Third Trimester Causes Of Bleeding

THIRD TRIMESTER CAUSES OF BLEEDING

✔ AMNIOTOMY: artificial rupture of bag of water ○ Causing fetal head to descent 1. PLACENTAL PREVIA abnormal low implantation of the placenta affecting mech., pressure @ - low implantation of the placenta so that it overlays placental site ctrl of bleeding some/all of the internal cervical OS ✔ DOUBLE SETUP: I/E in suspected placental previa Incidence: “ most common cause of bleeding @ 3rdtrimester”  2 setups Predisposing factors: (DIMM) ✔ DELIVERY: vaginal or CS if placental placement ○ Multiparity-single most impt factor prevents vaginal delivery and if the conditions for ○ Decreased vascularity of upper uterine segment d/t watchful waiting are absent tumor or narrowing ✔ HOME MNGT: ○ Increased age above 35 y/o *Monitor fetal well-being ○ Multiple Pz TYPE 1 & 2= home mngt TYPES/ DEGRESS OF P.PREVIA: Type 3 & 4= hosp for continuous TYPE 1: LOW LYING monitoring placenta @ lower 3rd of uterus not encroach of margins of OS NURSING CARE: TYPE 2 : MARGINAL • Bed & Px’ position: left side lying Placenta lies over the margins of os R: to prevent pressure in the vena cava TYPE 3 : PARTIAL • Assessment(FOBV) Placenta partially covers the os Fetal well being TYPE 4 : COMPLETE/TOTAL Onset & progress of labor Placenta totally covers the os w/c completely Blood Loss obstructs the birth canal V/S S/SX: • •

painless vaginal bleeding in 3rd trimester(7mos) intermittent pain 2nd to uterine contractions

DX: UTZ –95% accuracy Detects site of placenta

*fetal well being: FHT, mov’t., passage of meconium(thru vaginal d/c)

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TX: ✔ watchful waiting/ expectant mngt/conservative if: *mother is not in labor *fetus is STABLE; no distress, premature *bleeding is not severe

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• 2. ABRUPTIO PLACENTA – premature partial/complete separation of the

Don’t perform I/E or V/E R: it will increase bleeding Prepare for UTZ to detect placental site Institute shock measures prn ○ Bleeding is rarely severe life-threatening but may become profuse with I/E Psychologic and phys. Comfort Conservative mngt = double setup/ CS Classical CS performed bcoz of LUS is occupied by placenta Observe for bleeding after delivery LUS, the site of placental detachment = not contractile as U.fundal portion

Placenta from its implantation TYPE 2 MARGINAL/OVERT/EXTERNAL BLEEDING – occurs after 20th wk AOG Placenta separates at the margin – also called “accidental hemorrhage” and “ablation placenta” c. External bleeding, proportional to the amount of internal bleeding incidence: 2ND leading cause of 3rd trimester bleeding S/Sx: (SPER) predisposing factors: MAMST Painful vaginal bleeding @ 3rd trimester maternal HPN : PIH & renal dse (+) shock Rigid, boardlike, painful abdomen sudden uterine decompression as inEnlarged PZ and polyhydramnios uterus d/t concealed bleeding @ labor: titanic contractions c. the absence of alternating contraction & Advanced age due to insufficiency of hormone Dx: Multiparity CLINICAL Dx: s/sx Short umbilical cord – may pull the UTZplacenta says the retroplacental bleeding Trauma & fibrin defects Clotting studies: reveal “Disseminated Intravascular Coagulation”(DIS) e.g. massive bleeding causing depletion of blood Thromboplastin from supply retroplacental clot enters maternal circulation and depletion of fibrin Consumes maternal fibrinogen r/t: *villi separates containing cotyledons that are *DICattached – small fibrin clots in the circulation *villi detachment causing bleeding & rupture of blood vessels of mother & fetus *HYPOFIBRINOGENEMIA - normal fibrinogen r/t absence of Normal blood coagulation ACTIVEBLEEDING – Blood coagulation Complications: Hemorrhagic shock BLOODInfection CLOTS DIC Fibrin becomesCVA BIGGER from DIC Couvelaire Uterus – bleeding behind the placenta which may cause some EMBOLUS Of blood to enter the uterine musculature causing uterine Mngt: Muscles not to contract well once the placenta is delivered. O2 inhalation L E A D S TO CS delivery UTERINE ATONY (+) bleeding Fluid replacement and plasma expanders Renal failure Hypofibrinogenemia TYPES Fetal distress/demise TYPE 1 CONCEALED/COVERT/CENTRAL/INTERNAL BLEEDING Placenta detaches/separates center causing blood to Nursing @ Mngt.: accumulate behind the placenta Maintain bedrest @ LLR External bleeding is not evident Careful monitoring of: Signs of shock not proportional to the amountv/s of external bleeding Maternal Uterine pain

NRSG. MNGT:

FHT Bleeding not proportional to shock Labor once/progress I&O = oliguria/anuria

relaxation of uterus.

[ CRYOCRECIPITATEblood products that are rich in blood clotting factors type 4“Secondary” Packs of thrombocyte replacement Occurs due pancreatic tumor/infections or other endocrine disorders due to very slow metabolism Administer fluid, –plasma, blood asto ordered Prepare for Dx exams – explain results – Hypothyroidism secretions leads to HYPERGLYCEMIA Provide psychological – explain what is prepare for all exams HPL- Humansupport Placental Lactation = happening, blocks action of insulin And inform/explain results. PhysicallyNORMAL and emotionally prepare for emergency birthDM: either per vagina/CS METABOLIC CHANGES affecting Observe for associated problems after delivery ✔ Hormonal production by placenta *Couvelaire= poorly contracting uterus *DIC *neonatal sepsis

Metabolic rate in Pzcausing # of Islets of Langerhans  insulin production but rendered ineffective by “insulin PRE & CO-EXISTING DSES OF PZ antagonists” (HPL/HCS) ✔ Activity of the APG  tolerance for sugar DIABETES MELLITUS ✔ BMR and Co2 combining power raise the tendency of acidosis , metabolic disorder characterized by a deficiency of insulin production by ✔ Vomiting during pz= CHON intake = ACIDOSIS Pancreas’ islets of langerhans resulting to improper metabolic interaction of ✔ Fats, Muscular activity in labor depletes maternal glucose including glycogen stores = requires CHON intake carbohydrates, proteins, and insulin. ✔ Hypoglycemia is common In puerperium as involution and lactation occur.  hyperglycemia due to lack or inadequate insulin If pancreas cannot respond by producing more insulin, glucose crosses the placenta to the fetus where fetal  caused by ✔ heredity, envi and lifestyle insulin metabolizes it and by resembling the growth hormone, causing MACROSOMIA INCIDENCE: concurrent EFFECTS dseOF in Pz PREGNANCY or have its onset IN DM@ pz PREDISPOSING FACTORS: • DM is more difficult to control = difficult to maintain blood sugar ○ Family HX • Insulin shock and ketaacidosis ○ Rapid hormonal change in Pz • N-V are predispose to keta-acidosis ○ Tumor/infection of the pancreas –produces insufficient insulin • Insulin requirements: ○ Obesity ○ 1st 3mos: stable ○ Stress  Insulin may not be CLASSIFICATIONS OF D.M. may drop in 1st trimester Type 1 – “juvenile-onset”or Dose “insulin dependent” nd 2 3mos: – Occurs below 40 y/o rapid starts @ youth rd Type 2 – “maturity-onset” or “non-insulin dependent” 3 3mos: rapid – after 40 y/o Postpartum :rapid to prepregnant level Type 3 - “GESTATIONAL D.M.” Need insulin in the first 24h AC delivery ✔

- onset during pz and ends after termination of pz -however she becomes DIABETIC after Pregnancy

Hypoglycemics are c/I in Pz due to:

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secretion of pancreas @ GDM Dx: • Normal 1. production but not used in Pz OGTT (oral glucose tolerance test) 100 g GTT is sensitive Abnormal results: EFFECTS OF DM  POLYPHAGIA – excessive appetite Mother BABY  POLYDIPSIAexcessive thirst  POLYURIAexcessive urine ○ Infertility d//t ○ Congenital anomalies 2. 2hr postprandial sugar – greater than 120mg/dl chronic or persistent (3x) dueblood to persistent ○ PIH BS depletion BSinaccurate @ 3. Urine glucose monitoring as the urine of a pregnant woman is normally with sugar (+1 – normal baby ○ Spontaneous value) abortion Nursing Mngt.: ○ Polyhydramnios ○ early Macrosomia(LGA) ○ Infections 1. – Participate in detection ○ Fetal hypoxia(IUFD) Moniliasis 2. Encourage early, frequent medical and prenatal mngt and supervision ○ UTI Intrauterine fetal Every 2wks prenatal visit until 30th wk, then weekly death ○ Uteroplacental 3. Provide health teachings: ○ Stillbirths insufficiency a. NATURE OF DM: effects on pregnancy, and effects of DM ○ Perinatal mortality ○ Premature Labor b. S/sx of hypo/hyperglycemia ○ Neonatal ○ Hypoglycemia/Hype c. Need for exercise not only to regulate glucose level but also to enhance feelings of well-being and to control hypoglycemia @ r weight birth/postpartal ○ Dystocia- too large d. Insulin regulations/self administration of insulin ○ Prematurity shoulders of danger signs and signs of infection ○ reporting RDS ○ CS if indicated e. Prompt of DM ○ Hypocalcemia ○ Postpartal4. Promote control a. DIET cornerstone of mngt hemorrhage Calories: 35 cal/kg DBW 1800-2000 daily ○ From uterine atony CHON : 30-45% milk/bread @ 200mg/day PROTEIN: ½- 2KG BW of 70g daily ASSESSMENT FINDINGS: a. Hx FATS: saturated *Familial Taken regularly *previous large infant b. weighing Exercise400g/more : exercise the need for insulin * “ c/ congenital defectspolyhydramnios c. Insulin: oral diabetogenic agents are C/I *fetal wastage, abortion, stillbirths i. Need for insulin @ 2nd and 3rd 3mos *obesity c/ very rapid weight gain @ 3rd3mos needs may be tripled tendency to ketoacidosis * incidence of vaginal moniliasisand UTI ii.Regular insulin and NPH insulin are used b. Abdominal enlargement, marked from polyhydramnios and LGA iii.Rapid-acting regular insulin used in labor c. S/Sx of Hypoglycemia 1. Onset of action: 30 mins to 1hr 2. Peak of action : 2-4 h d.weight loss bcoz it is not properly metabolized 3. Duration of action: 4-6 hrs 4.

e.

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blood and urine sugar

Indications of Early termination of PZ:

4. prevention of infection and stress 1.UTZ: fetal growth detection 5.promote adherence to dietary regimen 6.encourage hospitalization m< AOG by m< BPD Purposes: *CTRL OF INFECTION 2.Urine/blood estriol levels : determine feto placental sufficiency *REGULATION OF INSULIN 3.AMNIOCENTESIS: determines lung maturity *ASSESSMENT OF FETAL JEOPARDY OR INDICATIONS FOR 2:1) EARLY (L/S ratio means mature lungs, above 36wks. TERMINATION OF PREGNANCY: L/S ration may be elevated in DM 7. prepare for early hospitalization for possible early labor induction for CS 4.PHOSPHATIDYGLYCEROL(PG) using amniotic fluid *The baby of a diabetic is large and when allowed to reach term a CPD may -more accurate way of estimating fetal lung maturity by Complicate a labor Determining lung surfactant *the final time of terminating Pz depends on fetal and maternal well-being 5. STRESS and NONSTRESS TESTS 8. Continued monitoring, mother and fetus, during the intrapartal period ○ Electronic fetal monitoring ○ Left lateral recumbernt R: to preventCARDIAC supine hypotensve syndrome PROBLEMS ○ Ensure fluid and electrolyte balance  of all cases-RHEUMATIC  D5IMB needed to maintain glucose PREDISPOSI Variety of heart conditions both congenital and acquired, 90% NG FACTORS:  Insulin added to IV of 5-10% D5IMB, tiltrated to maintain glucose ✔ Rheumatic fever Between 100-150 mg/dl ✔ Arteriosclerosis 9. provide postpartum care ✔ pregnant Pulmonary dses ○ There is a in insulin needed to ½ to 2/3 dose on st ✔ Renal dses 1 postpartum day if on full diet ✔ Heart surgery ○ Be alert for complications in the postpartum/prevention of: ✔ Congenital defects of the heart  HEMORRHAGE CLASSIFICATION OF HEART DSE:  INFECTIONS = candidiasis, UTI “avoid cathetherization”  INSULIN SHOCK Class 1 NO limitation of activity  PIH Regular activities do not produce SX Encourage breastfeeding --- it has ANTIDIABETOGENIC affect Class 2 SLIGHT limitation of activity  Hypoglycemia raises adrenaline level resulting to milk supply and Asymptomatic @ rest, but regular activities produces ○ Let down-reflex Palpitations, fatigue, dyspnea and angina pains ACETONURIA : stop breastfeeding while insulin/diet are being adjusted Class 3 MARKED limitations of activities May pump breast to maintain milk production Less than ordinary activities causing Sx Encourage contraception : reinforce Dr’s recommendations Class 4 MARKED limitation of activities ○ Oral contraceptive pills C/I CHO tolerance Less than regular activities cause Sx ○ Barrier using diaphragm/condom recommended TX: DIGITALIS  meds that regulate heart rhythm and heart rate ○ IUD c/I due to poor response to infection

COMPLICATIONS OF HEART DSES(SHIMP) In labor, analgesia anesthesia as there should be NO PAIN in labor = FORCEPS DELIVERY ➢ Spontaneous Abortion c/I: scopolamine, oral contraceptives, Oxytocin ➢ HEART FAILURE ➢ Intrauterine growth retardation ✔ as they further circulating volume ➢ Maternal Dysrythmias ✔ promotes retention of fluid ➢ Premature labor ✔ enhance dev’t of thromboembolism Dx of heart dse in Pz is not easy asNURSING there areMNGT: signs of mimic dse: 1. Encourage early & regular prenatal care-supervision 2. Encourage compliance w/ medical therapeutic regimen a. Workload of the heart i. Rest and sleep = 10h Criteria for establishing Dx of Cardiac Dses ii.Tx of early anemia & infections ✔ Persistent Diastolic/presystolic murmurs iii.Prevent exhaustion, fatigue and stress ✔ Loud systolic murmur iv.Avoid acts that O2 ✔ Permanent/unequivocal cardiomegaly v.Avoid constipation ✔ Severe dysrythmias b. Proper nutrition ✔ Severe dyspnea prior to stage of pressure in the diaphragm i. Sodium, adequate protein, h2O, fruits and veggies Signs of cardiac decompensation: ii. Fats & CHON Moist cough iii.Well balanced diet Pedal edema – signs of pulmo edema c. Frequent prenatal visit Dyspnea w/ minimal act d. Early hospitalization – pz puts more stress on the cardio system, mother needs more Tachycardia rest b4 labor Tachypnea – rapid, weak pulse 3. Provide care in labor Chest pains on exertion a. Position @ semi-recumbent c/ hands & legs supported Cyanosis b. O2 prn Heart murmurs c. NPO d. Continuous cardiac monitoring, be alert for Sx of cardiac failure and pulmo edema Meds: i. PR = most sensitive and reliable indicator of CHF DIURETICS ii.Report stat PR above 200 bpm ANTIBIOTICS  prophylaxis against rheumatic fever iii.RR more than 24 cpm Tx of bacterial infection in Pz IRON SUPPLEMENTS prevents anemia & treats it O2 prn e. strict/asepsits to prevent infection

f. provide emotional support ✔ poor absorption as in stomach and intestinal dses r: to reduce stress and encourage cooperation-participation PROGNOSIS g. episiotomy and foreceps nd Associated with fetal problems – IUGR, perinatal mortality r. to shorten the 2 stage Increased incidence : h. encourage Lamaze technique or other DBE patterns ABORTION PREMATURE LABOR INSTRUCT not to BEAR DOWN / PUSH PIH POST PARTAL HEMORRHAGE i. Prepare for regional anesthesia HEART FAILURE ii. Administer drugs as ordered,: INFECTION a. Digitalis, S/SX : b. Diuretics OBJ: pale skin and mucus lining c. Antibiotics Pearly-white sclera d. Oxytocin production Brittle, flattened nails PROVIDE POSTPARTAL CARE Altered V/S rise in Systolic pressure c/ widened pulse pressure Cardiac failure/ decompensation is likely to occur the postpartal period Tachycardia Because of the ff factors: Tachypnea 1. Loss of placental circulation 30-50% blood volume is reabsorbed SUBJ: 2. Normal dieresis circulating blood volume Fatigue 3. Rapid in intraabdominal pressure ff delivery resulting to vasocongestion Shortness of breath on exercise, headache, anorexia, andrapid @ C.O. Menorrhagia, heartburn, flatulence POSTPARTAL CARE Dx: 1. Rest physically and emotionally Physical signs 2. Frequent monitoring of V/S – RR & PR Lab. Findings: 3. Pain-relief R: to prevent neurogenic shock HgB (less than 10g/100ml) 4. Monitor blood loss, i&O fluid rate flow HcT (less than 37% in first tri) 5. Freq. assessment of S/Sx of bleeding,sepsis & CHF (less than 35% @ 2ND TRI) 6. Provide care typical of a normal postpartum mother LESS THAN 33% @ 3RD 3MOS Serum Iron less than 65 mmg/100ml blood ANEMIA NURSING MNGT: Decrease in 02-carrying capacity of blood d/t hemoglobin @ z-Tract blood injection method ➢ Use PREDISPOSING FACTORS: ➢ Inject 0.5ml of air before withdrawing needle to prevent tissue ✔ Nutritional intake/malnutrition necrosis ✔ Heredity, cultural practices, fads ➢ Do not rub site ✔ Demands Pz and adolescence ➢ Instruct not to wear constricting garments after injection ➢ Keep warm free from injection ○ No water bottles/heating pads because of decreased