Management of bleeding in pregnancy Presenter: Aliti Qarikau

Aim: To prepare the students for effective management of bleeding in pregnancy in hospital setting.

At the end of the lecture session, the student will be able to: ` Define key terms relating to bleeding in pregnancy ` Identify the various types of abortions ` Plan important nursing interventions for a pregnant woman experiencing vaginal bleeding ` Discuss nursing management of a woman experiencing vaginal bleeding irrespective of gestational age. ` Discuss placenta previa and placental abruption and their management according to protocols

During the first and second trimester of pregnancy, the major cause of bleeding is abortion. This is the expulsion of the fetus prior to viability, which is considered 20 weeks gestation. Abortions are either spontaneous, occurring naturally, or induced, occurring as a result of artificial or mechanical interruption. Miscarriage is a lay term applied to spontaneous abortion

Other complications that can cause bleeding in the first half of pregnancy are ectopic pregnancy and trophoblastic disease In the second half of pregnancy, particularly in the third trimester, two major causes of bleeding are placenta previa and Abruptio placenta.

1.Ectopic Pregnancy (tubal pregnancy)

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Implantation occurs at any point along the tube Sites can be ampulla, the isthmus, the interstitial portion etc Abdominal, and cervical pregnancy are rare. Rarely remains asymptomatic beyond 8 weeks Delay may endanger life of woman Requires prompt hospital referral if suspected.

Typical signs

Atypical signs (delay diagnosis & cause life threatening deterioration) Shoulder tip pain Nausea, vomiting Abdominal distention Dizziness, fainting Apyrexia

Localized /abdominal pain amenorrhea Vaginal bleeding or spotting

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Ensure that appropriate physical needs are addressed and monitor for complications. Assess vital signs, bleeding, and pain. Provide information about an ectopic pregnancy to client and family to relieve anxiety. Actively listen to client, encourage client to express feelings Activity usually on bed rest until the situation is resolved Administer analgesic as ordered and evaluate effectiveness Describe self-care measures, which depend on the treatment. Address emotional and psychosocial needs.

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Prepare for surgery as ordered/ begin preoperative teachings Start an I.V as ordered Report signs of developing shock immediately Diet- keep on NPO before and after surgery

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Laproscopic salpingectomy/salpingostomy Laparotomy seldom used unless rupture has occurred

x Laparotomy, to ligate bleeding vessels and repair or remove the damaged fallopian tube.

*salpingostomy- a surgical incision into a fallopian tube *salpingectomy- excision of a fallopian tube

Photo of a right tubal ectopic pregnancy at laparoscopy surgery The swollen right tube containing the ectopic pregnancy is on the right at E The stump of the left tube is seen at L this woman had a previous tubal ligation

Close view of the same ectopic pregnancy

The spontaneous (natural )/miscarriage or induced (purposeful) termination of pregnancy

Threatened

Unexplained bleeding/cramping. Cervix is closed and membranes intact Increased bleeding and cramping. Cervix begins to dilate/ membranes may rupture Some products of conception are expelled. Most often the placenta is not expelled, bleeding is heavy, cramping is severe All products of conception Embry or fetus dies but is retained, cervix is closed. If fetus is not expelled within 6 weeks, DIC may occur

Inevitable

Incomplete

complete Missed

Habitual

Any of the above occurring in three consecutive pregnancies Most commonly cervix dilates in the 2nd trimester (incompetent cervix)

Ensure that appropriate physical needs are addressed and monitor for complications. Assess vital signs, bleeding, and pain. Provide client and family teaching to relieve anxiety.
Explain the condition and expected outcome. Describe self-care measures, which depend on the treatment. Address emotional and psychosocial needs.

Threatened abortion- client advised to limit activities for 24 to 48 hours, if bleeding stops client should avoid stress, fatigue, strenuous activities and sexual intercourse. ` Have one or two rest periods during the day until pregnancy seems to be progressing normally ` Frequently assess: -amount of bleeding -presence of clots - Any expelled tissues - Provide information and prepare client for treatment
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Inevitable abortion- client is hospitalized to remove products of conception from the uterus via D&C (dilatation and curettage) Blood transfusion will depend on amount of blood loss Missed abortion- when POC are not expelled in 4-6 weeks, client is hospitalized 12weeks gestation D&C performed 12wks> induction of labour using oxytocin may be used.

Dilatation and curettage procedure

POST-PROCEDURE CARE Give paracetamol 500 mg by mouth as needed. Encourage the woman to eat, drink and walk about as she wishes. Offer other health services, if possible e.g. FP Counseling uncomplicated cases discharged in 12 hours. Advise the woman to watch for symptoms and signs requiring immediate attention: - prolonged cramping (more than a few days); - prolonged bleeding (more than 2 weeks); - bleeding more than normal menstrual bleeding; - severe or increased pain; - fever, chills or malaise; - fainting.

Habitual abortion If caused by incompetent cervix: -treated surgically by cerclage (shirodkar procedure) (purse string fashion sutures placed at level of internal os -done at about 16 weeks gest. -may be removed at term for vaginal birth -may remain for future pregnancies, but C/S done - Advise mother to report ASAP to hospital if: she goes into labour or ruptures her membranes
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1- Placenta preavia

The goals of management are to prevent bleeding and cervical dilation. Patients who have a complete placenta previa at the time of delivery require cesarean delivery; patients with partial or marginal placenta previa may be able to deliver vaginally.

1. Assess on admission and every 8 hours: vaginal bleeding (amount, color, and presence of clots) color, odor, and amount of vaginal discharge and/or amniotic fluid presence of uterine contractions (frequency, duration, and quality) abdominal tenderness fetal heart rate (if > 24 weeks) NOTE: Assess fetal heart rate daily weeks. compliance with activity restrictions

No vaginal examination should be attempted at least until a placenta previa is excluded by ultrasound as this could initiate torrential bleeding from a placenta praevia.

2. Assess twice daily: temperature pulse respiration blood pressure 3. Assess patient/family response to hospitalization daily. 4. Assess weekly (on Wednesday) weight urine protein LABS: 5. Monitor results of lab tests: CBC with platelets coagulation studies, e.g. PT, PTT, fibrinogen Secure blood results- Group/hold/ severe blood loss may require blood transfusion.

8. Perform external maternal/fetal monitoring

9. Maintain patient on bed rest in left or right lateral positions. 10. . Provide comfort measures. 11. Assist with diversional activities. 12. Provide diet as tolerated; encourage 8-10 glasses of fluid daily 13. Provide measures to prevent constipation: PO fluid intake high fiber foods prune juice/warm liquids medications

2-Placental Abruption

Concealed hemorrhage the placenta separation centrally, and a large amount of blood is accumulated under the placenta. External hemorrhage the separation is along the placental margin, and blood flows under the membranes and through cervix.

Once placental abruption is diagnosed, a woman's care depends on the amount of bleeding, the gestational age, and condition of the fetus. Goal :to assess, control, and restore the amount of blood lost; to deliver a viable infant; and to prevent coagulation disorders

1.Continuously evaluate maternal and fetal physiologic status, particularly: Vital Signs Bleeding Electronic fetal and maternal monitoring tracings Signs of shock rapid pulse, cold and moist skin, decrease in blood pressure Decreasing urine output Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity.

2.Asses the need for immediate delivery. If the client is in active labor and bleeding cannot be stopped with bed rest, emergency cesarean delivery may be indicated.
If vaginal delivery is elected, provide emotional support during labor. Sometimes because of the infants prematurity, the mother may not receive analgesics during labor and may experience intense pain. Reassure the patient of her progress through labor and keep her informed of the fetus condition.

3.Provide appropriate management. On admission, place the woman on bed rest in a lateral position to prevent pressure on the vena cava.
Monitor the FHR externally and measure maternal vital signs every 5 to 15 minutes. Administer oxygen to the mother by mask. Prepare for cesarean section, which is the method of choice for the birth Prepare the patient and her family for cesarean birth. Thoroughly explain postpartum care so the patient and her family will know what to expect. Provide emotional support. In the case of fetal demise, encourage the patient to seek counseling as appropriate.

4.Provide client and family teaching. 5.Address emotional and psychosocial needs. Outcome for the mother and fetus depends on the extent of the separation, amount of fetal hypoxia and amount of bleeding

will depend on fetal distress, the cause of the APH, extent of bleeding and gestation: For pre-term delivery and where immediate delivery is not necessary- maternal steroids may be indicated in order to promote fetal lung development and reduce the risk of respiratory distress syndrome Severe bleeding or fetal distress may require urgent delivery of baby irrespective of gestational age. Less severe bleeding, fetus less than 36 weeks and not distressed: expectant treatment with mother in hospital. If no further severe bleeding mother is allowed to continue pregnancy until 38 weeks when delivery mode can be chosen depending on degree of placenta praevia.

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Clinical findings help suggest a cause : Light bleeding with mucus suggests bloody show of labor. Sudden, painless bleeding with bright red blood suggests placenta previa. Dark red clotted blood suggests Abruptio placentae or uterine rupture. A tense, contracted, tender uterus suggests abruptio placentae An atonic or abnormally shaped uterus with abdominal tenderness suggests uterine rupture

McKinney. E., Ashwill. J., James. S. (2005). Maternal child nursing (2nd ed). St. Louis. Elsevier saunders. Noval. J. & Bromm. B. (1999). Maternal and Child Health Nursing (9th ed). St. Louis. Mosby Elsevier. Bennett. V., Brown. L. (1996). Myles textbook for midwives (12th ed). Edinburgh. Churchill Livingstone.

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