2. الرحيم الرمحن هللا بسم
َل َكَناَحْبُس ْاوُلاَقآَنَل َمْلِعّلِإ
ُميِلَعْال َتْنَأ َكّنِإ آَنَتْمَّلع اَم
ُميِكَحْال
العظيم اهلل صدق
سورةالبقرةأية32
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 2
3. 3
• Chairman of obstetrics &woman health
nursing department
• Pre. Vice of dean for students &Education
Affair
Faculty of nursing
Benha University
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan
4.
5. Learning objectives:-
Describe causes of bleeding in early pregnancy.
Apply nursing care plan for woman with
bleeding in late pregnancy.
Enumerate types of associated medical
problems during pregnancy.
Describe the nurses responsibilities in relation
to various types of associated medical problems
during pregnancy.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 5
8. 2- Ante partum Hemorrhage:
Bleeding in late pregnancy
(After 20 weeks Gestation)
Definition
Antepartum hemorrhage is defined as
bleeding occurring from the genital tract
after the 24th week of pregnancy, and
before the birth of the infant.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 8
9. Classification
◘ Placenta previa: –
Inevitable hemorrhage occurs from separation of an
abnormally situated placenta.The placenta lies partly
or wholly in the lower uterine segment.
◘ Abruptio placenta: –
bleeding occurs from the premature separation of a
normally situated placenta.
◘ Extraplacental bleeding: –
is vaginal bleeding from some other part of the
birth canal e.g. cervical polyp, varicose veins of the
vulva, etc.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 9
10. Complications of Antepartum
Hemorrhage
◘ Maternal Risks:
Hemorrhagic shock.
Acute renal failure.
Disseminated intravascular
coagulation (DIC)
Increased risk for
postpartum hemorrhage.
Severe anemia.
◘ Fetal Risks:
Prematurity and
birth asphyxia.
Intrauterine fetal
death.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 10
12. Abruptio Placenta
(Accidental Hemorrhage)
Definition
It is bleeding during the last
three months of pregnancy, the
first or second stage of labor,
due to premature separation
of a normally situated placenta.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 12
13.
14. Causes &Types
◘ The most important
cause is hypertension
due to toxemia of
pregnancy.
◘ The second most
common cause is trauma.
◘ Some deficiencies in
vitamins C and K.
◘ Torsion of the
pregnant uterus.
◘ Traction on a short
umbilical cord.
◘ Sudden reduction of
the size of the uterus.
◘Revealed: almost all
the blood expelled
through the cervix.
◘Concealed: almost
all the blood is retained
inside the uterus.
◘Combined: some
blood is retained inside
the uterus and some is
expelled through the
cervix.
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15. Causes of Premature Separation
The primary cause is unknown.
Incidence increase with:
1. High parity.
2. Advanced maternal age.
3. Short umbilical cord.
4. Chronic hypertensive disease.
5. Pregnancy-induced hypertension.
6. Direct trauma.
7. Vasoconstriction from cocaine or cigarette use.
8. Thrombophilitic conditions that lead to thrombosis.
9. Follow a rapid decrease in uterine volume, such as occurs with
sudden release of amniotic fluid.
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16. CriteriaGrade
No symptoms of separation were apparent from maternal or
fetal signs; the diagnosis that a slight separation did occur is
made after birth, when the placenta is examined and a
segment of the placenta shows a recent adherent clot on the
maternal surface.
0
Minimal separation, but enough to cause vaginal bleeding
and changes in the maternal vital signs; no fetal distress or
hemorrhagic shock occurs, however.
1
Moderate separation; there is evidence of fetal distress; the
uterus is tense and painful on palpation.
2
Extreme separation; without immediate interventions,
maternal shock and fetal death will result.
3
Degrees of Separation
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17. Premature separation of the placenta
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18. Signs and Symptoms
◘ Revealed accidental
hemorrhage:
Vaginal bleeding.
Signs of blood loss are
present (pale, irritable,
air hunger, increased
pulse). Blood pressure is
usually not affected.
If there is shock and
painful contractions are
present.
Laxed uterus between
contractions.
Fetal parts are easily felt.
Fetal head may be fixed
or engaged in the pelvis.
FHS are heard if less
than half of the placenta
is separated.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 18
20. Concealed accidental hemorrhage:
Sudden, severe
abdominal pain followed
by fainting and vomiting.
Shock is always present.
Patient becomes pale
and irritable.
Systolic pressure
decreases while diastolic
remain increased.
The abdomen is very
tender and rigid.The
uterus is very hard and
larger than expected.
If severe shock, no
uterine contractions are
felt.
Some scanty dark
bleeding.
Edema of lower limbs.
Heavy albuminuria.
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21.
22. Combined accidental
hemorrhage:
The blood is partially revealed
and partly concealed.
Signs and symptoms depend on
the amount of blood loss and
whether it is more revealed or
concealed.
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23. Complications
◘ Hemorrhage.
◘ Acute renal failure.
◘ Postpartum
hemorrhage.
◘ Pituitary necrosis.
Prognosis
◘ A mild case has a
good prognosis, while
a severe case has
serious
consequences for the
mother and fetus.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 23
24. Treatment:-
Treatment of concealed A.H
1- Correction of shock
2-T.O.P : divided into:
a- Dead fetus :
ARM+ syntocinon C.S if have
contraindicated of normalV.D
B- living fetus :C.S
Treatment of complication: DIC and PPH
25. Prevention:
Avoiding general pregnancy risk factors, such
as cocaine, alcohol, or smoking
Treating chronic high blood pressure or
other conditions, such as diabetes
Good antenatal care will help to identify
pregnancy risk factors and possibly allow
for early detection of placenta problems.
26. Nursing care
1- Assessment:
Nursing assessments include all
components described for clients with
spontaneous abortions and placenta
previa.Additional assessments are
necessary to identify an increasing
fundal height, which indicates
concealed bleeding.
27. 2- Nursing diagnosis:
Nursing diagnosis related to the care of the client with
abruption placenta focus on alterations in homodynamic
status, knowledge deficits, fears and anxiety of the woman
and fetal status. Many of the potential nursing diagnosis are
the same as for placenta previa. Additional potential nursing
diagnosis includes the following:
* Pain related to bleeding between the uterine wall and the
placenta secondary to premature separation of the
placenta.
* Grieving related to actual or threatened loss of infant.
* Power lessens related to maternal condition and
hospitalization.
28. 3- Planning:
* The woman will identify and use
available support systems.
* The woman will express relief of
pain.
* She will not develop complications.
* She will give birth to healthy infant
29. 4- Implementation:
Careful assessments are mandatory. Information
is given to the client and her family about
abruption placenta including cause, treatment and
expected out come. Vital signs are assessed
frequently to observe for signs of declining
homodynamic status. Fetal status is continuously
monitored if the fetus has survived the initial
result. Preparations are made for the birth, but it
should be kept in mind that an emergency
cesarean birth is always a possibility.
30. 5- Evaluation:
The nurse can be reasonably assured
that care was effective to the extent
that the goals for care have been met.
That is, the woman identifies and uses
available support systems, expresses
relief of pain does not develop
complications, and gives birth to
a healthy infant who has not
experienced fetal compromise.
