Hemorrhage in late pregnancy

Presentation by

Prativa Dhakal

M.Sc. Nursing

Maternal health nursing

Batch 2011

Contents

• Antepartum Hemorrhage

• Causes of Antepartumhemorrhage

• Definition of Placenta Previa

• Incidence

• Etiology

• Pathological anatomy

• Types of placenta Previa

• Clinical Features

• Conformation of diagnosis

• Complications

• Prognosis

• Management

• Nursing Management

• Research Evidence

• References

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Antepartum hemorrhage

• It is defined as bleeding from or into the genital tract afterthe 28th week /22nd week of pregnancy but before thebirth of baby.

• Placenta previa

• Abruptio placenta

• Rupture of uterus

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Causes of Antepartum Hemorrhage

Presenting symptoms and

other symptoms and signs

typically present

Symptoms and signs sometimes present

Probable

diagnosis

Bleeding after 22nd weeks

gestation

Intermittent or constant

abdominal pain

Shock

Tense/tender uterus

Decreased/absent fetal movement

Fetal distress or absent fetal heart sounds

Abruptio placenta

Bleeding (intra abdominal

and/or vaginal)

Severe abdominal pain

(may decrease after

rupture)

Shock

Abdominal distention/free fluid

Abnormal uterine contour

tender abdomen

Easily palpable fetal parts

Absent fetal movements and fetal heart

sounds

Rapid maternal pulse

Ruptured uterus

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Causes of antepartum hemorrhage cont…

Presenting symptoms

and other symptoms and

signs typically present

Symptoms and signs sometimes present Probable

diagnosis

Bleeding after 22 weeks

gestation

Shock

Bleeding may be precipitated by

intercourse

Relaxed uterus

Fetal presentation not in pelvis/lower

Uterine pole feels empty

Normal fetal condition

Placental

previa

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Causes of antepartum hemorrhage

A.P.H.

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Placental bleeding (70%)

Placenta previa (35%) and Abruptio placenta (35%)

Unexplained (25%) Or Intermediate

Extra placental causes (5%)Local cervico-vaginal lesions:

Cervical polypCarcinoma cervixVaricose veinLocal trauma

Placenta previa

• When placenta is implanted partially or completely overthe lower uterine segment it is called placenta previa.

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Incidence of Placenta Previa

United States:

• 0.3-0.5% of all pregnancies.

• Risks increase 1.5- to 5-fold with a history of cesarean delivery.

• Meta analysis: Rate of placenta previa increases with a rate of1% after 1 cesarean delivery, 2.8% after 3 cesarean deliveries,and as high as 3.7% after 5 cesarean deliveries.

• Of all placenta previas, the frequency of complete placentaprevia ranges from 20-45%, partial placenta previa accountsfor approximately 30%, and marginal placenta previa accountsfor the remaining 25-50%.

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Etiology

• Dropping down theory

• Persistence of chorionic activity in the deciduacapsularis and its subsequent development intocapsular placenta

• Defective decidua

• Big surface area of the placenta

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Predisposing factors

• Multiparity

• Increased maternal age (> 35 years)

• History of previous caesarean section or any other scar inthe uterus (myomectomy or hysterotomy)

• Placental size and abnormality

• Smoking-causes placental hypertrophy or compensatecarbonmonoxide induced hypoxemia

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Pathological anatomy

Placenta:

• Placenta may be large and thin.

• Tongue shaped extension from the main placentalmass.

• Extensive areas of degeneration with infarction andcalcification may be evident.

• Morbidly adherent placenta due to poor deciduaformation in the lower segment.

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Pathological anatomy cont…

Umbilical cord:

• Cord may be attached to the margin or onto themembranes.

• Insertion of cord may be close to the internal os or thefetal vessels may run across the internal os invelamentous insertion giving rise to vasa previa

Lower uterine segment:

• Lower uterine segment and the cervix becomes softand more friable.

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Types/degree of placenta previa

• Low-lying placenta (Type I)

• Marginal placenta previa (Type II)

• Partial or incomplete placenta previa (Type III )

• Total or central placenta previa (Type IV)

• Vasa previa

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Cause of bleeding

• As the placental growth slows down in later months and thelower segment progressively dilates, inelastic placenta issheared off the wall of lower segment.

• This leads to opening up of utero-placental vessels andleads to an episode of bleeding.

• As it is a physiological phenomena which leads to theseparation of placenta, the bleeding is said to be inevitable.

• The separation of the placenta may be provoked by traumaincluding vaginal examination, coital act, external version orduring high rupture of membranes.

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Clinical features

Symptoms:

• Painless, apparently causeless and recurrenthemorrhage

• Hemorrhage from the implantation site in the loweruterine segment may continue after placental delivery.

Signs:

• General condition and anemia are proportionate to the visible blood loss.

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Clinical features cont…

Abdominal examination

– Size of uterus is proportionate to POG.

– Uterus feels relaxed, soft and elastic.

– Persistence of malpresentation like breech or transverse orunstable lie is more frequent. There is also frequency oftwin pregnancy.

– Head is free floating in contrast to POG.

– FHS is usually present, unless there is major separation ofthe placenta with the patient in exsanguinated condition.

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Clinical features cont…

Vulval inspection

• Only inspection has to be done to note the amount,character of blood.

• Blood is bright red in colour.

Vaginal examination

• Must not be done outside the operation theater in thehospital.

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Confirmation of diagnosis

Localization of placenta

• Sonography: Transabdominal ultrasound (TAS)

• Transvaginal ultrasound (TVS)

• Transperineal ultrasound

• Colour Doppler flow study

Clinical

• By internal examination (Double setup examination)

• Direct visualization during caesarean section

• Examination of the placenta following vaginal delivery

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Complications

During pregnancy:

• APH with varyingdegrees of shock

• Malpresentation

• Premature labour

During Labour:

• Early rupture of membrane

• Cord prolapse

• Slow dilatation of cervix

• Intrapartum hemorrhage

• Increased incidence of operative interference

• PPH

• Retained placenta

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Maternal

Complications cont…

Puerperium

• Sepsis is increased due to

– Increased operativeinterference

– Placental site near tovagina and anemia

– Subinvolution

– Embolism

Fetal

• Low birth weight

• Asphyxia

• Intrauterine death

• Birth injuries

• Congenital malformation

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Prognosis

Maternal

• Substantial reduction of maternal deaths in placentaprevia throughout globe.

• Ultimate cause of death are hemorrhage and shock.

• Morbidity is raised due to hemorrhage and operativeinterference

Fetal

• Perinatal mortality ranges from 10-25%.

• The causes of death are prematurity, asphyxia andcongenital malformation.

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Prognosis cont…

• Maternal mortality rate ranges from 2-3%.

• Maternal mortality is 0.03% in the United States.

• Neonatal mortality associated with placenta previa is as high as 1.2%

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Prevention

• Adequate antenatal care to improve the health status ofwomen and correction of anemia

• Antenatal diagnosis of low lying placenta at 20 weeks withroutine ultrasound needs repeat ultrasound examinationat 34 weeks to confirm diagnosis.

• Significance of warning hemorrhage should not beignored

• Family planning and limitation of births reduce theincidence.

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Management

At home:

• The patient is immediately put in bed.

• To assess the blood loss

• Inspection of clothing soaked with blood

• To note the pulse, blood pressure and degree of anemia

• Quick but gentle abdominal examination to mark height ofuterus, to auscultate the FHS and to note any tenderness onthe uterus.

• Vaginal examination must not be done.

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Treatment

1. Immediate attention: Quickly assess

• Amount of blood loss: General condition, pallor, pulse rate andblood pressure.

• Blood samples: Cross matching, group and hemoglobin.

• An infusion of normal saline is started and blood transfusion

• Gentle abdominal palpation: Uterine tenderness and auscultationto note the fetal heart rate.

• Inspection of vulva to note the presence of any active bleeding.

Confirmation of diagnosis: History, physical examination and

sonographic examination.

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Treatment cont…

2. Formulation of line of treatment

• Depends upon the duration of pregnancy, fetal and maternal status and extent of the hemorrhage.

a. Expectant treatment

• Vital prerequisites: Availability of blood for transfusion, facilities for caesarean section

• Selection of cases:

– Mother is in good health status (Hemoglobin ≥ 10 gm%, hematocrit > 30%),

– Duration of pregnancy is <37 weeks,

– Active vaginal bleeding is absent,

– Fetal well being is assured.

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Treatment cont…

Conduct of expectant treatment:

• Bed rest with bathroom facilities

• Investigations: Hemoglobin estimation, blood grouping and urine for protein

• Periodic inspection of the vulval pads and fetal surveillance with USG at interval of 2-3 weeks

• Supplementary hematinics if the patient is anemic.

• When patient is allowed out of bed a gentle speculum examination is made to exclude local cervical and vaginal lesions for bleeding.

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Treatment cont…

Termination of the expectant treatment: Expectant treatment iscarried upto 37 weeks of pregnancy.

• Premature termination may have to be done in conditions, such as

– Recurrence of brisk hemorrhage and which is continuing

– The fetus is dead

– The fetus is found congenitally malformed on investigation

• Steriod therapy: If the duration of pregnancy is less than 34 weeks.

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Treatment cont…

Active interference:

• Bleeding occurs at or after 37 weeks of pregnancy.

• Patient is in labour

• Patient is in exsanguinated state on admission

• Bleeding is continuing and of moderate degree

• Baby is dead of known to be congenitally deformed.

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Definitive treatment

1. Vaginal examination in operation theatre followed by low ruptureof membranes or Caesarean section.

2. Caesarean section without internal examination

1. Vaginal examination: Double setup examination should be done in

operation theatre keeping everything ready for caesarean section.

• Contraindications of vaginal examination are:

– Patient is in exsanguinated state

– Major degree of placenta previa

– Associated complicating factors: Malpresentation, elderlyprimigravida, history of previous caesarean section, contractedpelvis etc.

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Definitive treatment cont…

a. Low rupture of membrane: Done in lesser degree of placentaprevia (Type I and Type II anterior).

b. Caesarean section: The indication are:

– Severe degree of placenta

– Lesser degree of placenta previa where amniotomy fails to stopbleeding or fetal distress appears.

– Complicating factors associated with lesser degrees of placentaprevia where vaginal delivery is unsafe.

– Caesarean section without internal examination

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Nursing Assessment

• Determine the amount and type of bleeding; also, review anyhistory of bleeding throughout this pregnancy.

• Inquire as to the presence or absence of pain in associationwith the bleeding.

• Record maternal and fetal vital signs.

• Palpate for the presence of uterine contractions.

• Evaluate laboratory data on hemoglobin and hematocritstatus.

• Assess fetal status with continuous fetal monitoring.

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Nursing Diagnoses

• Ineffective Tissue Perfusion, Placental, related toexcessive bleeding causing fetal compromise

• Deficient Fluid Volume related to excessive bleeding

• Risk for Infection related to excessive blood loss and openvessels near cervix

• Anxiety related to excessive bleeding, procedures, andpossible maternal-fetal complications

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Definition

• It is one form of antepartum hemorrhage where bleedingoccurs due to premature separation of normally situatedplacenta.

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Pathology• Initiated by hemorrhage into the decidua basalis.

• The decidua then splits, leaving a thin layer adhered to themyometrium.

• Consequently, the process in its earliest stages consists of thedevelopment of a decidual hematoma that leads toseparation, compression, and ultimate destruction of theplacenta adjacent to it.

• Inflammation—infection—may be a contributor to causalpathways.

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Pathology cont…

• Early stage: May be no clinical symptoms, and separationis discovered upon examination of the freshly deliveredplacenta.

– There is a circumscribed depression on the placenta's maternalsurface.

– Usually measures a few centimeters in diameter and is coveredby dark, clotted blood.

• In some instances, a decidual spiral artery ruptures tocause a retroplacental hematoma, which as it expands,disrupts more vessels to separate more placenta.

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Pathology cont…

• The area of separation rapidly becomes more extensiveand reaches the margin of the placenta.

• Because the uterus is still distended by the products ofconception, it is unable to contract sufficiently tocompress the torn vessels that supply the placental site.

• The escaping blood may dissect the membranes from theuterine wall and eventually appear externally or may becompletely retained within the uterus.

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Varieties of abruptio placenta

• Concealed Hemorrhage

• Revealed

• Mixed

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Concealed Revealed Mixed

Risk factors

• Increased age, poor socioeconomic condition and parity

• Preeclampsia

• Chronic hypertension

• Preterm ruptured membranes

• Folic acid deficiency

• Short cord

• Multifetal gestation

• Low birth weight

• Hydramnios

• Cigarette smoking

• Thrombophilias

• Cocaine use

• Prior abruption

• Uterine leiomyoma

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Abruptio placenta cont…

Couvelaire uterus

• Widespread extravasation of blood into the uterinemusculature and beneath the uterine serosa.

• Such effusions of blood are also occasionally seenbeneath the tubal serosa, between the leaves of thebroad ligaments, in the substance of the ovaries, and freein the peritoneal cavity.

• Incidence is unknown, can be demonstrated only atlaparotomy.

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Abruptio placenta cont…

• These myometrial hemorrhages seldom interfere withmyometrial contraction to cause atony, and they are notan indication for hysterectomy.

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Abruptio placenta cont…

Changes in other organs

• Liver: fibrin knots in the hepatic sinusoids

• Kidney: Acute cortical necrosis or acute tubular necrosis

• Shock proteinuria: is due to renal anoxia which usuallydisappears two days after delivery.

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Abruptio placenta cont…

Blood coagulopathy:

• It is due to excess consumption of plasma fibrinogen dueto DIC and retroplacental bleeding.

• There is overt hypofibrinogenemia (<150mg/dl) andelevated levels of fibrin degradation products and Ddimer.

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Clinical classification

Depending upon the degree of placental abruption and its

clinical effects, the cases are graded as follows:

• Grade 0: Clinical feature may be absent.

• Grade 1: External bleeding is slight. Uterus is irritable;tenderness may or may not be present. Shock is absent.FHS is good.

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Clinical classification cont…

• Grade 2: External bleeding is mild to moderate. Uterinetenderness is always present. Shock is absent. Fetaldistress or even fetal death occurs.

• Grade 3: Bleeding is moderate to severe or may beconcealed. Uterine tenderness is marked. Shock ispronounced. Fetal death is the rule. Associatedcoagulation defect or anuria is present.

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Clinical features

Depends upon

• Degree of separation of placenta

• Speed at which separation occurs and

• Amount of blood concealed inside the uterine cavity.

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The clinical features of the revealed and mixed variety are given below:

Revealed Mixed

Symptoms: Abdominal discomfort or pain

followed by vaginal bleeding

Active intense pain abdomen

followed by slight vaginal bleeding.

The pain becomes continuous.

Character of

bleeding

Continuous dark colour (slight to

moderate)

Continuous dark colour (usually

slight) or blood stained serous

discharge.

General

condition

Proportionate to visible blood

loss, shock is usually absent

Shock is pronounced which is out

of proportion with the visible

blood loss.

Pallor Related with visible blood loss Pallor is usually severe and out of

proportion to visible blood loss.

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The clinical features of the revealed and mixed variety are given below:

Revealed Mixed

Features of

preeclampsia

May be absent Frequent association either

preexisting or appear.

Uterine height Proportionate to POG Disproportionately enlarged and

globular.

Uterine feel Normal feel with localized

tenderness, contractions frequent

and local amplitude

Uterus is tense, tender and rigid

Fetal parts Can be identified easily Difficult to make out

FHS Usually present Usually absent

Urine output Normal Usually diminished

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The clinical features of the revealed and mixed variety are given below:

Revealed Mixed

Laboratory

Blood Hb%

Low value proportionate

to blood loss

Markedly lower, out of proportion to

blood loss

Coagulation

profile

Usually unchanged Variable changes :

Clotting time increased (>6 min)

Fibrinogen level low (<150mg/dl)

Platelet count low

Increased PTT

Increased FDP and D dimer

Urine for protein May be absent Usually present

Confusion in

diagnosis

With placenta previa. With acute obstetrical gynecological

surgical complication

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Abruptio placenta cont…

Sheehan Syndrome

• Severe intrapartum or early postpartum hemorrhage rarely isfollowed by pituitary failure.

• Characterized by failure of lactation, amenorrhea, breast atrophy,loss of pubic and axillary hair, hypothyroidism, and adrenal corticalinsufficiency.

• Exact pathogenesis is not well understood but such endocrineabnormalities develop infrequently in women who hemorrhageseverely.

• Varying degrees of anterior pituitary necrosis and impairedsecretion of one or more trophic hormones (in some cases)

• Diagnosis: MRI

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Distinguishing features of placenta previa and abruptio placenta

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Placenta previa Abruptio placenta

Clinical features

Nature of bleeding

Character of

bleeding

General condition

and anemia

Features of pre-

eclampsia

Painless, apparently

causeless and recurrent

Bleeding is always revealed

Bright red

Proportionate to visible blood

loss

Not relevant

Painful, often attributed to

preeclampsia or trauma

and continuous

Revealed, concealed or

usually mixed

Dark coloured

Out of proportion to the

visible blood loss in concealed

or mixed variety

Present in one-third cases

Distinguishing features contd…

Placenta previa Abruptio placenta

Abd. examination

Height of uterus

Feel of uterus

Malpresentation

FHS

Proportionate height

Soft and relaxed

Malpresentation is common.

The head is high floating

Usually present

May be disproportionately

enlarged in concealed type

May be tense, tender and rigid

Head may be engaged

Usually absent specially in

concealed type

Placentography Placenta in lower segment Placenta in upper segment

Vaginal examination Placenta is felt on lower

segment

Placenta is not felt on lower

segment. Blood clots should not

be confused with placenta.

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Management

• Depending on gestational age and status of mother and fetus.

• With a fetus of viable age, and if vaginal delivery is notimminent, then emergency cesarean delivery is chosen.

• Resuscitation and acute management, with massive externalbleeding, intensive resuscitation with blood plus crystalloidand prompt delivery to control hemorrhage are lifesaving forthe mother and hopefully, for the fetus.

• If the diagnosis is uncertain and the fetus is alive but withoutevidence of compromise, then close observation can bepracticed in facilities capable of immediate intervention.

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Prevention

• Prevention, early diagnosis and effective therapy ofpreeclampsia and other hypertensive disorders of pregnancy.

• Needle puncture during amniocentesis should be underultrasound guidance.

• Avoidance of trauma specially forceful external cephalicversion under anesthesia

• To avoid sudden decompression of the uterus

• To avoid supine hypotension

• Routine administration of folic acid from early pregnancy.

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In the hospital

1. Revealed type: assessment is to be done as regards:

– Amount of blood loss

– Maturity of fetus

– Whether the patient is in labour or not

Preliminaries

• Blood for Hemoglobin and hematocrit estimation, coagulationprofile, ABO and Rh grouping and urine for detection ofprotein.

• RL solution drip started with wide bore cannula andarrangement for blood transfusion.

• Close monitoring of maternal and fetal condition.

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Management cont…

Patient is in labour

• Labour is accelerated by low rupture of membranes.

• Oxytocin drip is started to accelerate labour.

The patient is not in labour:

• Pregnancy 37 weeks or more: induction of labour is to bedone by low rupture of membrane with or withoutoxytocin.

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Management cont…

• Pregnancy less than 37 weeks:

– Bleeding moderate to severe and continuing—lowrupture of membrane, administration of oxytocin drip

– Bleeding slight or has stopped—the patient is put onconservative management, close observation of themother and careful monitoring is essential.

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Management cont…

2. Mixed or concealed type

Principles of management of concealed type are:

• To correct hypovolemia and to restore blood loss. Normalsaline or hemaccel infusion is started

• To bring about effective uterine contraction and terminationof the abruption process.

• To observe blood coagulation profiles at two hourly interval.

• Close monitoring of maternal and fetal condition ismaintained.

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Management cont…

• Vaginal delivery

• Caesarean section:

– Early: Unfavourable cervix where speedy vaginal delivery is notpossible and there is good prospect of fetal survival.

– Late: If inspite of amniotomy and oxytocin, the progress oflabour is delayed (6-8 hours) and instead, the general conditiongradually deteriorates with appearance of complicating factorslike oliguria or falling fibrinogen level or there is evidence offetal distress.

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Nursing Diagnoses

• Ineffective Tissue Perfusion: Placental related to excessivebleeding, hypotension, and decreased cardiac output,causing fetal compromise

• Deficient Fluid Volume related to excessive bleeding

• Fear related to excessive bleeding, procedures, andunknown outcome

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Rupture of uterus

• Dissolution in the continuity of uterine wall any timebeyond 28 weeks of pregnancy is called rupture of uterus.

• Injury to the wall of uterus in early months of pregnancyis called perforation either instrumental or perforatinghydatidiform mole.

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Classification of rupture uterus

Uterine rupture typically is classified as either:

• Complete

• Incomplete

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Causes1. Spontaneous

2. Scar rupture

3. Iatrogenic

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Causes cont…

Spontaneous

1. During pregnancy: previous dilatation and curettage operation orMRP, grand multiparity, congenital malformation of the uterus ofbicornuate variety, in couvelaire uterus.

• Usually complete, involves the upper segment and usually occurs inlater months of pregnancy.

2. During labour:

• Obstructive rupture: involves lower segment and usually extendsthrough one lateral side of the uterus to the upper segment.

• Non-obstructive rupture: Grand multiparae , rupture usually occursin early labour, usually involves fundal area and is complete.

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Causes cont…

Scar rupture

• Incidence of lower uterine segment scar rupture is about 1-2%,Classical: 5-10 times higher.

• During pregnancy: Classical or hysterotomy scar is likely to give wayduring later months of pregnancy. Lower segment scar rarelyruptures during pregnancy.

• During labour: The classical or hysterotomy scar is more vulnerable to rupture during labour.

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Causes cont…

Iatrogenic or traumatic:

During pregnancy:

– Injudicious administration of oxytocin

– Use of prostaglandins for induction of abortion or labour.

– Forcible external version specially under general anesthesia

– Fall or blow on the abdomen

During labour:

– Internal podalic version, Destructive operation

– Manual removal of placenta

– Application of forceps or breech extraction through incompletely dilated cervix

– Injudicious administration of oxytocin for augmentation of labour.

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Dehiscence and scar rupture

Dehiscence:

– Disruption of part of scar and not the entire length

– Fetal membranes remain intact and

– Bleeding is almost nil or minimal

Rupture includes:

– Disruption of the entire length of scar

– Rupture of membranes with varying amount of bleeding from the margins or from its extension.

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Diagnosis

During pregnancy

1. Scar rupture

Classical or hysterotomy

• Dull abdominal pain all over the area with slight vaginal bleeding.

• Tenderness on uterine palpation.

• FHS may be irregular or absent.

• Sooner or later the rupture becomes complete.

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Diagnosis cont…

2. Spontaneous rupture in uninjured uterus:

• Confined to the high parous women.

• Acute onset but sometimes insidious.

• Acute type: Patient has acute pain abdomen with faintingattacks and may collapse.

• Presence of features of shock, acute tenderness onabdominal examination, palpation of superficial fetalparts, if the rupture is complete and absence of FHS.

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Diagnosis cont…

3. Rupture following fall, blow or external version or use ofoxytocics:

• History of such accident followed by acute pain abdomenand slight vaginal bleeding.

• Rapid pulse and tender uterus, confirmation is done bylaparotomy.

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Diagnosis cont…

During labour

1. Scar rupture:

• Classical or hysterotomy scar rupture: Features are same asthose occur during pregnancy. The onset is usually acute.

• Lower segment scar rupture (silent rupture): The onset isinsidious, no classical feature of lower segment scar rupture,confirmation is by laparotomy.

2. Spontaneous or obstructive rupture: Has distinct premonitoryphase prior to rupture.

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Diagnosis of spontaneous obstructive rupture cont…

Premonitory phase:

• Multipara in labour with features of obstruction.

• Pain becomes severe in an attempt to overcome theobstruction and come to quick intervals.

• Gradually the pains become continuous and mainlyconfined to the suprapubic region.

• Patient is exhausted and dehydrated.

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Diagnosis of spontaneous obstructive rupture cont…

• Pulse rate and temperature rise.

• Distended tender lower segment.

• Bandl’s ring may be visible

• Fetal distress or FHS absent.

• Presenting part is found jammed in the pelvis and thevagina becomes dry and oedematous.

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Phase of rupture in spontaneous obstructive rupture

• Sense of something giving way at height of uterinecontraction.

• Constant pain is changed to dull aching pain with cessation ofuterine contraction.

• Features of exhaustion and shock.

• Abdominal examination: Superficial fetal parts, absence ofFHS, absence of uterine contour and two separate swellings,one contracted uterus and the other fetal ovoid.

• Vaginal examination: Recession of presenting part and varyingdegrees of bleeding.

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Diagnosis cont…

3. Spontaneous non-obstructive rupture:

• Rare and confined to high parous women.

• Height of uterine contraction is suddenly seized with anagonizing bursting pain followed by a relief with cessationof contractions.

• Presence of shock, evidences of internal hemorrhage,tenderness over the uterus and varying amount of vaginalbleeding.

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Diagnosis cont…

4. Rupture following manipulative or instrumental delivery

• Sudden deterioration of general condition of patient withvarying amount of vaginal bleeding following manipulativedelivery

• Exploration of uterus to feel the rent confirms the diagnosis.

• Shortening of cord immediately following a difficult vaginaldelivery

• Placenta being extruded out into abdominal cavity, throughthe rent in the uterus.

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Prevention

• At risk mothers likely to rupture should have mandatoryhospital delivery. There are

– Contracted pelvis

– Previous history of caesarean section, hysterotomy ormyomectomy

– Uncorrected transverse lie

– Multiparity with pendulous abdomen

– Grand multiparity

– Known case of hydrocephalous

• General anesthesia should not be used to give undue force inexternal version

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Prevention cont…

• Undue delay in the progress of labour in a multipara withprevious uneventful delivery should be viewed with concernand cause should be sought for.

• Judicious selection of cases with previous history of caesareansection for vaginal delivery.

• Judicious selection of cases and careful watch are mandatoryduring oxytocin infusion either for induction or acceleration oflabour.

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Prevention cont…

• Internal podalic version in singleton fetus should never bedone in obstructed labour.

• Attempted forceps delivery or breech extraction throughincompletely dilated cervix should be avoided.

• Destructive vaginal operations should be performed by skilledpersonnel.

• Manual removal in morbid adherent placenta should be doneby senior person.

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Treatment

Resuscitation and laparotomy

• Depending upon the state of clinical condition, eitherresuscitation is to be done followed by laparotomy or in acuteconditions, resuscitation and laparotomy are to be donesimultaneously.

• Any of the following procedures may be adopted followinglaparotomy

– Hysterectomy

– Repair

– Repair and sterilization

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Nursing Assessment

• Continuously evaluate maternal vital signs; especially note anincrease in the rate and depth of respirations, an increase inpulse, or a drop in BP indicating status change.

• Observe for signs and symptoms of impending rupture (ie, lackof cervical dilatation, tetanic uterine contractions,restlessness, anxiety, severe abdominal pain, fetal bradycardia,or late or variable decelerations of the FHR).

• Assess fetal status by continuous monitoring.

• Speak with family, and evaluate their understanding of thesituation.

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Nursing Diagnoses

• Deficient Fluid Volume related to active fluid loss from hemorrhage

• Ineffective Tissue Perfusion, Maternal Vital Organ and Fetal, related to hypovolemia

• Fear related to surgical outcome for fetus and mother

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References 1. Fraser DM, Cooper MA. Myles Textbook for Midwives. 15th edition.

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