Late Pregnancy Bleeding and

abnormalities in amniotic fluid

Teri Stone Godena, RN, CNM,
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MSN
N 344 Spring, 2016

Bleeding in Pregnancy
Leading cause of maternal mortality worldwide (Bleeding after 20 weeks occurs
about 6% of pregnancies)
All bleeding requires investigation
Contributors to mortality

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Etiology of Pregnancy Bleeding by trimester

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Cervical Insufficiency
Definition: Painless dilatation of the
cervix in the absence of uterine
contractions. May be watery discharge.

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Cervical Insufficiency
Incidence:
Risks:
Diagnosis by ultrasound
Medical treatment

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Abruptio Placenta
Premature detachment of the
placenta from the wall of the uterus.
Associated factors

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Nature of Bleeding

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Classification of abruption
Abruption is classified by severity of
symptoms not necessarily the amount of
bleeding observed.
Two systems: mild, moderate, severe
Class 0,1,2,3

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 Maternal

Morbidity

Fetal

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Establishing a Diagnosis
Nurses role: Clinical History:
Physical examination
Maternal
Fetal

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Medical management
Conservative
Active

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Clinical Application
Keisha presents to triage at 32 weeks
gestation with abdominal pain and
moderate vaginal bleeding
What are your 1st 5 actions?
What is a likely diagnosis?

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Clinical Application
You confirm Keishas 18 week U/S showed a
fundal placenta.
VS are: BP 90/56, HR 110, RR 22, T 97.6. Her
abdomen is rigid. The FHR baseline is 100
bpm, with contractions every 6 minutes but no
uterine relaxation between. You have notified
the provider
What are your next steps?
How will you explain the plan to Keisha and her
partner?
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Placenta Previa
Definition: Implantation of the placenta
partially or wholly in the lower uterine
segment.

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Types of Placenta Previa

Determined based on distance from
internal os.

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Placenta Previa
Establishing a diagnosis
Management

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Major Sequelae Pl. previa

Maternal Morbidity

R.R.

Neonatal Morbidity

Antepartum
hemorrhage/anemia
hemorrhage

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Prematurity/LBW.
17% births prior to
Prematurity
34 weeks; 28% 34-37 weeks

Need for hysterectomy

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NICU stay

Transfusion

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Jaundice

Septicemia

5.5

Anemia/isoimmunization

Thrombophlebitis

Abnormal presentation

Endometritis

6.6

Growth restriction

Morbidly adherent placenta

(MAP) Accreta etc. *

Neurodevelopmental delay
Mortality

*With a history of 2 prev. C/S and a current

placenta previa, the risk of MAP Is
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40%

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Clinical application
Yasmin H. is a 38 year old G5 P2113 who
presents at 35 weeks gestation with a
small amount of painless, bright red vaginal
bleeding. She has recently immigrated and
had no
prenatal care.
What questions do you need
to ask?
What are the possible dx?

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 What would be your nursing management

if she
A. Had a placenta previa
B. Had an abruption
C. Was in preterm labor

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Velamentous insertion of the cord

Definition: The placental end of the cord consists
of divergent umbilical vessels surrounded only by
fetal membranes, with no Wharton's jelly

Up to date

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Vasa Previa Definition

Definition: Fetal blood vessels present in
the amniotic membranes covering the
internal cervical os.
.
Implications

Up to date

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Vasa Previa

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Uterine rupture

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Disseminated Intravascular Coagulation

overactivation of clotting cascade
Platelets and clotting factors are used up
RBCs are destroyed

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Collaborative management of DIC

Medical management:
CORRECT the Cause
Usually cured by delivery as
source of coagulation
resolves
Delivery of dead fetus
Treat infection
Treat PEC
Remove abrupted
placenta

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Nursing Care
EMOTIONAL SUPPORT
Assess signs of bleeding( IV
site, eyes, nose, ears)
Administer:
blood/plasma/platelets, IV fluid
Cardiac monitoring
Ins and Outs/Foley
Side-lying tilt
O2
Protect from injury

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Labor
Term labor will be covered in depth in the
Section on labor and birth

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Amniotic fluid volume

Amniotic fluid index (AFI) is the sum of the
measurement of the vertical pockets of
amniotic fluid at least .5 cm wide in 4
quadrants of the uterus.

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Excessive amniotic fluid

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Collaborative management
Nurses Role

Medical Management
US for fetal anomalies
Observation (mild)
Amnioreduction
(therapeutic amniocentesis)

Pharmacological
treatment

History for risk factors

Coordinate lab work: GTT,
TORCH
Monitor maternal physical
status and fetal status
Physical exam: VS,
Leopolds, fundal ht.
Emotional support

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Oligohydramnios
Definition

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Fetal Growth Restriction

Definition
Incidence
Associated factors
Diagnosis
Asymmetric vs Symmetric
Risks to fetus

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Collaborative management
Medical

Nurses Role

Establish diagnosis
US to monitor fetal growth
and fluid level Q2-3 weeks
Fetal testing: NSTs twice
weekly, BPPs weekly
Determining appropriate
timing for birth

History
Coordinate diagnostic studies
Monitor maternal physical
status and fetal status
Physical exam: VS,
Counseling: fetal movement
Encourage fluid intake
Emotional support
Counsel re: modifiable risks
Continuous EFM in labor

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Clinical application
Angie is a 17 year old smoker who
weighed 93 pounds before pregnancy
(height 52) and has had a total weight
gain of 12 pounds at 36 weeks. Her fundal
height 2 weeks ago was 32 cm. It is
unchanged today. Her BP has been normal
until today. It is now 142/92
What are her risk factors for growth
restriction?
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