CASE STUDY

OF
MRS.MOSLEME BIBI WITH
ANTEPARTUM HAEMORRHAGE

Submitted to
Madam M. Roy ,
Senior Lecturer
Govt College of Nursing ,Burdwan

Submitted by
Anupama Jash ,
M.Sc Nursing student , 2nd Year,
Govt College of Nursing ,Burdwan
INTRODUCTION
Nursing care study is generally viewed as an individual learning activity. It provides opportunities for the
application of previously learned knowledge & skills to a patient for whom we provide daily nursing care.
It is also a comprehensive study on a particular patient. I gave care to a mother, on whom I got opportunity
to apply this case study process.

IDENTIFICATION DATA:
Name of the hospital: BMCH Burdwan

Name : Moslema Bibi Age: 24 years

Address: W/O Jahangir Mallick

Vill+ P.O – Kaitan,PS- Katwa, Dist-Burdwan Religion: Islam

Registration No- 26771 Ward: LCF Bed no : 31

Unit: I Under: Dr N .Jana

Date and time of admission: 09.09.13 at 5pm( referred from Katwa S.D Hospital)

Date and time of delivey: 11.09.13

Mode of delivery: Caesarean section

Sex of the baby: Girl Condition of the baby at birth : Cried immediately after birth

Disc no of the baby: 126

CHIEF COMPLAIN ON ADMISSION—

9 months amenorrhea with bleeding p.v since morning on 08.09.13

DELIVERY NOTE- Emergency LUCS was done on 11.09.13 at 10 am. A live girl baby born. Baby cried
after birth. Baby disc. No-126. Sex – girl. Birth weight – 2200gms.

HISTORY OF THE MOTHER:

Social History:

Type of family: Nuclear/Joint Family members: 4 Adult:3 Child: 1

Support person in the family: 1 (Mother in law)

Total earning members: 1 Monthly income of the family: Rs.3000/-

Education: Husband- vi Wife: literate

Occupation: Husband- Carpenter Wife: Housewife

Habitation:((Rural/Urban/Slum) Housing:(Kancha/Pucca/Mixed

Type of house: own house/rented house

Ventilation: Adequate/Not Adequate

Sanitation: Sanitary latrine/Open field/Others

Sources of drinking water: Tap water

Personal History:
Addiction: Nothing significant

Allergy: Nil Contraception: uses oral contraceptive pills

Medical surgical history : past: Nothing significant

Medical surgical History: present: Nothing significant

Family History: Father is hypertensive

Brother is mentally challanged

Diet history: Breakfast: Puffed rice with cucumber or boiled potato

Lunch: Rice with vegetables ,fish

Dinner : Chapati with vegetable

Menstrual History:

Menarche: 12 Years Cycle: 26+2

Duration: 3 days Amount: Normal Any problem: Nil

 OBSTETRICAL HISTORY:
Past: uneventful LCB :5 yrs

No of Year Abortion Any Mode of delivery Baby Any problem Remarks

pregnancy With year problem Alive/ during
during still puerperium
antenatal birth
period
01 2008 - un Normal vaginal alive uneventful Baby was
eventful delivery breastfed and
immunized

Present obstetric history

Parity P1+0 Gravida: 2nd

L.M.P- 01.02.13 EDD: 8.11.13

Booked /unbooked No of antenatal checkup: 3

Immunization: Inj TT taken two doses Total weight gain: 9 kgs

Any problem arised during pregnancy: yes. bleeding p.v since morning on 08.09.13

If yes, treatment given:Admitted to hospital

Physical examination:

General appearance:

Body build: obese/Average/Thin Gait/Posture: Normal

Height: 156cm Weight : 56 kgs
Vital Signs
Temperature: 98.4° F BP-100/60 mm of hg
Pulse rate : 90 beats/min Respiratiory rate: 26 breath\min

Head to toe examination:

Skin Condition
Colour : pallor / jaundice / cyanosis./Normal
Hair and scalp: clean and healthy. No dandruff and pediculosis.
Eyes : Pallor and jaundice present, no discharge.
Ears : Normal, no discharge
Nose : No nasal polyp, septum normal and no discharge
Mouth:
Lip: Moist, pale, intact
Teeth- Normal, no dental caries, no gum bleeding Tongue- Moist, pallor and jaundice present
Throat: Cervical glands not palpable, Thyroid gland not enlarged
Breasts: elevated nipple and striae present as sign of previous pregnancy,
No palpable mass , no discharge from nipple
Chest: Chest movement is bilateral symmetrical, no abnormal sound
Heart: S1 S2 heard. no abnormal sound
Liver: Palpable Spleen: NAD

Upper extremities : Axillary lymph node not palpable, joints are flexible, Capillary refilling time less than
3 sec.
Lower extremities: Normal Back and spine: Normal

 Obstetrical examination: INSPECTION:

Uterine shape—Ovoid, Linea nigra & Striae graviderum present, Fetal movement visible, No skin
rash or incisional scar marks are present.

PALPATION FINDINGS:

Fundal Height:

In cm.—32cm

In weeks—32 wks.

Abdominal girth in cm—105cm.

Presentation & Position of fetus—Cephalic & LOA

Relative size of Head to pelvic—not engaged

AUSCULTATION:

Fetal Heart sound – 132bts/min.

Laboratory Investigation:
Blood: on 7.7.13 Hb:10.8 gm/dl
ESR: 25 mm 1st hr Blood group-AB+ve
Blood sugar Fasting /PPBS-90 mg/dl

HIV- Non reactive VDRL-Nonreactive

Urine: sugar: Nil Albumin: Nil

USG report: on 10.09.13 – Single live foetus , cephalic presentation, gestational age 35 weeks 4 days.

Placental maturity- Gr II, placenta previa, attachment partial central ( type III)

Liquor- adequate

Amniotic fluid index-8cm

DEFINITION OF APH: It is defined as bleeding from or into the genital tract after the 28th week of
pregnancy but before birth of the baby

CAUSES

IN BOOK IN MY PATIENT

Placental bleeding- Placenta Praevia

 Placenta previa
 Abruptio placenta
Unexplained: Indeterminant(Excluding
placental bleeding and local lesion)
Extraplacental cause:
 Cervical polyp
 Carcinoma cervix
 Varicose vein
 Local trauma

DEFINITION OF PLACENTA PREVIA:

When the placenta is implanted partially or completely over the lower segment of (over and adjacent to the
internal os ) it is called placenta previa

INCIDENCE: 0.5-1% among hospital delivery

In 80% cases it is found in

 Multiparous women,
 Beyond age of 35 years,
 With high birth orders pregnancies and
 Multiple pregnancy
TYPES OR DEGREE:

Type –I (Low lying): the major part of the placenta is attached to the upper segment and only the lower margin
encroaches onto the lower segment but not upto the os.

Type –II ( Marginal) : The placenta reaches the margin of the internal os but does not cover it.

Type –III( Incomplete or partial central): The placenta covers the internal os partially( covers internal os when
closed but does not entirely do so when fully dilated.

Type –IV ( Central or total): The placenta completely covers the internal os even after it is fully dilated .

CLINICAL CLASSIFICATION:

Mild degree- type –I and II anterior

Major degree: Type II posterior, Type III, Type IV

CAUSES OF BLEEDING:

 Placental growth slows down in later months and

 Lower segment progressively dilates,
 The inelastic placenta is sheared off the wall of the lower segment
 This leads to opening up of utero placental vessels and leads to episodes of bleeding.
 The separation of placenta also may be due to trauma caused during vaginal examination, coital act, external
version or during high rupture of membrane.
CLINICAL FEATURES:

IN BOOK IN MY PATIENT
Symptom: Vaginal bleeding-
Vaginal bleeding-  Sudden onset, painless, apparently
 Sudden onset, painless, apparently causeless recurrent ,
causeless recurrent , Unrelated to activity
 Unrelated to activity ,
 Often occurs during sleep and the patient
becomes frightened on awakening to find
herself in pool of blood.
In about 5% cases it occurs for the first time during
labour.

SIGNS:
Abdominal examination: Abdominal examination:
 Size of uterus is proportionate to the period  Size of uterus is proportionate to the period
of gestation of gestation
 The uterus feels relaxed, soft , and elastic  The uterus feels relaxed, soft , and elastic
without any localized area of tenderness without any localized area of tenderness
 Persistence of malpresentation like breech  The head is floating in contrast to period of
or transverse lie gestation
 The head is floating in contrast to period of  The head can not be pushed down into the
gestation pelvis
 The head can not be pushed down into the  Fetal heart sound- ranges from 130-144
pelvis beats/min
 Fetal heart sound- Slowing of fetal heart
sound on presenting the head down into the
pelvis which soon recover promptly as the
pressure is released suggests presence of
low lying placenta specially of posterior
type( stallworthy’s sign)
Vulval inspection: Only inspection is to be done
Character of blood- bright red or dark coloured
Amount of blood loss- to be assessed by checking
no of cloths soaked.
Per vaginal examination: not done

INVESTIGATIONS

IN BOOK IN MY PATIENT

USG-10.09..13
Ultra sonography- Trans abdominal Single live foetus ,cephalic presentation,
Transvaginal gestational age 35 weeks 4 days.
Trans perineal Placental maturity- Gr II, placenta previa type
Colour Doppler flow study III
Liquor- adequate
MRI
Amniotic fluid index-8cm
COMPLICATIONS

IN BOOK IN MY PATIENT
Maternal
During pregnancy
 Ante partum hemorrhage with varying  Ante partum hemorrhage with varying
degree of shock degree of shock
 Malpresentation
 Premature labour
 Death due to massive hemorrhage during
ante partum, intrapartum or postpartum
period
During labour
 Early rupture of membrane
 Cord prolaps due to abnormal attachment
of cord
 Slow dilatation of the cervix due to the
attachment of placenta on the lower
segment.
 Intrapartum hemorrhage due to further
separation of placenta with dilatation of the
cervix
 Increased incidence of operative
interference.
 PPH
 Retained placenta.
Puerperium
 Sepsis
 Sub involution
 Embolism

FETAL COMPLICATION IN PLACENTA

PREVIA

 Low birth weight  Low birth weight

 Asphyxia  Asphyxia
 Intrauterine death
 Birth injuries
 Congenital malformation
MANAGEMENT
IN BOOK IN MY PATIENT
PREVENTION
 Adequate antenatal care to improve health
status of women and correction of anemia
 Antenatal diagnosis of low lying placenta
at 20 week with routine ultrasound
examination.
 Significance of warning hemorrhage
should not be ignored.
AT HOME:
 Bed rest
 Assessment of blood loss
 Assessment of vital sign
 Gentle but quick abdominal examination
 Vaginal inspection

TRANSFER TO HOSPITAL: Arrangement is

made to shift the patient to an equipped hospital
having facilities of blood transfusion, emergency
caesarean section and neonatal intensive care unit
Admitted to hospital
ADMISSION TO HOSPITAL:
All cases of APH, even if the bleeding is slight or
absent the patient should be admitted.

TREATMENT ON ADMISSION:
IN BOOK IN MY PATIENT
Assessed amount of blood loss
IMMEDIATE ATTENTION Checked vital sign-
 Overall assessment on amount of blood loss, Temperature: 98.4° F BP-120/80
vitals, gentle palpation of abdomen to note
mm of hg
uterine tenderness and auscultation to note fetal
heart rate. Pulse rate : 90 beats/min
Respiratiory rate: 26 breath\min
 Blood samples are taken for grouping, cross
matching and estimation of hemoglobin  Blood samples are taken for grouping,
 IV infusion with normal saline, cross matching and estimation of
hemoglobin
 IV infusion with RL 8 hourly
EXPECTANT MANAGEMENT:
Selection of cases: i) mother is in good health
status(haemoglobin>10gm%; haematocrit >30%
ii) Duration of pregnancy< 37 weeks ,
iii) Active vaginal bleeding is absent.
iv)Fetal wellbeing is assured
IN BOOK
Conduct of expected management:
 Bed rest with bathroom privileges  Bed rest provided
 Periodic inspection of the vulval pad and fetal  Moist O2 inhalation given
surveillance with USG at interval 2-3 weeks  Inj Decadran 8mg 1amp IM 8 hourly 3
 Supplementary haematinics should be given days
and blood loss is replaced by blood transfusion.  Inj Drotin 1amp im stat
 Use of tocolysis (magnesium sulphate) can be  Inj Reglan 1amp
done if vaginal bleeding is associated with  Inj Rantac 1amp IM/IV stat
uterine contraction.  Foleys catheterization done
 Rh immunoglobulin to Rh negative mothers  2units blood transfused.
 Steroid therapy is indicated when the duration 
of pregnancy is less than 34 weeks.
Betamethasone reduces the risk of respiratory
distress of neonate when preterm delivery is
indicated.
DEFINITIVE MANAGEMENT:

Indication: Bleeding occurs at or 37 weeks of delivery

ii)patient is in labour iii) patient is in exsanguinated state
on admission iv) bleeding is continuing and of moderate
degree v) baby is dead or known to be congenitally
deformed
Caesarean delivery: If placental edge is within 2 cm
from the internal os
Vaginal delivery: If placental edge is clearly 2-3 cm Caesarean section done on 11.09.13 at 10 am
away from the internal cervical os
ARM + Oxytocin→ satisfactory progress of
labour→ vaginal delivery.

PRE OPERATIVE MANAGEMENT:

 Light diet on day before operation

 Perineal toileting done
 Consent taken

PREPARATION ON DAY OF OPERATION

 NPM since morning

 A thorough bath given
 Vital sign checked
 A dose of inj Ceftriaxone with APST and inj Reglan and Rantac given
 Send the patient to OT with all necessary articles and
OPERATION NOTE:

Skin prepared with spirit and betadine solution. abdomen opened→ uterus opened →delivery of baby →placenta
separated→Uterus closed in two layer. A girl baby delivered at 10 am . Baby was asphyxiated suctioning done-Baby
was kept under radiant warmer -tactile stimulation given –PPV continued for 30 sec- baby cried after that.

POST OPERATIVE ADVICE ON 11.09.13

First 24 hours---

 Moist O2 inhalation
 Nothing per mouth.
 Monitoring Pulse, Blood Pressure, Intake / output chart,bleeding per vagina.
 RL: DNS 1:1 at 6 hourly.
 Injection syntocinon 10 unit in 1st three bottle.
 Inj.ceftriaxone 1 gm I/V BD.
 Inj. Metrogyl 100 ml. I/V TDS.
 Inj. Genticine 80 mg. I/V BD.
 Inj. Voveran 1 amp IM BD.
 Inj. Rantac 1 amp I/V BD.
 Inj. Calmpose 1 amp IM Stat & SOS
 Inj. Fortwin 1 amp IM Stat & SOS.

Second day---

 Omit I/V fluid.

 Omit catheter
 Allow sips of water per mouth.
 Inj. Ceftriaxone 1gm IV BD.
 Inj. Genticine 80 mg. I/V BD.
 Tab. Rantac 1 tab. BDPC.
 Inj. Tramazac 1 amp. HS.

Third day ---

 Normal diet.
 Cont. all medicine.

Sixth day ----

 Stitches are removed.

 Incision area is healthy.
 She is discharged & following advices are given—

- - To take rest
 --To maintain personal hygiene.
--To take nutritious died & more amount of fluid.
--To take medicine as per prescription.
--To give exclusive breast feeding up to 6 months to the baby.
--To complete all immunization of the baby according to schedule.
--To keep baby clean & warm.
--To adopt family planning metho
POST-OPERATIVE CARE

In book In case of my client

 First 24 hours---
First 24 hours—  Nothing per mouth.
 Nothing per mouth.  Monitoring Pulse, Blood Pressure, Intake / output
 Checking of Pulse, Blood Pressure, chart,bleeding per vagina.
Temperature, Respiration, vaginal  RL: 5% D 2:1 at 4 hourly.
bleeding, behaviour of the uterus.  Injection syntocinon 10 unit in 1st three bottle.
 I/V fluid, blood (if required),  Inj.ceftriaxone 1 gm I/V BD.
 Medication – Inj. Methergin,  Inj. Metrogyl 100 ml. I/V TDS.
analgesic, antibiotic,  Inj. Genticine 80 mg. I/V BD.
 Ambulation.  Inj. Voveran 1 amp IM BD.
Second day—  Inj. Rantac 1 amp I/V BD.
 Oral feeding in the form of plain or  Inj. Calmpose 1 amp IM Stat & SOS
electrolyte water or raw tea may be  Inj. Fortwin 1 amp IM Stat & SOS.
given. Second day---
 The baby is put to the breast.  Omit I/V fluid.
Third day—  Allow sips of water per mouth.
 Light solid diet of the patient’s  Inj. Ceftriaxone 1gm I/V BD.
choice.
 Inj. Genticine 80 mg. I/V BD.
 Bowel is kept emptied & if not
 Tab. Emanzac 1 tab. BDPC.
spontaneously moved, 4-6 teaspoons
 Tab. Rantac 1 tab. BDPC.
of milk of magnesia is given at bed
time.  Inj. Tramazac 1 amp. HS.
Sixth or seventh day— Third day ---
 The abdominal skin stitches are to be  Normal diet.
removed on the sixth day.  Cont. all medicine.
Discharge—
The patient is discharged on the day Sixth day ----
following removal of stitches, if otherwise  Stitches are removed.
fit. Following advices are given---  Incision area is healthy.
 To take rest  She is discharged & following advices are given—
 To maintain personal hygiene.  To take rest
 To take nutritious died & more  To maintain personal hygiene.
amount of fluid.  To take nutritious died & more amount of fluid.
 To take medicine as per  To take medicine as per prescription.
prescription.  To give exclusive breast feeding up to 6 months to
 To give exclusive breast feeding the baby.
up to 6 months to the baby.  To complete all immunization of the baby
 To complete all immunization of according to schedule.
the baby according to schedule.  To keep baby clean & warm.
 To keep baby clean & warm.  To adopt family planning method.
 To adopt family planning method.

DAY TO DAY PROGRESS:

Date Vital sign Fluid electrolyte P v bleeding/ Other
 balance Dressing complain/special
management
10.09.13 Temp-98.4°F I.V Fluid RL 8 hourly, with oral Pv bleeding FHR-110 to 132
Pulse-90bts /min intake present bts/min
Resp-24 br/min Urine passed through catheter 2 pad soaked
B.P-100/60 mm Total intake 2000 ml One unit blood
of Hg Output-1200 ml transfused
Blood send for
Hb,TC,DC
Hb- 9.4 mg/dl
11.09.13 IVF omitted, allowed sips of water. LUCS done at
Temp-98.°F Pv bleeding 10.30 am
Pulse-88bts /min Urine passed through catheter present in
Resp-26 br/min Total intake-2700 ml normal amount One unit blood
B.P-90/70 mm of Urinary output-2000ml transfused after
Hg dressing dry returning fromOT

12.09.13 I/V fluid running up to 4 pm. sips of Per vaginal pain present in
Temp-97.4°F water is given per mouth from bleeding is incision area.
Pulse-90bts /min morning 10.30 am. Liquid diet is normal. Breast is soft&
Resp-20 br/min given from evening. Dressing is dry colostrums present
B.P-110/70 mm Catheter is removed on 2nd day & secured.
of Hg evening .
Total intake-2540 ml
Urinary output-2000ml

13.09.13 Temp-98.6°F Normal diet given, She passed urine Per-vaginal pain present in
Pulse-90bts /min & stool bleeding is incision area.
Resp-26 br/min normal Breast is soft&
B.P-110/70 mm Dressing is dry secretory
of Hg & secured
14.09.13 Vital sign normal Passed urine and stool Per-vaginal Pain reduced to
15.09.13 bleeding is some extent
normal
Dressing is dry
& secured

16.09.13 Vital sign normal Mother is doing well Per-vaginal Wound healthy
bleeding is Stiches removed
normal Mother is
discharged

BABY NOTES-
Day 1-11.09.13- Baby was asphyxiated .Resuscitated with suctioning, tactile stimulation and positive
pressure ventilation .Baby was send to nursery.

Day -2 -12.09.13 -Baby is active & well. Baby sucked well. Passed urine & stool normally. Baby is given
to mother and kept along with mother. No complication is there.

Baby is also discharged along with mother on 16.09.13

NURSING PROCESS – on mother & baby is written in the next page.

CONCLUSION—

This mother admitted in the hospital as in emergency condition. But by taking prompt & good decision by
the doctor mother & baby both were now in safe condition. After doing case study on this mother it is very
much clear to me & I gain practical experience & competency on giving care to a mother with antepartum
Hemorrhage.