LATE BLEEDING DISORDERS

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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

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