Page 744 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 721

should be transferred to a tertiary obstetric centre prior Antepartum Haemorrhage
to delivery.
Antepartum haemorrhage (APH) is defined as any bleed-
ing from the genital tract occurring between the 20th
week of gestation and the birth of the baby and occurs in
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2–5% of all pregnancies. Bleeding from the vagina prior
Practice tip
to 20 weeks’ gestation is referred to in terms of miscar-
Many maternity professionals abbreviate preeclampsia to PE. riage (e.g. threatened) and is not classified as an APH. The
This can be very confusing given that in other health care two main causes of APH are placental abruption and
settings, the abbreviation PE usually stands for pulmonary placenta praevia.
embolism. Be clear in any notes that you make, and clarify when
reading notes that have been given to you. Placental abruption (or abruptio placentae)
Placental abruption is premature separation (i.e. before
the birth of the baby) of a normally-sited placenta from
OBSTETRIC HAEMORRHAGE the uterine wall and is responsible for about 25% of
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APH. Only a portion of the placenta separates with two-
Obstetric haemorrhage is a leading cause of maternal thirds separation considered severe. There are two rele-
mortality across the world and directly accounts for an vant matters to consider with placental abruption: how
estimated 127,000 deaths each year. Postpartum haemor- much blood the woman has lost and how much placenta
rhage (PPH) is responsible for the majority of these remains attached and functionally able to support the
maternal deaths. The past decade has seen an increase in fetus. If the placenta partially separates along an edge of
both the incidence and severity of obstetric haemorrhage, the placenta, blood loss is usually visible via the vagina.
with more women requiring a blood transfusion for post- In some cases the centre part of the placenta detaches,
partum haemorrhage than in the past. Severe bleeding leaving the rim attached all the way around (like the rim
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in childbirth is estimated to occur once in every 200–250 of a dinner plate) and in these cases, the blood loss is
births, although incidence is highly dependent on how usually not visible via the vagina (i.e. is concealed).
‘severe bleeding’ is defined. Major obstetric haemor- However, the woman may have lost substantial blood
24
rhage is often sudden and unexpected, and is frequently volume and be in hypovolaemic shock. This type of
associated with an acute coagulopathy. Early recognition placental abruption is usually accompanied by severe
and treatment of major obstetric haemorrhage is vital to abdominal pain and DIC commonly develops in response
ensure the best outcome for mother and fetus. A repeated to blood being forced into uterine muscle tissue; referred
finding in maternal death reviews is a delay by obstetric to as a couvelaire uterus. Once half to two-thirds of the
providers in recognising the severity of haemorrhage and placenta is detached, the likelihood of fetal survival is
a consequent deterioration in maternal condition. 24 low, especially if the woman is also hypotensive. In the
majority of cases, only women with severe placental
Obstetric haemorrhage may occur after the 20th week
gestation up to the birth (antepartum haemorrhage) and abruption are admitted to ICU and usually admission
after the birth of the baby (postpartum haemorrhage). occurs following an emergency caesarean section. Under-
Severe obstetric haemorrhage is a common reason standing of the aetiology of placental abruption is not
for postpartum women to be admitted to ICU complete with approximately 20% of cases unexplained.
at 0.7/1000 deliveries, with many women experiencing For most women, placental abruption is associated with
3
haemorrhage before and after the birth of the baby. a known related factor like preeclampsia, blunt trauma
Although not classified technically as an obstetric (e.g. car crash) and sudden reduction in uterine
haemorrhage, ruptured ectopic pregnancy can also volume (e.g. after delivery of the first baby in a twin
result in life-threatening haemorrhage and result in pregnancy).
ICU admission. The common causes of antepartum Placenta praevia
and postpartum haemorrhage are described below with
common management strategies presented at the end of Placenta praevia is when some or the entire placenta is
the section. See also Box 26.4. abnormally sited in the lower segment of the uterus, often
referred to as a low-lying placenta. Placenta praevia is
graded into four categories of severity according to the
location of the placenta in relation to the cervix (Box
26.5). A vaginal birth is not possible with Grades III and
BOX 26.4 What about vaginal bleeding IV as the placenta blocks the passage for the baby, neces-
before the 20th week of gestation? sitating a caesarean section. The lower uterine segment
does not fully form until 28–32 weeks’ gestation and the
Vaginal bleeding before the 20th week of gestation (usually a shearing stress as the lower uterine segment forms may
type of miscarriage, e.g. threatened, incomplete) is considered precipitate detachment of the placenta from the uterine
‘early pregnancy bleeding’ and is not categorised as obstetric wall causing maternal bleeding. However, bleeding can
hae morrhage per se. Septic abortion (or miscarriage) can cause occur at any time, is usually painless and may be massive.
profound bleeding in the days after the event when the infec- Placenta praevia is the main cause of APH accounting for
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tion has become established. 30% of cases. As with placental abruption, management
is dictated by the size of the blood loss and maternal