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Case study 1: Placenta Previa

Call to: a 38-year-old woman 32+4 weeks gestation complaining of significant vaginal bleeding over the past hour.

PMx: No previous history of illnesses, G3P2, two previous vaginal births. No antenatal care. Nil complications. Nil PMx.

Family Hx: Nil

Vital Signs: Respiratory Rate – 22/min

Pulse Rate – 72bpm

SaO2 — 98% room air

Temperature — 36.5 C (Mildly Febrile)

Pain score- 0/10

Fetal Heart Rate -100bpm

Physical Exam- pallor in color, PV Bleeding bright red in color. Mild contractions, denies continuing abdominal pain, denies trauma.

Provisional Diagnosis

Provisional Diagnosis: Placenta Previa

Differential Diagnoses: Abruptio Placentae, Normal labor, miscarriage.

Epidemiology / Aetiology / Pathophysiology

The woman has placenta Previa which is a low-lying placenta in the uterus that covers all or part of the cervix. The PV bleeding is bright red in colour with no abdominal pain which is in contrast with a normal labor. There is clinical suspicion of placenta Previa in all women experiencing vaginal bleeding in the second half of the pregnancy. The reason for suspicion is that in the last stages of the pregnancy, the placenta moves up as the uterus expands (No, 2011). However, in some case the placenta to lie on lower parts of the uterus. There is no exact known cause of the condition. However, it is related to certain risk factors such as:

  • Advancing maternal age (above 35 years)

  • Multiple gestations (twin lives)

  • Short inter-pregnancy interval

  • Maternal smoking or cocaine use (Silver, 2015).

Worldwide, the condition occurs in 0.3% to 0.5% of pregnancies. The prevalence is partly dependent on the population’s underlying risk factors. There is a documented 50% increased risk for women who have previously had a cesarean delivery. However, placenta Previais uncommon in first pregnancies.

Placenta Previa is said to take place when the blastocyst is abnormally implanted on the or near the cervical orifice. Most occurrences of the condition are accidental as they result from a normal variation of the placenta. However, the predisposing factors, such as previous cesarean delivery and so on, may cause some damages on the endometrium. Thus, the existence of a uterine scar interferes with the development of placental implantation (Clark, 2016). 

The condition takes two forms, Complete and Marginal Previa. A Complete Previa wholly covers the cervical orifice while in the Marginal Previa the placenta covers less than two cm of the orifice. Due to placental trauma bleeding occurs impulsively. During the onset of labor as the cervix opens, the placenta may be torn, or it may separate from the uterus causing bleeding. The bleeding can cause anemia and in some postpartum cases hysterectomy or an infection. The hemorrhage can result in the death of the mother and fetus when left untreated (Abbott, Bowyer & Finn, 2013). 

Investigations

The signs and symptoms of placental Previa are shown in the table below:

Table. 1 Signs and symptoms

According to scholarly sources

According to the patient

The general condition of the patient is pale due to apparent blood loss (Kollmann, 2016).

The patient is pallor in colour.

The blood discharge should be bright red in colour (Roberts,2012)

The patient has visible PV bleeding that is bright red

Sudden onset (Roberts,2012)

The patient has been previously well. The bleeding only occurred over the past hour

Painless bleeding

The patient is not experiencing any abdominal pain, and her pain score is 0/10

The condition has no apparent cause (Kollmann, 2016).

The patient denies any trauma

Cervical Examination

A cervical examination was not done because it would increase the risk of hemorrhaging. Minimal investigations were done to avoid threatening the life of the mother and the fetus. A digital cervical examination cannot be performed unless the patient is in the operating room preparing for cesarean delivery (Kollmann, 2016).

Blood investigation

The patient’s blood must be collected for a full blood count and to determine the blood group and cross-match. Two units of blood should be made available in case the bleeding spirals(Roberts, 2012).

Fetal Assessment

Pre-hospital emergency care for placenta previa focuses on establishing and maintaining adequate ventilation, oxygenation, and circulation. Therefore, the patient must be provided with a high concentration of oxygen, one large-bore intravenous line, and a normal saline to retain mother and fetal perfusion. The vital signs of the patient must be closely monitored as well as fetal heart rate to determine whether there is fetal distress. The patient must have lost at least 30% of her circulating blood volume to exhibit any signs of shock as our patient has. Fetal heart rate should be monitored using a Doppler on the abdomen of the pregnant patient, and it is important that the fetal heart rate taken does not correlate with the hart rate of the mother. If fetal distress is established the patient must be immediately transported to a medical facility that equipped with obstetric capabilities (Beebe & Myers, 2011)

Management

The woman must first be counseled on the diagnosis and the options presented to them. To manage the heavy blood loss, uterotonics such as Methergine, misoprostol, and concentrated oxytocin can be used as pharmacological agents to deal with uterine atony. Blood transfusion is also an option that is reserved for management of severe cases (Trivedi, 2015).

Transport

The patient requires immediate transportation to a maternity for a safe delivery. A delay could lead to more blood loss.

Case study two: Primary Post-partum haemorrhage

Call to: A 24-year-old woman who has just birthed unexpectedly at home. She is G1P0 41 weeks gestation.

She has had an uneventful pregnancy.

PMx: None

She has been attending antenatal care at the antenatal clinic in the maternity hospital.

She has been taking Multivitamins

All blood tests, screening, and ultrasounds are up to date and NAD.

She has NKDA.

Family Hx: None

Vital Signs: Respiratory Rate – 24/min

Pulse Rate – 120/min (Tachycardia)

SaO2 — 95% room air

Temperature – 36.80 C

Blood Pressure is 70/50

Pain score 5/10

Physical examination: She is pale.

The placenta has not yet birthed

The fundus is boggy.

Provisional Diagnosis

Provisional Diagnosis: Primary Post-partum haemorrhage

Differential Diagnoses: Wound breakdown, Genital tract manipulation.

Epidemiology / Aetiology / Pathophysiology

Edhi et al, 2013)The causes of PPH are described as tone, trauma, thrombin, and tissue (

  • Tone: uterine atony

  • Trauma: lacerations to the genital track

  • Tissue: retention of the placenta and blood

  • Thrombin: pre-existing or acquired deformity of the clotting system.

Similar risks factors may manifest in different etiologies have for example uterine atony and lower genital tract trauma (Owiredu, 2016). PPH has some risk factors like:

  • Retained placenta 

  • Prolonged labor

  • Placental abruption

  • Pregnancy-induced hypertension

  • Maternal obesity

In Australia, PPH is not classified as a main cause of maternal death. Studies indicate that there are 5-10% of PPH incidences. However, the severity of the condition is dependent on the definition and regional variation. Severe and life-threatening PPH is recorded at 0.3-1.86%. A study done by Fullerton et al (2013) showed that 10% of the 34 334 women participating experienced a PPH in their first pregnancy.

During the pregnancy period, there is an increase in maternal blood by roughly 50%. One of the reasons for this is to supply a reserve for the blood loss that takes place on delivery. At delivery, the uterine blood vessels supplying the placental site contract and retract to allow the birthing of the placenta. After the expulsion, the muscles fibers continue contracting and retracting to aid in the constriction of the blood vessels. Lack of the contractions can lead to excessive blood loss and hemorrhage (King, 2015). The case is primary PPH because it occurred within 24 hours of the birth.

Investigations

The woman has had an uneventful pregnancy and all blood tests, screening and ultrasounds are up to date. Physical investigation shows that the placenta has not yet birthed, and a gentle massage to the stomach confirms that the fundus is boggy. The patient seems to have lost a lot of blood for a vaginal birth. The blood loss of above 500ml within the first 24 hours of delivery increases risks to the patient. The loss of blood is accompanied by pain and shock, and the patient is pale and weak signifying that she has lost a significant amount of blood (Baker, 2014).

Treatment and management

A minor PPH requires regular pulse and blood pressure monitoring, and the recommended time is after every 10-15 minutes. Paramedics should try and determine the cause of PPH. In the identification of a uterine atony, an abdominal uterine tonus assessment is vital (World Health Organization, 2012). In the case of uterine atony, the following measures should be taken before the woman is taken to the Emergency room:

  • Uterine compression to stimulate contraction manually.

  • Make sure the bladder is empty.

  • Oxytocin 5 units by slow IV infusion. A repeat may be necessary.

  • Oxytocin infusion

Postpartum management

Postpartum anemia is safely regulated using iron supplements. A 100 mg of iron supplements for three months to women is beneficial during the postpartum period. Blood transfusion is not recommended for a PPH, and it should be reserved for severe cases that require immediate attention, women at a higher risk of significant bleeding, and patients with looming cardiac compromise (Pavord & Maybury, 2015).

Transport

The patient requires immediate transport to the Emergency room for fast treatment. The patient is at a risk of losing more blood and developing complications such as liver failure, Hypovolaemic shock, and acute respiratory distress and so on. Therefore, there is a need to ensure that the patient receives urgent treatment.

Case study 3: Breech Birth

Call to: a woman in labor; she is 41 weeks gestation, G3P2

Has had an uneventful pregnancy

PMx: fibroids and asthma, currently taking Multivitamins, Ventolin PRN, and all blood tests, screening and ultrasounds are up to date and NAD.

Antenatal care has been attended to by an obstetrician.

Allergic to Penicillin.

Family Hx: Elder None

Vital Signs: Respiratory Rate – 20/min

Pulse Rate – 95/min (Tachycardia)

SaO2 — 99% room air

Temperature – 36.90 C

Blood Pressure is 110/70.

Fetal heart is 130bpm

Physical examination: fundal height is appropriate, ruptured membranes and there is clear liquor draining.

There is a bottom emerging due to the woman’s involuntary pushing.

Provisional Diagnosis

Provisional Diagnosis: breech birth known as Frank breech

Differential Diagnoses: Transverse lie, unstable lie

Epidemiology / Aetiology / Pathophysiology

Frank breech presentation happens when the fetal hips are flexed and knees are extended. The breech is presented in 60-65% of pregnancies. As the gestational period advances, the risk of a breech delivery decreases. Thus, prior to 28 weeks’ gestation the percentage is at 22-25%, at 32 weeks there is a decrease to 7-15% while at term the percentage goes as low as 3-4%.A breech pregnancy affects fetus of both sexes (The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2016).

There is no known cause of breech pregnancies. However, there are factors that predispose a woman to such (Kotaska, 2009). The risk factors include:

  • Fetus congenital anomalies

  • abnormal amniotic fluid volume

  • history of breech birth

  • uterine anomalies

  • Placenta Previa

  • Low birth weight

The risk factors are associated with fetal anomalies, and infant mortality (Vistad, 2013).

The size of the fetus and uterus can persuade a breech presentation. A smaazll-sized uterus will make a preterm fetus to change their utero position, and large fetuses will present in a cephalic version during late gestational periods because of space and alignment limitations in the uterus. To reduce breech presentations, there is a need for parity-related relaxation of the uterine wall (Hehir, 2015).

Investigations

Normally a diagnosis is made in later pregnancies through an ultrasound to confirm any abnormalities. A breech presentation can also be felt on the woman’s abdomen. In our patient and the membrane has rapture, there is a clear liquid draining, this shows that the woman is already going into labor. Additionally, the patient has already commenced involuntary pushing, and a cervical examination shows a bottom emerging. The pregnancy is already at term, and the woman is in labor. Therefore, necessary measures must be put in place for a safe delivery (Ford et al. 2010).

Treatment and Management

  • Treatment should be inpatient for a safe labor and delivery.

  • General measures encourage a cesarean delivery to decrease the rate of neonatal morbidity. However, our patient is already in labor and crowning, so a vaginal breech delivery is appropriate.

  • During labor, the patient should have as much bed rest as possible.

  • A breech delivery can either be vaginal or through a cesarean section

  • A thorough check of the patient’s blood tests, screening and ultrasounds are crucial to determine the position of the baby before vaginal delivery.

  • During labor and delivery, there should be a constant fetal heart rate monitoring.

  • The procedure for a vaginal breech delivery include:

  • A ready and skilled birth attendant for a breech delivery, a scrubbed assistant, an anesthesiologist for rapidly inducing general anesthesia, and a specialist in neonatal resuscitation (Tharpe, Farley, & Jordan, 2016). 

  • Some patients may prefer an epidural as a form of anesthesia.

  • The membrane should be left intact for some time to avoid potential cord prolapsed.

  • The patient should only push when fully dilated to avoid a partial delivery that could trap the head in the cervix.

  • Cutting a larger episiotomy to permit sufficient room for delivery could be beneficial

  • Guide the fetal head through the abdomen to keep it flexed as it descends.

  • Traction of the infant should only take place after the umbilicus passes the maternal perineumto reduce the risk of perinatal mortality (Tharpe, Farley, & Jordan, 2016`).

  • Grasp the fetal hips and maintain a downward traction with the fetal back anterior until the head is visible.

  • Check for a nuchal arm

  • To allow delivery, rotate the infant until the shoulders lean anteriorly and posteriorly when the axilla becomes visible (Kotaska, 2009).

  • The head should be delivered face-down pose using Piper forceps or through manually flexing of the head (Kotaska, 2009).

  • After delivery, the cord blood gasses must be obtained.

The obstetrician must discuss the options available to the woman and explain the risks and benefits of a caesarian delivery and vaginal delivery. The woman is already in labour and she should be informed of the risks associated with a vaginal delivery so that she can give her consent. However, there should be a ready caesarean section in case of any complications (Berghella, 2012).

Transport
The patient is already in labor, and immediate transport is needed to the maternity for a safe delivery. The urgency of the transport is essential because of the breech presentation as well as the contractions that are 5 minutes and moderate in strength for the past two hours.

Reference List

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Abbott, J., Bowyer, L., & Finn, M. (2013). Women’s health: 2. Chatswood, N.S.W: Elsevier Australia.

Baker, K. (2014). How to… manage primary postpartum haemorrhage. Midwives17(4), 34.

Beebe, R. & Myers, J. (2011). Medical emergencies, maternal health & pediatrics. Clifton Park, N.Y: Delmar Cengage Learning.

Berghella, V. (2012). Obstetric Evidence-Based Guidelines, Second Edition. CRC Press.

Clark, V. (2016). Oxford textbook of obstetric anaesthesia. Place of publication not identified: Oxford Univ Press.

Edhi, M. M., Aslam, H. M., Naqvi, Z., &Hashmi, H. (2013). Post partum hemorrhage: causes and management. BMC research notes6(1), 1.

Ford, J. B., Roberts, C. L., Nassar, N., Giles, W., & Morris, J. M. (2010).Recurrence of breech presentation in consecutive pregnancies. BJOG: An International Journal of Obstetrics &Gynaecology117(7), 830-836.

Fullerton, G., Danielian, P. J., & Bhattacharya, S. (2013). Outcomes of pregnancy following postpartum haemorrhage. BJOG: An International Journal of Obstetrics &Gynaecology120(5), 621-627.

Hehir, M. P. (2015).Trends in vaginal breech delivery. Journal of epidemiology and community health, jech-2015.

King, T. L., Brucker, M. C., Fahey, J., Kriebs, J. M., Gegor, C. L., Varney, H., & Varney, H. (2015). Varney’s midwifery. Burlington, MA: Jones & Bartlett Learning

Kollmann, M., Gaulhofer, J., Lang, U., &Klaritsch, P. (2016). Placenta praevia: incidence, risk factors and outcome. The Journal of Maternal-Fetal & Neonatal Medicine29(9), 1395-1398.

Kotaska, A., Menticoglou, S., Gagnon, R., Farine, D., Basso, M., Bos, H., … & Murphy-Kaulbeck, L. (2009). Vaginal delivery of breech presentation: No. 226, June 2009. International Journal of Gynecology & Obstetrics,107(2), 169-176.

No, G. T. G. (2011). Placenta praevia, placenta praeviaaccreta and vasa praevia: diagnosis and management. London: RCOG, 1-26.

Owiredu, W. K., Osakunor, D. N., Turpin, C. A., &Owusu-Afriyie, O. (2016). Laboratory prediction of primary postpartum haemorrhage: a comparative cohort study. BMC pregnancy and childbirth16(1), 1.

Pavord, S., &Maybury, H. (2015). How I treat postpartum hemorrhage. Blood125(18), 2759-2770.

Roberts, C. L., Algert, C. S., Warrendorf, J., Olive, E. C., Morris, J. M., & Ford, J. B. (2012). Trends and recurrence of placenta praevia: A population‐based study. Australian and New Zealand Journal of Obstetrics and Gynaecology52(5), 483-486.

Silver, R. M. (2015). Abnormal placentation: placenta Previa, vasa Previa, and placenta accreta. Obstetrics & Gynecology126(3), 654-668.

Tharpe, N., Farley, C. L., & Jordan, R. G. (2013). Clinical practice guidelines for midwifery & women’s health. Burlington, Massachusetts : Jones & Bartlett Learning

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists,. (2016). Management of breech presentation at term (C-Obs 11) Review. Retrieved from https://www.ranzcog.edu.au/document-library/breech-management-term.html

Trivedi, S. (2015). Management of high-risk pregnancy — a practical approach. Place of publication not identified: Jaypee Brothers Medical P.

Vistad, I., Cvancarova, M., Hustad, B. L., &Henriksen, T. (2013). Vaginal breech delivery: results of a prospective registration study. BMC pregnancy and childbirth13(1), 1.

World Health Organization. (2012). WHO recommendatioins for the prevention and treatment or postpartum haemorrhage: evidence base.