1. Ante partum hemorrhage : Islamic University of Gaza faculty of Nursing

2. Bleeding from the genital tract in late pregnancy after 24 th weeks gestation and before the onset of labor.

3. * effect on fetus: Fetal mortality Fetal morbidity. Still birth. Neonatal death. Hypoxia to baby. Neurological damage to baby.

4. effect on the mother : (sever bleeding) shock: hemorrhagic. DIC permanent illness. maternal death

5. * Types of ante partum hemorrhage : 1. placenta previa. 2. placenta abruption. Initial intervention ApHge : reduce anxiety both parents. Assess the situation. History and details to know the cause of bleeding. Nature type of ApHge. ?? D.D : cause of bleeding.

6. Maternal condition Assessment : - observe Pallor breathlessness - signs of shock. Tachycardia, tachypnea - subnormal temperature and hypotension. Assess amount of blood loss gentle abd. examination. Observe signs of labor.

7. . Don’t do vaginal or rectal examination. Avoid use of enema or suppositries,This will exacerbate the condition

8. fetal condition ask about movement of the baby. Auscultation FHR by CTG. U/S ? D.D 1-location of the placenta. 2-pain "continuous intermittent, painless.

9. 3-onset of bleeding after trauma, sexual inter course. 4-Amount of visible blood 5-color of blood [Bright,red, dark]

10. 6-degree of shock. 7-consistency of abdomen "tense, tender, soft, board like" 8-lie,presentation, engagement. 9-F.H.R –positive –ve. 10-uls – site of placenta.

11. Supportive treatment: Emotional support. Fluid replacement, plasma,blood. Strong analgesia. Bed rest. Prepare for emergency ambulance

12. The placenta is partially or wholly implanted in the lower uterine segment either anterior or posterior wall. Lower uterine segment stretch and grow after 12 weeks later weeks,placenta separate and cause sever bleeding Placenta previa:

13. -Cause of bleeding: Shearing stress between placental trophoblast and maternal venous blood sinus. separation of placenta previa put mother and her fetus on risk. degree of placenta previa

14. type I- Majority of placenta in uus. Vaginal birth. Mild blood loss. Mother and fetus in good condition

15. Type II : partially in lower uterine segment. Near the cervical os. Called placenta previa marginal's Vaginal birth possible " placenta anterior" Moderate blood loss. Maternal shock. Fetal hypoxia

16. Type III – placenta located over the internal cervical os,but not centrally -Sever bleeding -C.S delivery better

17. Type IV placenta located centrally over the internal cervical os – torrential Hge C.S delivery.

18. Pictures of previa: painless vaginal bleeding. soft uterus. abd lax. lie unstable.

19. presenting part above the pelvic brim. uls confirm the DX and determine degree, vaginal bleed this type never bleed. type I early pregnancy heavy bleeding

20. Assessing of mother condition: Amount of vaginal bleeding. Hx of small repeated blood loss (intervals) After 20 th weeks gestation. Common after 34 th weeks.

21. Degree of the Hge : mild, moderate, sever. Occur when doing activity, or even on bed rest. Bright red color bleeding (fresh). Retro placental blood clot not formed "So no pain

22. General examination: V/S – stable, signs of shock. According to amount of blood loss. Air hunger - RBCs carrying o2 pale skin – cold moist. lose of consciousness

23. Abdominal examination -lie—oblige, Transverse. Head high not engaged. (PG) -abdomen lax not tender -contraindication to do vaginal examination, it will worse the condition -quantify blood loss,blood soaked material for fluid replacement

24. assessing fetal condition : -fetal activity -cessation of fetal movement -signs of hypoxia, bad CTG -excessive fetal movement : signs of fetal hypoxia -u\s,CTG,pinards

25. Management depends on amount of bleeding -mother &fetus condition Location of placenta Stage of pregnancy

26. Conservative management : -slight bleeding -mother and fetus in well condition -bed rest (hospitalization many weeks until bleeding stop) -fetal kick chart -CTG

27. -u\s repeated, site of placenta -fetal growth -placental perfusion -IUGR -Psychological &social care -group education

28. -parent education -visit special care baby unit -answering question ?preterm birth -sever bleeding,reach maturity NVD -37 weeks IOL -risk of ppHge :placenta lower uterine segment,living ligature action is broken

29. -active management : Sever vaginal bleeding :c.s regardless location of placenta ( preterm baby ) -CBC,blood group,cross match, clotting studies

30. -IV fluid rapidly,several unit of blood may need infused rapidly -consent form -emergency blood group o –ve -anesthetics consultation -intake & output

31. -,epidural or general anesthesia -comforting mother & sharing information -support partner -placenta anterior -type 3,4 require c.s even the baby died to stop hemorrhage & prevent maternal death

32. Incidence : -comes after 20 weeks -complicate 3-6 \1000 -multigravida 1\90 -

33. increasing age – increase parity -little percentage occur in prima gravida Etiology : unknown -?smoker -previous c.s -recurrence 4-8 %

34. Complications : -maternal shock, resulting from blood loss and hypovolaemia anesthetic and surgical complications, which are more common in women with major degrees of placenta praevia. placenta accreta, in up to 15% of women with placenta praevia

35. air embolism, an occasional occurrence when the sinuses in the placental bed have been broken postpartum hemorrhage: occasionally uncontrolled hemorrhage will continue, despite the administration of uterotonic drugs at delivery

36. – even following the best efforts to control it, and a ligation of the internal iliac artery, a caesarean hysterectomy may be required to save the woman's life maternal death, a very rare outcome

37. fetal hypoxia and its sequelae due to placental separation fetal death, depending on gestation and amount of blood loss