Bleeding During Pregnancy

And Nursing Care Plan

Posted on September 20, 2011 by Nursing help

Definition
Vaginal bleeding during pregnancy can be scary. Its common, however, and it isnt always a sign
of trouble. Most women who experience vaginal bleeding during pregnancy particularly during
the first trimester (weeks one through 12) go on to deliver healthy babies.
Still, its important to take vaginal bleeding during pregnancy seriously. Sometimes vaginal
bleeding during pregnancy indicates an impending miscarriage or a problem that needs prompt
treatment. By understanding the most common causes of vaginal bleeding during pregnancy,
youll know what to look for and when to contact your health care provider.

Causes
Vaginal bleeding during pregnancy has many causes. Some are serious, and some arent.
First trimester
Possible causes of vaginal bleeding during the first trimester include:
Cervical cancer
Cervical changes, including more blood flow to the cervix and softening of the cervix, which
may result in harmless vaginal bleeding after sex or a pelvic exam

 Ectopic pregnancy
Implantation bleeding, which occurs about 10 to 14 days after fertilization when the fertilized
egg attaches to the lining of the uterus
Miscarriage
Some cervical infections
Second or third trimester
Possible causes of vaginal bleeding during the second or third trimester include:
Miscarriage

Placenta previa
Placental abruption

Premature opening of the cervix (cervical insufficiency), which can lead to preterm

birth
Problems with the cervix, such as a cervical infection, inflamed cervix or growths on
the cervix

Normal vaginal bleeding during pregnancy

In addition to potentially worrisome causes of bleeding, some vaginal bleeding near the end of
pregnancy is normal. As the cervix begins to thin out and relax in preparation for labor. . When
this happens, you may notice a thick or stringy discharge that may be tinged with blood. This
bloody show is a normal sign of impending labor that may occur up to a week or two before
delivery.

Bleeding During Pregnancy Symptoms

It is helpful for your health care provider to know the amount and the quality of the bleeding that
you have. Keep track of the number of pads used and passage of clots and tissue. If you pass a
clump of tissue and are going to see your doctor, bring the tissue with you for examination.
.Other symptoms you may experience are increased fatigue, excessive thirst, dizziness, or
fainting. Any of these may be signs of significant blood loss. You may notice a fast pulse rate that
increases when you stand up from lying down or sitting. Dizziness may increase when you stand
up as well.

Bleeding During Pregnancy Overview

Because bleeding during all phases of pregnancy may be dangerous, you should call your health
care provider if you have any signs of vaginal bleeding during your pregnancy.
Vaginal bleeding is any blood coming from your vagina (the canal leading from the uterus to the
external genitals). This usually refers to abnormal bleeding not associated with a regular
menstrual period.
Bleeding from the vagina after the 28th week of pregnancy is a true emergency. The bleeding can
range from very mild to extremely brisk and may or may not be accompanied by abdominal pain.

Bleeding in Early Pregnancy

Many women have vaginal spotting or bleeding in the first 12 weeks of pregnancy. Bleeding of
the cervix may occur during sex. An infection of the cervix can also cause bleeding.
If you are bleeding in early pregnancy, your doctor may do a pelvic exam. You will be asked how
much blood you have passed and how often bleeding has occurred. Your doctor also will ask
whether you have had any pain, and if so, its location and severity.
A blood test may be done to measure human chorionic gonadotropin (hCG). This substance is
made by your body during pregnancy. You may have more than one test because hCG levels
increase throughout pregnancy. Your blood type also will be checked to see if you need treatment
for Rh sensitization. Ultrasound may be used to find the cause of the bleeding. Sometimes the
cause is not found.
If you have bleeding while you are pregnant, you may need special care. You have a higher
chance of going into labor too early (preterm labor), having an infant who is born too small, or
having a miscarriage.

Bleeding in Late Pregnancy

The causes of bleeding in the second half of pregnancy differ from those in the first half. Common
problems that cause light bleeding include an inflamed cervix or growths on the cervix. These
may be treated with medication.
Heavy bleeding usually involves a problem with the placenta. The two most common causes at
this time are placental abruption and placenta previa. Preterm labor also can cause such
bleeding.
Late bleeding may pose a threat to the health of the woman or the fetus. It may require
treatment in a hospital or delivery.

Placental Abruption

The placenta is attached to the uterine wall. separation of the placenta from the inner wall of the
uterus before the baby is delivered. It may detach from the wall before or during labor. This may
cause vaginal bleeding. It often causes pain, even if bleeding is light or not seen.It may be
classified as partial,complete,or marginal.

Types of placental abruption. (A) Revealed placental abruption, where blood tracks between the
membranes, and escapes through the vagina and cervix. (B) Concealed placental abruption
where blood collects behind the placenta, with no evidence of vaginal bleeding

When the placenta becomes detached, the fetus may get less oxygen and nutrients . This can
pose a danger. The larger the area that detaches, the greater the amount of bleeding.

Placental abruption occurs about once in every 120 births. It is also called abruptio
placenta.

Causes placental abruption?

Other than direct trauma to the uterus such as in a motor vehicle accident, the cause of placental
abruption is unknown. It is, however, associated with certain conditions, including the following:

previous pregnancy with placental abruption

hypertension (high blood pressure)

cigarette smoking
multiple pregnancy

Why is placental abruption a concern?

(complication)
Placental abruption is dangerous because of the risk of uncontrolled bleeding (hemorrhage).
Although severe placental abruption is rare, other complications may include the following:

hemorrhage and shock

disseminated vascular coagulation (DIC) a serious blood clotting complication.

poor blood flow and damage to kidneys or brain

stillbirth

postpartum (after delivery) hemorrhage

Fetal death.

Maternal death.
Prematurity.

symptoms of placental abruption?(clinical

manifestations)
The most common symptom of placental abruption is dark red vaginal bleeding with pain during
the third trimester of pregnancy. It also can occur during labor. However, each woman may
experience symptoms differently. Symptoms may include:
vaginal bleeding
abdominal pain
uterine contractions that do not relax
blood in amniotic fluid
nausea
thirst

 faint feeling
decreased fetal movements

Nursing assessment
1. Determine the amount and type of bleeding and the presence or absence of pain.
2. Monitor maternal and fetal vital signs ,especially maternal Bp ,pulse ,fetal heart rate.
3. Palpate the abdomen .
4. Measure and record fundal height to evaluate the presence of concealed bleeding.
5. Prepare for possible delivery.

Nursing Diagnosis::
Ineffective tissue perfusion:placental related to excessive bleeding,hypotention,and decreased
cardiac output,causing fetal compromise.
Deficient fluid volume related to excessive bleeding.
Fear related to excessive bleeding,procedures,and unknown outcome.

Nursing Intervention
1. Maintaining tissue perfusion by: Evaluate amount of bleeding by weighing all pads,monitor CBC
and v/s.

Position in left lateral position,with the head elevated to enhance placenta perfusion.
Maintain oxygen saturation level above 90% by using pulse oximetry monitoring.

Evaluate fetal status with continuous external fetal monitoring.

Encourage relaxation techniques.

Prepare for possible cesarean delivery if maternal or compromise is evident.

2. Maintaining fluid volume by :Maintain large bore I.V line for fluids and blood products,Evaluate
coagulation studies,Monitor maternal v/s and contractions,Monitor vaginal bleeding .

3. Decreasing fear by :Inform the women and her family about the status of her-self and the
fetus,Explain all procedures in advance when possible,Answer questions in a calm manner using
simple terms,Encourage the presence of asupport person.

Placenta Previa
When the placenta lies low in the uterus, it may cover the cervix, condition in which the placenta
attaches to the uterine wall in the lower portion of the uterus and covers all or part of the cervix.
That means it partly or completely blocks the opening. This is called placenta previa. It may
cause vaginal bleeding. This type of bleeding often occurs without pain.

Placenta previa is classified as:

Marginal placenta previa: Placenta extends to the margin of the internal cervical os
Partial placenta previa: Placenta partially covers internal cervical os
Complete placenta previa: Placenta completely covers internal cervical os
A low-lying placenta is near the cervical opening but not covering it. It will often move upward
as your due date approaches.

Placenta previa occurs in 1 in 200 women. It is more common in those who Causes placenta
previa:
The cause of placenta previa is unknown, but it is associated with certain conditions including the
following

women who have scarring of the uterine wall from previous pregnancies

women who have fibroids or other abnormalities of the uterus

women who have had previous uterine surgeries or cesarean deliveries

older mothers (over age 35)

African-American or other minority race mothers

cigarette smoking
placenta previa in a previous pregnancy

Previous abortion
Multiple births

Symptoms of placenta previa:

The most common symptom of placenta previa is vaginal bleeding that is bright red and not
associated with abdominal tenderness or pain, especially in the third trimester of pregnancy.
However, each woman may exhibit different symptoms of the condition or symptoms may
resemble other conditions or medical problems. Always consult your physician for a diagnosis

Complications of placenta previa

Placenta accrete(abnormally adherent to uterine wall)

 Immediate hemorrhage,with possible shock and maternal death

Postpartum hemorrhage resulting from decreased contractility of uterine muscle.
Increase risk for anemia (blood loss)
Fetal mortality resulting from hypoxia in utero and prematurity.

Nursing assessment of placenta previa

1. Determine the amount and type of bleeding and any history of bleeding throughout any
pregnancy.
2. Record maternal and fetal vital signs .
3. Palpate for the presence of uterine contractions.
4. Evaluate laboratory data on hemoglobin and hematocrit status.
5. Assess fetal status with continuous fetal monitoring.

Nursing Daignosis of placenta previa

Ineffective tissue prefusion, placental,related to excessive bleeding causing fetal compromise .
Deficient fluid volume related to excessive bleeding.
Risk for infection related to excessive blood loss and open vessels near cervix .
Anxiety excessive bleeding, procedures,and possible maternal fetal complications.

Nursing Intervention for placenta previa

Promoting tissue perfusion:

1. Frequently monitor mother and fetus,pulse,respiration,and BP,should be taken every 5-15 min
in the presence of active bleeding or if the patient is unstable ,after stabilization vital signs
should be taken every 30 to 60 min .
2. Administer I.V fluids as prescribed.
3. Position patient on her side to promote placental perfusion.
4. Administer oxygen by face mask ,as indicated.
5. Prepare for emergency delivery .
Maintaining fluid volume:
6. Establish and maintain a large-bore I.V line .
7. Draw blood for CBC ,platelets ,PT/PTT to be ready for any bleeding .
8. Assist the patient to a sitting position to allow the fetus to compress the placenta and decrease
blood .
9. Inspect bleeding every 1 to 2 hours when stable ,or frequently as indicated
10. Note character ,color,and amount of bleeding.
11. If bleeding is profuse and delivery cannot be delayed,prepare the women physically and
emotionally for a cesarian delivery.
12. Administer blood or blood products as prescribed.
Preventing infection:
13. Use septic technique when providing care .
14. Evaluate white blood cell (WBC) .
15. Teach perineal care and hand-washing techniques.
16. Assess odor of all vaginal bleeding or lochia.

Decreasing anxiety:
17. Explain all treatments and procedures ,and answer all related questions.
18. Provide information on a cesarean delivery ,and prepare patient emotionally.
19. Encourage verbalization of feelings by patient and family .
20. Inform the women and her support persons that long term hospitalization or prolonged bed
rest may be necessary and inform them of the effects.
Women who have had placenta previa at risk for postpartum hemorrhage because of the
decrease contractility of the lower uterine segment .
Like placental abruption, placenta previa is a serious condition that needs to be treated quickly.

Spontaneous abortion
Is the unintended termination of pregnancy at any time before the fetus has attained viability (20
weeks gestation or fetal weight of more than 500g)
Causes of Spontaneous abortion
1. Cause frequently unknown ,but 50% are due to chromosomal anomalies
2. Poor maternal nutritional status.
3. Maternal illness with virus ,such as rubella ,active herpes ,and toxoplasmosis .
4. History of diabetes ,thyroid disease.
5. Smoking or drug abuse or both .
6. Post mature sperm or ova .
7. Abnormal uterine development or structural defect.
8. Imperfect sperm or ova.

9. Environmental factors such as drugs,radiation,or trauma.

Signs and symptom
1. Uterine cramping ,lower back pain .
2. Vaginal bleeding usually begins as dark spotting ,then progresses to frank bleeding as the
embryo separates from the uterus.

Complications of Spontaneous abortion

1. Hemorrhage
2. Uterine infection
3. Septicemia
Nursing assessment:
1. Evaluate the amount and color of blood that is present.
2. Monitor maternal vital signs for indication of complication ,such as hemorrhage , infection.
3. Evaluate any blood or clot tissue for the presence of fetal membranes ,placenta,or fetus.
Nursing diagnosis:
4. Risk for deficient fluid volume related to maternal bleeding .
5. Risk for infection related to dilated cervix and open uterine vessels.
6. Acute pain related to uterine cramping and possible procedures.

Nursing intervention of Spontaneous

abortion
1. Maintaining fluid volume :
1. Report tachycardia ,hypotention,pallor,indicating hemorrhage and shock.

2. Draw blood for CBC as well as type and screen for possible blood administration .
3. Establish and maintain an I.V with large bore catheter for possible transfusion and large
quantities of fluid replacement.
2. Preventing infection:
1. Evaluate temperature every 4 hours if normal ,and every 1 to 2 hours if elevated .
2. Check vaginal drainage for increased amount and odor,which may indicate infection .
3. Instruct on and encourage perineal care after each urination and defecation to prevent
contamination.
3. Promoting comfort:
1. Instruct patient on the cause of pain to decrease anxiety .
2. Instruct and encourage the use of relaxation techniques to augment analgesics.
3. Administer pain medications as needed and as prescribed.

Ectopic pregnancy
An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus
and the placenta and fetus begin to develop there. The most common site is within a Fallopian
tube(96% of ectopic pregnancies occur in fallopian tube), the term (tubal) pregnancy is
commonly used, however, ectopic pregnancies can occur in the ovary, the abdomen, and in the
lower portion of the uterus (the cervix)

Causes of Ectopic pregnancy

1. The fertilized ovum implants outside the uterus
a. Most tubal pregnancies occur in the distal (ampullary) two thirds of the tube .
b. Some are located in the proximal portion of the extrauterine part of the tube (isthmic)
c. Rarely , intrauterine and extrauterine gestation can exist as the same time .(heterotopic
pregnancy)

3. Structural factors that prevent or delay the passage of the fertilized ovum include adhesions of
the tube ,congenital and developmental anomalies of the fallopian or uterine tube .
4. Previous ectopic pregnancy.
5. Use of an intrauterine device for more than 2 years .
6. Multiple induced elective abortions .
7. Functional factors include menstrual reflux and decrease tubal motility.
8. Maternal age and race , previous tubal surgery ,history of pelvic inflammatory disease ,surgical
correction of fallopian tube occlusions.

Signs and symptoms of Ectopic pregnancy

1. Abdominal or pelvic pain (most common).
2. Irregular vaginal bleeding , usually scanty and dark (most common)
3. Amenorrhea ,in 75%of the cases.
4. Abdominal tenderness on palpation.
5. Shoulder pain .
6. Increase pulse and anxiety .
7. Nausea ,vomiting, faintness, or vertigo .

Complication of Ectopic pregnancy

1. Infertility.
2. Hemorrhage and death.
Nursing assessment:

1. Maternal vital signs .

2. Presence and amount of vaginal bleeding .
3. Amount and type of pain .
4. Presence of abdominal tenderness on palpation \ shoulder pain.
5. Date of last menstrual period .
6. Rh type .

Nursing diagnosis of Ectopic pregnancy

1. Risk for deficient fluid volume related to blood loss from ruptured tube .
2. Acute pain related to ectopic pregnancy or rupture and bleeding into peritoneal cavity.
3. Anticipatory grieving related to loss of pregnancy and potential loss of childbearing capacity .

Nursing interventions of Ectopic pregnancy

Maintaining fluid volume:
1. Establish an I.V line with a large-bore catheter ,and infuse fluids and packed RBCs as
prescribed .
2. Obtain blood samples for complete blood count (CBC) and type and screen for whole blood ,as
directed.
3. Monitor vital signs and urine output frequently ,depending on condition .
Promoting comfort :
1. Administer analgesic as needed and prescribed .
2. Encourage the use of relaxation techniques .
Providing support through the grieving process :

1. Be available to patient and provide emotional support .

2. Listen to concerns of patient and significant others.
3. Be aware that family may be experiencing denial or other stage of grieving .

Hydatidiform mole
Hydatidiform mole (gestational trophoblastic disease) is an abnormal pregnancy resulting from a
developmental anomaly of the placenta ,It is characterized by the conversion of the chorionic villi
into a mass of clear vesicles .there may be no fetus , or a degenerating fetus may be present , In
this type of mole, the abnormal placental tissue has villi, clusters of tissue ,swollen with fluid,
giving it the appearance of a cluster of grapes
If a fetus begins to develop along with a hydatidiform mole, it typically has many malformations
and almost never can be delivered as a living baby
. The mole develops for a while the same as a normal pregnancy but there is no embryo. Only the
placenta develops and, because of this, the hormones develop which will make a woman feel
pregnant, and also test positive.
This condition may be picked up by a routine ultrasound scan.

Causes of Hydatidiform mole

1. Genetic abnormalities .

2. It arises in fetal rather than maternal tissue .

3. Large amount of B-Hcg are present secondary to the proliferation of chorionic tissue.
4. Chromosomal abnormalities ,malnutrition, hormonal imbalance, age under 20 or over 40, and
low economic status.

Signs and symptoms of Hydatidiform mole

1. First trimester vaginal bleeding .
2. Absence of fetal heart tones and fetal structures.
3. Rapid enlargement of the uterus (size greater than dates)
4. Expulsion of the vesicles.
5. Hyperemesis(sever nausea and vomiting ).

Complications of of Hydatidiform mole

1. Significant blood loss.

Nursing assessment of Hydatidiform mole

1. Monitor maternal vital signs ,note presence of hypertension.
2. Assess the amount and type of vaginal bleeding ,note the presence of any other vaginal
discharge .
3. Assess the urine for the presence of protein.
4. Palpate uterine height .
5. Determine date of last menstrual period and date of positive pregnancy test.
6. Evaluate CBC results and Rh type.

Nursing diagnosis of of Hydatidiform mole

1. Risk for deficient fluid volume related to maternal hemorrhage.
2. Anxiety related to loss of pregnancy and medical intervention.

Nursing intervention of of Hydatidiform mole

Maintaining fluid volume :
1. Obtain blood samples for type and screen ,and have 2 to 4 units of whole blood available for
possible replacement .
2. Establish and maintain I.V line ,start with largeneedle to accommodate possible transfusion
and large quantities of fluid.
3. Assess maternal vital signs ,and evaluate bleeding.
4. Monitor laboratory results to evaluate patient status .
Decreasing anxiety
1. Prepare the patient for surgery ,explain preoperative and postoperative care along with
intraoperative procedures.
2. Educate patient and family on the disease process.
3. Allow the family to grieve over the loss of the pregnancy .