LATE BLEEDING DISORDERS

PREMATURE LABOR

• Are uterine contractions occurring before 37th week of gestation

RISK FACTORS HIT-MP

• HPN
• Incompetent cervix
• Third trimester bleeding
• Multiple gestation
• Polyhydramnios (excessive amount of Amniotic fluid)

CLINICAL MANIFESTATION

• (Primary) Contractions occurring in increasing frequency & intensity
• Premature ROM (rupture of membranes)

MANAGEMENT

If there is (-) bleeding & (-) Cervical Dilation

1. Administration of TOCOLYTIC MEDICINES = meds used to suppress contractions

a) RITODRINE (Yutopar) = muscle relaxant to control Uterine contraction
SIDE EFFECTS

• Hypotension
• Tachycardia
• Altered fetal heart rate

Nursing alert! Monitor FHR, if greater than 180bpm (NORMAL: 120-160) CR, if greater than 120bpm (NORMAL: 80-100) Notify the MD!

b) ISOXSUPRINE (Vasodilan) = Intravenous (IV) vasodilator
SIDE EFFECTS

• Hypotension
• Tachycardia

c) TERBUTALINE (Bricanyl) = bronchodilator
SIDE EFFECTS

• Tachycardia
• Nervousness & tremor

d) ETHYL ALCOHOL (Ethanol) = is given to block the release of Oxytocin; thru IV
SIDE EFFECTS

• Nausea & vomiting
• Can cause Mental confusion
  

If there is (+) Cervical Dilation

1. Give ANALGESICS in a minimum dosage to avoid FETAL RESPIRATORY DEPRESSION

2. STEROIDS - BETAMETHASONE (Celestone) are given to help in FETAL LUNG MATURITY = it hastens the production of “surfactants”
Contraindications HID

• HPN
• Infection (d/t depressed Immune System)
• Diabetes Mellitus (which contains Polysaccharides)

3. CAUDAL/ SPINAL anesthesia is preferred because it does not affect Fetal RR

NURSING CARE PAM

• Provide emotional support
• Assist in the delivery if there are maternal complications present
• Minimize fetal complication – if SUPINE = causes FHR to decrease, position the pt in LEFT LATERAL
  
  

PLACENTA PREVIA

• abnormal implantation of the placenta in the Lower Uterine segment

PREDISPOSING FACTORS AIR

• Advanced maternal age
• Increasing parity
• Rapid succession of pregnancy

TYPES

• LOW LYING/ MARGINAL PLACENTA – placenta is approaching the RIM of the Internal cervical Os, but not covering it.
• PARTIAL– placenta partially covers the Internal cervical Os
• COMPLETE – totally covers the Internal cervical Os

DIAGNOSTIC PROCEDURE

• Placental scan – CT scan of the placenta
  Ask pt for Hx of allergies to seafood (Iodine)
  After the procedure, educate the pt to increase fluid intake
• Ultrasound – to ascertain the position of the placenta & distinguish its type
  US is repeated on the last part of the 3rd trimester d/t “MIGRATING PLACENTA PHENOMENON” = its just an illusion that the placenta is rising on the uterus

CLINICAL MANIFESTATION

• (primary) Painless, bright RED vaginal bleeding
• d/t the tearing of the placental attachment, as a consequence of the Internal Os dilation
• Starts @ 7 months
• Bleeding may STOP, but can reoccur

MANAGEMENT
IF IT OCCURS @ less than 37 WEEKs AOG;

• Provide CBR
• Monitor V/S & FHR
• Monitor Hgb/Hct status (index to the hydrating status of the pt or FLUID BALANCE)
• Prepare O2 & blood for possible transfusion
• NEVER attempt Pelvic/ rectal exam’n
  = If the MD’s will perform an IE: prepare your DOUBLE SET UP
  = NSD if Marginal Placenta previa & with decreased bleeding

IF THE FETUS IS MATURED;

• CAUTION! Be careful that the NURSE does not perform an IE, because it will cause BLEEDING in pts = indication for CSD.
• CS PREP
  1. Abdomino-perineal prep
  2. give pre op meds – CHECK the BP before & after the administration
  3. insert the foley cath (Female: french 12-14)

COMPLICATIONS HIP

• Hemorrhage
• Infection
• Prematurity

NURSING CARE PA

• Provide Nsg care associated with hemorrhage BAMP
  1. blood typing & cross matching
  2. administer meds, as ordered
  3. monitor I & O
  4. provide IVF
• Assess for complications associated with Placenta previa
  1. PP hemorrhage
  2. Lower Uterine segment is FRAGILE
  
  

ABRUPTIO PLACENTA

• Premature separation of normally implanted placenta leading to Hemorrhage

PREDISPOSING FACTORS PPM-DISH

• PIH
• Polyhydramnios
• Multiple pregnancies
• Direct trauma
• Increasing maternal age & parity
• Short umbilical cord
• Hypofibrinogenemia

TYPES

• EXTERNAL – blood escapes from the vagina with separation of the placenta
• CONCEALED or INTERNAL – hemorrhage occurs within the uterine cavity
• PARTIAL SEPARATION – may occur with external bleeding/ be associated with concealed bleeding
• COMPLETE SEPARATION – most severe & profound symptoms of shock
• MARGINAL – like Duncan’s presentation
• CENTRAL – like Schultz presentation

CLINICAL MANIFESTATION

• If MARGINAL, (quite rare) there is presence of painless vaginal bleeding
• If CENTRAL, (most common) presence of cramp like abdominal pain/ sharp like stabbing pain in the fundus, hard, board like uterus, rigid abdomen, hypovolemic shock symptoms, hemorrhage may be concealed

MANAGEMENT

• Medical Tx of blood loss & shock,
• prior to Surgery – type & cross match blood for BT
• Surgical emergency à CS delivery

NURSING CARE

• Provide Nsg care associated with hemorrhage
• Assess for early COMPLICATIONS:
  
  

1. DIC (Disseminated Intravascular Coagulation)
= concealed uterine hemorrhage & damage to uterine wall BECAUSE of large amounts of thromboplastin released into the maternal bloodstream.
= Administer HEPARIN, blood, frozen plasma, & cryoprecipitate
HEPARIN = monitor PTT (Partial Thromboplastin Time)
antidote: PROTAMINE SULFATE
= Administer WARFARIN or COUMADIN
monitor PT (Prothrombin Time)
antidote: AQUAMEPHYTON (phytomenadione)

2. HYPOVOLEMIC SHOCK

3. COUVELAIRE/ COUVELARIE UTERUS
= bleeding in the MYOMETRIUM causes uterine muscles to lose its power to contract, uterus becomes ECCHYMOTIC & COPPER colored, MANAGEMENT: hysterectomy