Vaginal Bleeding in Later Pregnancy and Labor

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Vaginal Bleeding in Later Pregnancy and Labor

• Managing Complications in Pregnancy and Childbirth

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Session Objectives

• To review best practices for the diagnosis and
  management of vaginal bleeding in later pregnancy
  and labor
• To review strategy for specifically diagnosing
  placenta previa

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Definition

• Vaginal bleeding that occurs
• After 22 weeks of pregnancy (late)
• During labor before childbirth

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General Management

• Shout for helpmobilize personnel
• Rapidly evaluate breathing and state of
  consciousness
• Check airway, pulse and blood pressure
• If shock suspected, immediately begin treatment
• Infuse IV fluids

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Diagnosis of Bleeding in Late Pregnancy

• Abruptio placenta
• Placenta previa
• Ruptured uterus

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Abruptio Placenta

• Detachment of normally located placenta from
  uterus before fetus is delivered

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Diagnosis of Abruptio Placenta

• Bleeding (may be retained in uterus) after 22
  weeks gestation
• Intermittent or constant abdominal pain

• Symptoms sometimes present
• Shock
• Tense/tender uterus
• Decreased/absent fetal movements
• Fetal distress or absent fetal heart sounds

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Management of Abruptio Placenta

• Assess clotting status using bedside clotting
  test (No clot after 7 min. or soft clot that
  breaks down easily, suggests coagulopathy)
• Transfuse as necessary
• If bleeding is heavy, deliver as soon as
  possible
• If the cervix is fully dilated, deliver by vacuum
  extraction
• If vaginal delivery not imminent, deliver by
  cesarean section
• Note In every case of abruptio placenta, be
  prepared for postpartum hemorrhage

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Management of Abruptio Placenta (continued)

• If bleeding is light to moderate (the mother is
  not in immediate danger), the course of action
  depends on fetal heart sounds
• If fetal heart sounds are normal or absent,
  rupture membranes with amniotic hook or Kocher
  clamp
• If contractions are poor, augment labor with
  oxytocin
• If cervix is unfavorable, perform cesarean
  section
• If fetal heart sounds abnormal (lt 100 or gt 180
  beats/min.)
• Perform rapid vaginal delivery
• If vaginal delivery is not possible, deliver by
  immediate cesarean section

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Placenta Previa

• Placenta previa Implantation of placenta at or
  near cervix
• Three types
• Low placental implantation
• Partial placenta previa
• Complete placenta previa

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Diagnosis of Placenta Previa

• Bleeding after 22 weeks gestation

• Symptoms sometimes present
• Shock
• Bleeding may be precipitated by intercourse
• Relaxed uterus
• Fetal presentation not in pelvis/lower uterine
  pole feels empty
• Normal fetal condition

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Confirming Placenta Previa

• Localize placenta with ultrasound, if available
• If placenta previa is confirmed, plan childbirth
  if fetus is mature
• If diagnosis is uncertain
• Manage expectantly as placenta previa until 37
  weeks gestation
• If pregnancy is 37 weeks or more, examine under
  double set-up

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Expectant Management of Placenta Previa

• Assess amount of bleeding
• Do not perform a vaginal examination
• If bleeding is heavy and continuous, deliver by
  cesarean section regardless of gestation
• Consider expectant management if
• Bleeding is light or has stopped
• Fetus is alive but less than 37 weeks gestation

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Expectant Management of Placenta Previa
(continued)

• Keep woman in hospital until childbirth or heavy
  bleeding occurs
• Correct anemia with ferrous sulfate 60 mg by
  mouth daily for 6 months
• Ensure blood is available for transfusion
• If bleeding recurs, weigh benefits and risks for
  woman and fetus of further expectant management
  versus childbirth

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Childbirth for Placenta Previa

• Plan delivery by cesarean section if
• Hemorrhage is severe enough to cause risk to
  mother
• Fetus is at least 37 weeks gestation
• Fetus is dead or cannot survive
• Vaginal delivery may be possible with low
  placental implantation
• Women with placenta previa are at high risk for
  postpartum hemorrhage and placenta accreta/increta

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Management of Ruptured Uterus

• Perform cesarean section
• Repair uterus if it can be repaired with less
  operative risk than hysterectomy would entail and
  edges of tear are not necrotic
• Perform subtotal hysterectomy if uterus cannot be
  repaired or total hysterectomy if tear extends
  through cervix and vagina

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Summary

• Vaginal bleeding in later pregnancy and labor can
  be catastrophic
• Evaluate rapidly
• Resuscitate if patient in shock
• Differentiate abruptio placenta and placenta
  previa because of difference in mode of childbirth