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(a.k.a Accidental Hemorrhage or Ablatio Placenta) -
Premature separation of the implanted placenta
before the birth of the fetus
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O. Incidence: second leading
cause of bleeding in the 3rd
Trimester; occurs in O:300*
pregnancies.

O 
Types
a. Type I: concealed, covert, or central type; the classic type
½ Placenta separates at the center causing blood to accumulate
behind the placenta.
½ External bleeding not evident.
½ Signs of shock not proportional to the signs of external
bleeding.
Types
b. Type II: Marginal, overt, or external bleeding type.
½ Placenta separates at the margins.
½ Bleeding is external, it is usually proportional to the
amount of internal bleeding.
½ May be incomplete or complete depending on the degree of
detachment.
½ietermine the amount and type of bleeding and the presence or absence of pain.
½Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and

FHR variability or alterations.

½Palpate the abdomen


c˜ote the presence of contractions and relaxations between contractions (if

contractions are present).

cIf contractions are not present assess the abdomen for firmness.

½ Measure and record fundal height to evaluate the presence of concealed bleeding.

½ Prepare for possible delivery.


i  
    

a. Painful vaginal bleeding in the 3rd trimester.


b. Rigid, board-like, and painful abdomen.
c. Enlarged uterus due to concealed bleeding; signs of shock
not proportional to the degree of external bleeding (classic
type).
d. If in labor: tetanic contractions with the absence of
alternating contraction and relaxation of the uterus.

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A. Clinical iiagnosis ² Signs and symptoms
B. Ultrasound ² detects the retro placental defects.
C. Clotting- reveal iIC, clotting defects.
½ The thrombosplastia from retroplacental clots enter maternal
circulation and consumes maternal free fibrinogen
resulting in:
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arterial vessels in the
( basal layer of
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*+! decidua*
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Bleeding
Splits decidua, leaving a thin
layer attached to the placenta
-ŒŒ.) -/,)
Obliteration of the
Hematoma formation intervillous space*

Compression of the basal


layer* iestruction of the placental tissues

Ô  
Concealed Visible   

Bleeding Bleeding    

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 Blood reaches the

edge of the placenta
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Port wine
discoloration
of discharges
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Ineffective tissue perfusion (placental) related to excessive
bleeding, hypotension, and decreased cardiac output, causing
fetal compromise

½Evaluate amount of bleeding by weighing all pads. Monitor CBC results


and VS.
½Position in the left lateral position, with the head elevated to enhance
placental perfusion.
½Administer oxygen through a snug face mask at 8-O  per minute.
½Evaluate fetal status with continuous external fetal monitoring.
½Prepare for possible CS delivery if maternal or fetal compromise is evident.
Acute Pain related to increase
uterine activity

½Instruct patient on the cause of pain to decrease anxiety .

½Instruct and encourage the use of relaxation technique to augment

analgesics.

½Administer pain medications as needed and as prescribed.


Fluid volume deficit related to
excessive bleeding

½Establish and maintain a large-bore IV line, as prescribed and draw blood


for type and screen for blood replacement.
½Evaluate coagulation studies.
½Monitor maternal VS and contractions.
½Monitor vaginal bleeding and evaluate fundal height to detect an increase
in bleeding.
Risk for infection related to excessive blood
loss

½Use aseptic technique when providing care.

½Evaluate temperature q4h unless elevated; then evaluate q h.

½Evaluate WBC and differential count.

½Teach perineal care and hand washing techniques.

½Assess odor of all vaginal bleeding or lochia.


Fear related excessive bleeding procedures
and unknown outcome

½Inform the woman and her family about the status of herself and the fetus.

½Explain all procedures in advance when possible or as they are performed.

½Answer questions in a calm manner, using simple terms

½Encourage the presence of a support person .


½Maternal shock
½Anaphylactoid syndrome of pregnancy*
½Postpartum hemorrhage or Hemorrhagic shock
½Acute respiratory distress syndrome
½Sheehan·s syndrome*
½Renal tubular necrosis*
½Rapid labor and delivery
½Maternal and fetal death
½Prematurity, fetal distress/demise (IUSi)
½COUVEAIRE UTERUS: the bleeding behind the placenta
may cause some of the blood to enter the uterine musculature
causing the uterine muscles not to contract well once the
placenta is delivered.
½iisseminated Intravascular Coagulation (iIC)
½Hypofibrogenemia
½Infection
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a. Maintain bed rest, R
b. Careful monitoring:
½ Maternal v/s
½ FHT
½ abor onset/progress
½ I & O, oliguria/anuria
½ Uterine pain
½ Bleeding (not proportional to degree of shock)
c. Administer IV fluid, plasma, or blood as ordered.
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