2. INTRODUCTION
Death from hemorrhage still remains a leading
cause of maternal mortality. Is one of the
leading causes of ante partum hospitalization,
maternal morbidity, and operative intervention.
MEDICAL EMERGENCY !
It is the per vagina blood loss after 20
weeks’ gestation. Complicates close to
and is a

3. Abruptio placenta – 19 percent
Placenta previa – 7 percent

4. The most common types include
Placenta Previa Types
Abruptio Placenta

6. Placenta Previa

7. Placenta Previa
The abnormal implantation of
placenta in the lower uterine
segment, partially or completely
covering the internal cervical os.

8. Difference between the normal and
abnormal implantation of placenta. :

9. CLASSIFICATIONS
Total Placenta Previa (Complete)
The placenta completely covers
the cervix

10. Partial Placenta Previa
The placenta is partially over
the cervix

11. Marginal Placenta Previa
The placenta is near
the edge of
the cervix

12. Low lying placenta
The placenta encroaches the lower segment
of the uterus but does not infringe on the
cervical os.

13. Advancing maternal age
Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa

14. Here do nonwhite Gender
familial ethnicity Race abortion
Previous
Age (35- Predisposing Factors: Previous
40) placenta
VBAC previa
Lifestyle
(vaginal Endome
(smoking,
birth after Multiple
etc.)
cesarean tritis births
delivery)
Damage to endometrium
Defective decidual vascularization exists (2 to
inflammatory or atrophic changes)
Incomplete development of the fibrinoid layer

15. Adherence of embryo (embryonic plate) in 
the lower uterus
Attachment of placenta to lower uterine segment
Accreta Covers cervical opening as placenta 
Increases in size
Total P. Previa Partial P. Previa Marginal P. Previa 

16. Thinning of the area (implantation site) 
Disruption of placental attachment 
Uterus unable to contract/ Unable to stop 
flow of blood from the open vessels

17. .
Promote contraction
Bleeding at the implantation site
Release of Thrombin from the bleeding sites
bleeding
Promote contraction
Placental
Contraction
separation

18. Promote Contraction
bleeding
Placental
Contraction
separation

19. The most characteristic event in placenta 
previa is painless hemorrhage.
(This usually occurs near the end of or after 
the second trimester)
The initial bleeding is rarely so profuse as to 
prove fatal.
It usually ceases spontaneously, only to recur. 
Placenta previa may be associated with
placenta accreta, placenta increta or
percreta.
Coagulopathy is rare with placenta previa. 


20. Placenta previa or abruption should always be 
suspected in women with uterine bleeding during
the latter half of pregnancy.
The possibility of placenta previa should not be 
dismissed until appropriate evaluation, including
sonography, has clearly proved its absence. The
diagnosis of placenta previa can seldom be
established firmly by clinical examination. Such
examination of the cervix is never permissible
unless the woman is in an operating room with
all the preparations for immediate cesarean
delivery, because even the gentlest examination
of this sort can cause torrential hemorrhage.

21. The simplest and safest method of placental 
localization is provided by transabdominal
sonography.
Transvaginal ultrasonography has substantively 
improved diagnostic accuracy of placenta previa.
MRI At 18 weeks, 5-10% of placentas are low 
lying. Most ‘migrate’ with development of the
lower uterine segment.

22. MANAGEMENT
Admit to hospital NO VAGINAL EXAMINATION 
IV access Placental localization

23. Determine the amount and type of bleeding 
Inquire as to presence or absence of pain in
association with the bleeding Record
maternal and fetal VS Palpate for the
presence of uterine contractions
Evaluate laboratory data on HCT and HGB 
Assess fetal status with continuous fetal
monitoring
Never perform a vaginal examination when 
pt is bleeding


24. Altered Tissue Perfusion related to excessive 
bleeding causing fetal compromise
Frequently monitor mother and fetus
Administer IV fluids as prescribed Position on
side to promote placental perfusion
Administer oxygen as facemask as indicated
(8-10 per minute)


25. Fluid volume deficit related to excessive bleeding
Establish and maintain a large-bore IV line, as prescribed
and draw blood for type and screen for blood replacement
Position in a sitting position to allow weight of fetus to
compress the placenta and decrease bleeding
Maintain strict bed rest during any bleeding episode
Prepare woman for a cesarean delivery
Administer blood or blood products protocol per institutional
policy

26. Risk for infection related to excessive blood loss 
Use aseptic technique when providing care 
Evaluate temperature q4h unless elevated;
then evaluate q2h
Evaluate WBC and differential count 
Teach perineal care and hand washing 
techniques
Assess odor of all vaginal bleeding or lochia 

27. Placenta accreta 
Immediate hemorrhage, with possible shock and 
maternal death
Increased risk for anemia secondary to increased 
blood loss
infection secondary to invasive procedures to resolve 
bleeding
Intrauterine growth restriction (IUGR) 
Congenital anomalies 
Fetal mortality resulting from hypoxia in utero 
prematurity 

28. 

30. Defined as the premature separation of the 
normally implanted placenta.
The Latin abruptio placentae, means 
"rending asunder of the placenta
Occurs in 1-2% of all pregnancies 
Perinatal mortality rate associated with 
placental abruption was 119 per 1000 births
compared with 8.2 per 1000 for all others.

31. premature separation of the implanted 
placenta before the birth of the fetus
Hemorrhage can be either occult(covert) or 
apparent(overt).
With an occult hemorrhage, the placenta 
usually separates centrally, and a large
amount of blood is accumulated under the
placenta.
When the apparent hemorrhage is present, 
the separation is along the placental margin,
and blood flows under the membranes and
through the cervix.

32. The primary cause of placental abruption is 
unknown, but there are several associated
conditions
Increased age and parity Preeclampsia Chronic 
hypertension
Preterm ruptured membranes 
Multifetal gestation 
Hydramnios 
Cigarette smoking 
Thrombophilias 
Cocaine use Prior abruption Uterine leiomyoma 
External trauma 

33. Predisposing Heredofamilial
Smoking Factors: Age (> Gender Predisposing
35y.o) Factors
Previous abruptio
placenta
Abdominal Cocaine use
trauma PIH
(Chorioamnionitis )Damage in small arterial
vessels in the basal layer of decidua
Bleeding Splits decidua
leaving a thin layer attached to the
placenta .
, Destruction of the placental tissues
OCCULT /APPARENT

34. Hematoma formation
Compression of the basal layer
Obliteration of the intervillous space
Destruction of the placental tissues
Impaired exchange of respiratory gases and nutrients
Concealed Bleeding Visible Bleeding
Blood passes
Concealed Bleeding through the
Blood reaches the edge membranes of
of the placenta amniotic sac

36. PATHOGNOMONIC SIGN
Blood passes through Port wine
the membranes of discoloration of
amniotic sac discharges
Small amount of blood
goes out to the vagina
(not an indication of the
severity of condition)

37. Vaginal bleeding companied with abdominal pain
Mild type abruption
1/3, apparent vaginal bleeding
Severe type abruption > 1/3,
large retro placental hematoma,
vaginal bleeding companied by persistent abdominal
pain,
tenderness on the uterus,
change of fetal heart rate.
shock and renal failure.

38. Treatment for placental abruption varies
depending on gestational age and the status of
the mother and fetus.
Admit History & examination
Assess blood loss Nearly always more than
revealed IV access, X match, DIC screen
Assess fetal well-being Placental localization

39. Ultrasonography (Position of placenta,severity of
abruption)
survival of fetus Signs-retroplacental hematoma
Negative findings do not exclude placental abruption
Laboratory examination
consumptive coagulopathy:
Rt, DIC Function of liver and kidney.

40. Diagnosis sign and symptom
Vaginal bleeding
Uterine tenderness or back pain
Fetal distress
High frequency contractions
Hypertonus
Idiopathic preterm labor
Dead fetus
Ultrasonography :Differential diagnosis (Placenta previa-
Painless bleeding, Pre-rupture of uterus dystocia

41. MEDICAL &
SURGICAL
MANAGEMENT

42. Determine the amount and type of bleeding and 
the presence or absence of pain.
Monitor maternal and fetal vital signs, especially 
maternal BP, pulse, FHR, and FHR variability.
Palpate the abdomen Note the presence of
contractions and relaxations between contractions
(if contractions are present)
If contractions are not present assess the abdomen 
for firmness
Measure and record fundal height to evaluate the 
presence of concealed bleeding.
Prepare for possible delivery. 

43. Evaluate amount of bleeding by weighing all pads.
Monitor CBC results and VS Position in the left lateral
position, with the head elevated to enhance placental
perfusion Administer oxygen through a snug face mask at 8-
12L per minute
Evaluate fetal status with continuous external fetal monitoring
Prepare for possible CS delivery if maternal or fetal
compromise is evident

44. Instruct patient on the cause of pain to decrease
anxiety
Instruct and encourage the use of relaxation
technique to augment analgesics
Administer pain medications as needed and as
prescribed

45. Fluid volume deficit related
to excessive
Establish and maintain a large-bore IV line, 
as prescribed and draw blood for type and
screen for blood replacement Evaluate
coagulation studies Monitor maternal VS and
contractions Monitor vaginal bleeding and
evaluate fundal height to detect an increase
in bleeding

46. Use aseptic technique when providing care
Evaluate temperature q4h unless elevated; then
evaluate q2h Evaluate WBC and differential count
Teach perineal care and hand washing techniques
Assess odor of all vaginal bleeding or lochia

47. Inform the woman and her family about the status 
of herself and the fetus
Explain all procedures in advance when possible 
or as they are performed Answer questions in a
calm manner, using simple terms
Encourage the presence of a support person 

48. Maternal shock
Anaphylactoid syndrome of pregnancy
Postpartum hemorrhage
Acute respiratory distress syndrome
Sheehan’s syndrome
Renal tubular necrosis
Rapid labor and delivery
Maternal and fetal death
Prematurity