Home | | Maternal and Child Health Nursing | Bleeding In Late Pregnancy

Chapter: Maternal and Child Health Nursing : Obstetric Emergencies

Bleeding In Late Pregnancy

This is bleeding from the genital tract after 24 week of gestation and before the birth of the baby. It may place the life of the mother and unborn child at risk.

Bleeding In Late Pregnancy:


Ante partum Hemorrhage (APH):


This is bleeding from the genital tract after 24 week of gestation and before the birth of the baby. It may place the life of the mother and unborn child at risk.


Any bleeding of this type is said to have been caused by placental separation. It may endanger the life of the mother and baby. The origin of this bleeding has two main sources.


1.           Placental causes


2.           Non-Placental causes


Placental causes

1.           Placental Praevia: Unavoidable haemorrhage


2.           Abruptio Placenta – Accidental haemorrhage


Non-Placental causes:


Incidental causes – Bleeding from other lesion of t he genital tract e.g. Cervical causes – cervical erosion, cervical l aceration, Polyps, cervical carcinoma.


Vaginal causes – laceration, vaginitis, ruptured va ricose veins of the vulva.


Management of Undiagnosed APH


Any bleeding from the genital tract during late pregnancy is dealt with as been due to placental separation until the actual diagnosis is made. Either in the District or Hospital the first Aid management is the same. Hospitalization in imperative either the bleeding is slight or severe because she stands the chance of further bleeding. In all cases:


1.           No vaginal examination is made


2.           Save all soiled linens & pads for Dr’s inspection.

3.           Enquire the cause of bleeding: Fall, coitus, continuous or intermittent.


4.           Abdominal examination is done gently – noting pain, tenderness, uterine contraction and consistency, mal-presentation, high head and fetal heart rate or movement.


5.           Record is made of the name, age, parity, week of gestation, blood loss, BIP, Pulse, urine passed, FH and drugs administered.


6.           Ultrasound scanning to locate the placental site.


7.           No enema is given.


Treatment by Midwife in the District


Put the woman to bed, on her side, reassure the woman, monitor vital signs, send for medical aid immediately, make arrangement to transfer to hospital, give pethidine 100mg or morphine 15mg or omnopon 20gm i.m., transfer in a comfortable transport and a midwife and relations must accompany the woman, to give detail of management.


Treatment in the Hospital

In addition to the First Aid treatment


1.           Blood is taken for – Group and cross matching, Hb estimation, Rhesus factor, clotting time, plasma fibrinogen level and serological test for syphilis (if not already done).


2.           Intravenous administration of blood, glucose, Ringers lactate solution, Oxytocin and fibrinogen


3.           Analgesics or sedation e.g. Pethidine 100mg i.m.


4.           Urinalysis Administer oxygen, to increase oxygen concentration to the fetus.


5.           Vital signs, fetal condition using soniaid, Pulse 5-15mins, FH 10-20min or continuous monitoring B/P 15mins.


6.           Fluid chart record.


7.           Consent for operation.


8.           Reassure the woman and her spouse.


Mild case

Aim is to prolong pregnancy


1.           Give the first Aid Treatment

2.           Shave the vulva.


3.           No enema on admission


4.           Speculum examination after 48hrs bleeding has stopped to rule out cervical causes and confirm diagnosis.

5.           A papanicolaou smear may be taken


6.           She is allowed out of bed after five days of no bleeding.


7.           Discharge after a week of no other obstetrical complications to report if bleeding occurs or in labour.


8.           Monitor fetal wellbeing


9.           Give high protein diet


10.      Maintain hygiene.


Severe case

Aim is to resuscitate and deliver the baby as soon as possible.


1.           Immediate resuscitation is imperative.


2.           No time must be wasted on obtaining blood.


3.           Admit in the special care unit, procedure for slight bleeding is carried out.


4.           Check vital signs, fibrinogen and clotting time.


5.           Sedation for apprehension. Analgics  for pain


6.           I.V. Infusion of Dextrose 5%, Ringers lactate while blood is being cross matched.


7.           Transfuse with fresh blood O-ve.


8.           Monitor Fetal Heart rate 10-15mins on cardiograph


9.           Measure abdominal girth for concealed bleeding.


10.      Further management depends on patient’s condition.


Placental Praevia


When placenta is partially or wholly implanted in the lower uterine segment; either anterior or posterior wall. The anterior location is less serious than the posterior. Bleeding from placenta praevia is unavoidable and inevitable due to the stretching of the lower uterine segment in later weeks of pregnancy which tears the anchoring chorionic villi. Bleeding may be slight or severe depending on how much encroachment in the lower segment. When placenta lies on the internal Os bleeding is severe during

effacement and dilatation of the cervix. Bleeding may also be precipitated by coitus. Hemorrhage of this type places mother and baby at high risk and constituted obstetric emergency.


Incidence: About 0.5% of all pregnancies more common in multigravidae.


Signs & Symptoms


1.           Painless vaginal bleeding which may be continuous or intermittent during rest or sleep.


2.           Occasionally is accompanied with uterine contractions.


3.           Increased bleeding


4.           Mal presentations may be associated – Breech Transv erse or oblique lie.


5.           High presentation – Non engagement of the presentin g part.


6.           Unstable lie


7.           Laterally – It pushes the head to one side. Posteri orlly – Overlapses the head, pushes the head anteriority giving the impression of cephalo pelvic disproportion.


Placenta Praevia is classified into degree according to placental location known as types.


Type 1 Placenta Praevia


The majority of the placenta is in the upper uterine segment. Only a tip of the placenta tissue touches the lower segment. Bleeding is usually mild. Vaginal delivery is possible, mother and fetus are in good condition.


Type 2 Placenta Praevia


The Placenta is partially located in the lower uterine segment near the internal OS – (Marginal Placenta Praevia). A bit of the placenta touches the internal OS, vaginal delivery is possible if it anteriorly, bleeding is moderate. The fetus is usually more affected than the mother, that means fetal hypoxia is common.


Type 3 Placenta  Praevia


The placenta covers the internal OS but not centrally but does not when the lower segment starts to stretch and cervix begins to efface and dilates up to 6cm. Vaginal delivery is not appropriate because the placenta precedes the fetus.


Type 4 Placenta Praevia


The placenta lies over the internal OS centrally. The OS is covered completely even at full dilalation of the cervix and torrential hemorrhage is very likely. Vaginal delivery should not be considered. Caesarean Section is essential to save the life of the mother and fetus.


Causes of placenta praevia;

1.           Grande multiparity; Previous C/S,


2.           Multiple Pregnancy, Previous Placenta Praevia


3.           Certain fetal abnormalities.


4.           Age – older mother are more at risk than younger on es.


5.           Abnormal Placenta – Bipartita and succenturiate pla centae



·              Commonly it manifest 34-38wk though sometimes earlier.


·              On general examination the woman may be clinically normal.


·              On Abdominal Examination: Difficulty in identifying the fetal part on palpation.


1.           Fundal height may be normal


2.           Uterus is normal in consistency, no tenderness or tension

3.           Fetal Heart rate may also be normal – depending on severity of bleeding.


4.           Presentation may be abnormal e.g. Breech.


5.           High head, oblique or Transverse lie or unstable



·              On vulva Inspection Slight or severe bleeding


·              Fetal movement – Excessive or slow or normal.


·              Rapid respiration, Pulse – Signs of shock in the mo ther



Objectives of Management;


·              To control hemorrhage


·              Save mother and infant’s life


Management depends on the amount of blood loss; may be active or conservative, condition of the mother or fetus, the location of the placenta, the stage of the pregnancy. In all cases Hospitalization is necessary.


Conservative Management

Mild bleeding, mother and fetus are well.


The woman will be on admission


·              Bed rest until bleeding stops.


·              Speculum examination to rule out incidental causes, after 24hrs of no bleeding.


·              Monitor placental function by using fetal kick chart.


·              Ultrasound scanning at intervals to locate placenta


·              Monitor fetal growth.


·              Vaginal delivery may be possible – 1 & 2 Anterior


·              Remain on admission till term.


·              Examination under anesthesia (EUA) – from 37weeks followed by Caesarean Section if a bulge is felt. If not the patient is induced.


Active Management

Caesarean section is necessary in cases of Severe bleeding, Types 3, 4 and 2 posterior even if fetus is dead, Bad obstetric history, elderly primip, Malpresentation – Breech. Active bleeding with induction.

Give emergency treatment


·              Resuscitate


·              Prepare for EUA and C/S


·              C/S if fetal heart is present in respective of gestational age. In a hospital with facilities for special care of preterm.


i.                  I.V. infusion of 5% Dextrose saline


ii.                  Blood transfusion – O- negative blood.


Hysterectomy if bleeding becomes uncontrollable to save the woman’s life.



1.           Post partum hemorrhage due to atony of the uterus


2.           Maternal shock from blood loss (hypovolaemia)


3.           Maternal death maternal mortality


4.           Fetal hypoxia due to placenta separation


5.           Fetal death 5-15% - usually fresh still birth


6.           Placenta acreta, (in up to 15%  cases)


7.           Anesthetic & surgical complications.


Abruptio Placenta


Bleeding is due to premature separation of a normally situated placenta occurring after 22wks of pregnancy. (Sometime refered as Abruption – tear asunder) Accidental ble eding, it is about 2% of all pregnancies. It may occur at any stage of pregnancy or during labour.




The aetiology of haemorrhage is not always clear (40%) but it is often associated with hypertensive disease in pregnancy, sudden reduction in uterine size polyhydramnious, preterm labour, rupture of membrane, acute emotional state previous history of placenta abruption. Strenuous physical exercises over distension of the uterus, road traffic accident, direct trauma to abdomen or version.


Multiparty, cigarette smoking, Poor nutritional status, Infection, after the delivery of 1st twin – Recurs in 10-25% of cases.


1. Revealed hemorrhage


In this case blood escapes from the vagina it is the commonest type. Bleeding may become severe from slight. It may be accompanied by abdominal pain and tenderness, delivery of the baby should be accomplished within a few hours (6 hrs) to avoid coagulation failure developing. Bleeding is proportional to the amount of visible vaginal blood loss.


2. Mixed or combined hemorrhage.


This hemorrhage is primarily concealed then later becomes revealed with little vaginal bleeding. A degree of shock is exhibited which is usually severe compared with the vaginal bleeding. It is usually associated with blood coagulation disorders.


3. Concealed hemorrhage


This is a serious condition with high maternal and fetal mortality. It account for 55% of maternal death. It is associated with severe bleeding but no vaginal bleeding occurs but large retro-placental clot forms behind the placenta – maternal surface.


Mother shows signs and symptoms of hypovolaemic shock, uterine enlargement and severe pain.


Signs and Symptoms:


History of pregnancy induced hypertension, headache, nausea and vomiting, epigastric pain, following road traffic accident or trauma.


Mild - general condition is fair, pain on one side of the uterus, there may or may be no vaginal bleeding, vital signs may be normal and B/P may be raised.




Shock – B/P may be below 90/60 or more, Severe abdo minal pain, anxiety, Uterus is tender to touch, No fetal heart beat is heard or not heard, Pulse is rapid and thready, signs of pre-eclampsia pitied oedema, Urine is scanty – protein is positive or ne gative, Fetal lie is normal. Amount of visible bleeding is not a guide to severity of the hemorrhage.





Admit, treat as undiagnosed APH, Set up I.V. infusion Destrose 5%, Set up sintocynon to induce labour, ARM is done if she is over 37 weeks, Observations of vital signs, blood loss, pallor oedema and record, Vaginal delivery is contemplated.




1.           Routine blood investigation; Plasma fibrinogen and clotting time test. The Fi-test Baxter hyland for hypofinogenaemia when facilities for laboratory test are not available.


2.           Pethidine 100mg, morphine 15mg to relief pain


3.           Blood transfusion of at least 2 litres of fresh blood within 1hr


rapidly .Fibrinogen 4-6g intravenously followed b y 1gm at ½ hourly until clotting mechanism is normal – fresh blood is the best source.


4.           Monitor Renal secretion – at least 30mls per hour. Record fluid intake – urinalysis for protein.


5.           When Clotting defect is controlled Caesarean Section is done.


6.           Record weight of retro placental clot.


7.           EUA is done in the theatre. Rupture the membranes to reduce intra uterine pressure and induce labour. Oxytocin is set up to start uterine contraction.


8.           Vigilant observation of the vital signs, contractions and Fetal heart beats.


9.           Usually labour is rapid.


10.      To prevent PPH deliver the placenta by controlled cord traction.


11.      Examine the placenta for retro placental clots .


12.      Prepare for resuscitation of an asphyxiated baby – pediatrician should be around.


Post Natal Care

1.           Observe carefully for renal function – Acute renal  failure.


2.           Restrict fluid intake to 1000mls daily.


3.           Low Protein diet, low sodium and potassium, Estimate blood area, Potassium for 3 days.

4.           Accurate fluid balanced chart.


5.           Report signs of Oliguria (less than 500mls daily.


6.           Treat anaemia – Transfusion or give haematinics.




1.           Disseminated intravascular coagulation (DIC) – mode rate & severe


2.           PPH. Due to convelaire uterus or DIC.


3.           Renal failure – hypovolaemia, poor kidney perfusion .


4.           Pituitary necrosis resulting from prolonged and severe hypotension – shock.


5.           Increased mortality for the infants – 50-80%


Disseminated Intravascular Coagulation (DIC)


This is a situation of appropriate of blood within the vessels. Consumption of clothing factors, fibrin and platelets occurs, resulting in failure of the blood to clot at bleeding site. DIC is secondary to some other disease process e.g. placenta abruption, intra uterine death amniotic fluid embolism, pre-clampsia and eclampsia management.


Midwife should watch out for this complication in conditions that predispose to it. She should be alert for signs of clotting abnormality.


Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail
Maternal and Child Health Nursing : Obstetric Emergencies : Bleeding In Late Pregnancy |

Privacy Policy, Terms and Conditions, DMCA Policy and Compliant

Copyright © 2018-2023 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.