delivery caesarean delivery
Decreased cardiac output related to blood loss
as manifested by increase in heart rate.
• Monitor Vital Signs
• Provide adequate rest &
• reposition client
• Encourage relaxation techniques
• Elevate Hb of the client
Ineffective tissue perfusion related to
decrease in Hb in blood as manifested
• Monitor Vital Signs.
• Encourage quiet & restful environment.
• Encourage use of relaxation techniques.
• Provide supplemental oxygen to the client
as prescribed by the physician.
Deficient fluid volume related to Blood
Loss as manifested by vital signs
• Monitor Vital Signs
• Monitor FHR.
• Initiate IV fluids as ordered by the
• Place the patient in left lateral position.
Fear related to outcome of pregnancy as
manifested by facial expressions of the
• Assess fetal heart sounds.
• Allow the mother to share her feelings.
• Answer the mother’s questions honestly.
• Include the mother in the planning of the
care plan for both the mother and the baby.
• Perry, Hockenberry, Lowdermilk et al. Maternal Child
Nursing Care. Elsevier. 5th
• Cunningham, Leveno, Bloom et al. Williams Obstetrics. Mc
graw Hill Education. 24th
• D.C.Dutta’s . Textbook of Obstetrics. New central Book
Agency(P) Ltd. 7th
• Renu mishra.IAN DONALD’S Practical Obstetric
problems. Wolters kluwer. 7th
edition ; 315-320
• Adele pillitteri. Maternal and child health nursing. Walters