Bleeding after the 20th week of pregnancy before the birth of the baby

ANTEPARTUM HAEMORRHAGE

Epidemiology

• Complicates 4% of pregnancies (Cunningham et al, 2001)

• Emergency/maternal death

Causes• Placenta Previa 0.5% pregnancies (Boyle, 2002)• Placental Abruption 1:150 births (Boyle, 2002)

Other causes of bleeding in pregnancy 50% are made up of the following (Cunningham et al, 2001)• Fetal Vessel rupture• Velamentous cord insertion• Vasa Previa• Uterine rupture• Clotting disorders, severe cervicitis, polyps, benign & malig. Neoplasms, vaginal lacerations, varices.• Haemorrhoids, congenital bleeding disorder• Abdominal/pelvic trauma• 2nd trimester miscarriage• Preterm labour & multiple pregnancy• *As always there are unknown causes

NORMAL PLACENTA

ABRUPTIO PLACENTA

PLACENTA ACCRETA

PLACENTA PREVIA

LOW LYING MARGINAL

TOTALPARTIAL

TYPES OF PLACENTA PREVIA

A PLACENTA WHICH HAS IMPLANTED OVER THE OS

Placenta

Cervix

Uterus

Causes of Placenta Previa• Previous caesarean section

In the U.S. alone the C/S in 2009 was 32.9%. It is predicted that if it continues to rise at the current rate then it will be 56.2%.

This will cause a rise in the rate of possible complications:• an additional 6236 placenta previas• An additional 4504 placenta accretas• An additional 130 maternal deaths annually (Solheim et

al, 2011)

SYMPTOMS of Placenta Previa• Painless vaginal bleeding• Bleeding with contractions• Bleeding post coitus• Breech presentation or unstable lie• Fetal distress• Soft Uterus • In excessive blood loss symptoms of shock

(Boyle, 2002)

Midwifery Actions-Identified at 19wk scan • 5-6% of all pregnancies (Boyle, 2002)

Due to the formation of the lower segment of the uterus:• Order rescan at – 32wks (Boyle, 2002)

Order rescan at – 36wks (Pairman et al, 2006)

Initial advice to woman• Reassurance that 90% of women rescanned will be

normal• Contact maternity unit should there be any bleeding

during pregnancy• Anecdotal evidence that sex should just be avoided in

the last trimester when placenta previa has been diagnosed

Midwifery Actions-Woman presents with painless bleeding

• Calm attitude• Inform Obstetric staff• T, P, BP• CTG• Palpation• NO Vaginal Examination until location of placenta has been confirmed by ultrasound• Take history of amount of blood loss, explore possible causes.• Establish venous access• Take blood for Group & Hold, Full blood count, clotting & Kleihauer if rh neg• IV fluids as prescribed• Usually occurs after 34wks + 50% of cases birth before 35wks (Boyle, 2002)

Induction of labour • Is possible in:

Management• In the absence of excessive bleeding expectant management until 37 wks gestation• Ensure blood available• Monitor for anaemia• Anti D if Rh Neg• Steroids for fetal lung development

Midwifery Actions• Consider anxieties of woman in hospital with other children to care for• Possible visit to the neonatal unit• Include in discussions surrounding expectant birth date of the baby

Possible complications• Uncontrollable bleeding• Anaemia• Infection• Renal failure due to severe shock• Hysterectomy• Sheehan’s syndrome as a result of severe shock

(Damage to the pituitary gland – hypopituitarism)• Fetal hypoxia• Premature birth• Fetal death• Psychological effects• Placenta accreta

Placental Abruption

Causes• Trauma

• -Polyhydramnios with rapid decompression on membrane rupture

• -cocaine use

• -tobacco use

• -PPROM

• -short umbilical cord

Signs and Symptoms• Red or brown loss PV• Signs of shock• Abdominal Pain• Tense, firm uterus• Tender to palpate• Reduced or excessive fetal movements• Fetal distress or no fetal heart

Bleeding CharacteristicsSEVERITY OF BLEEDING:

Clinical Vital Signs Laboratory

MILD Spotting Normal Normal

MODERATE

1 to many pads/hr Normotensive +/- tachycardia

+/- low Haemocrit, normal Coags.

SEVERE Active Haemorrhage Tachycardia/hypotensive

DIC

Full History involvesRecord of bleeding characteristics

Assessment of associated factors• Pain – Pelvic, abdominal, back pain• Contractions• Vaginal discharge• Rupture of membranes

Assessment of causal factors• Recent examination• Abdominal or pelvic trauma• Intercourse

Assessment of• Fetal movements

Reading of• Previous ultrasounds

Physical ExaminationRecord of vital signs • can be normal despite significant blood loss

Abdominal Examination• Pain on palpation• Contractions on palpation• Hypertonic Uterus

Pregnancy Assessment• CTG• Scan

Emotional support• Woman & partner will be very anxious

Management• Stabilize the woman• T, P, BP• Full history• IV access• Blood for group & hold, Full blood count, Coag & Kleihauer if rh neg

Caesarean Section Expectant Management

• If unstoppable labour• If fetal distress• If life threatening

Haemorrhage

• If preterm • No profuse haemorrhage• Not life threatening• No fetal distress

Midwifery Input• Keep woman and family informed at all times• Effective communication in the multidisciplinary team• Monitoring of the woman & baby’s condition

References• Boyle, M., (2002). Chapter 5, Antepartum haemorrhage, Emergencies Around Childbirth. Oxon U.K. Radcliffe Medical Press

• Cunningham, F.G., Grant, N., Leveno,K.J., Gilstrap iii, L.C., Hauth, J.C. & Wenstrom, K.D. (2001). Williams Obstetrics. (21st ed.). New York:Mcgraw Hill• Pairman, S., Pincombe, J., Thorogood, C., Tracy, S., (2006) Midwifery Preparation for Practice (1st ed.). Elsevier, Australia

• Solheim, K. N., Esakoff, T. F., Little, S. E., Cheng, Y. W., Sparks, T. N., & Caughey, A. B. (2011). The effect of cesarean delivery rates on the future incidence of placenta previa, placenta accreta, and maternal mortality. J Matern Fetal Neonatal Med.