What order should the nurse expect for a patient admitted with a threatened abortion

Symptoms

The most important symptom in placenta previa is painless vaginal bleeding after 20 weeks. However, there are causes of vaginal bleeding other than placenta previa. All bleeding during pregnancy should be reported to your doctor for prompt investigation and treatment.

Why the bleeding happens

During the later stages of pregnancy, the bottom part of the uterus thins and spreads to accommodate the growing baby. If the placenta is anchored to the bottom of the uterus (as occurs with placenta previa), this thinning and spreading separates the placenta and causes bleeding.

Sexual intercourse can also cause bleeding from the placenta previa in later pregnancy. During labour, the cervix thins and dilates, which would normally allow the baby to exit into the vagina. In placenta previa, the dilation of the cervix further tears the placenta and causes bleeding.

Possible complications

Some of the complications of placenta previa include:

• Major haemorrhage (bleeding) for the mother
• Shock from loss of blood
• Fetal distress from lack of oxygen
• Premature labour or delivery
• Health risks to the baby, if born prematurely
• Emergency caesarean delivery
• Hysterectomy, if the placenta fails to come away from the uterine lining
• Blood loss for the baby
• Death.

Causes and risk factors

Some of the possible causes and risk factors of placenta previa include:

• Low implantation of the fertilised egg
• Abnormalities of the uterine lining, such as fibroids
• Scarring of the uterine lining (endometrium)
• Abnormalities of the placenta
• Multiple babies, such as twins
• Multiple pregnancies - a woman who has already had six or more deliveries has a risk of one in 20.

Diagnosis methods

A pregnant woman who experiences any vaginal bleeding should be admitted to hospital and tested. Some of the tests used to diagnose placenta previa include:

• Ultrasound scan
• Feeling the mother’s belly to establish the baby’s position (the baby is sideways or presenting bottom-first in around one in three cases of placenta previa).

Digital vaginal examinations should be strictly avoided

It is sometimes difficult to tell the difference between placenta previa and placental abruption. Placental abruption is a condition where the placenta separates from the uterine wall. Both conditions are flagged by heavy bleeding of bright red blood. A vaginal examination is often used to help diagnose placental abruption, but could trigger heavier bleeding in the case of placenta previa. An ultrasound scan should always be taken first, and digital (finger) vaginal examinations strictly avoided in the case of placenta previa.

The doctor may do a speculum vaginal examination very gently to make sure the bleeding is not coming from the cervix or vagina. Once the diagnosis is made, the pregnancy needs to be very carefully monitored. Placenta previa is a potentially life-threatening condition for the both the mother and her baby.

Treatment options vary

Treatment depends on a number of factors, including:

• Whether the placenta previa is complete or partial
• The exact location of the placenta
• The amount of blood lost
• The gestational age of the baby
• The position of the baby
• The health of the baby
• The health of the mother.

Treatment during pregnancy

Medical treatment aims to ease the symptoms and prolong the pregnancy. Options may include:

• Bed rest.
• Hospitalisation.
• Close monitoring, such as using a fetal monitor and regularly checking the mother’s vital signs (for example, blood pressure).
• Blood transfusion for the mother.
• Avoiding any activity that triggers uterine contractions or irritates the cervix, such as sexual intercourse or orgasms.

Delivery

Once the baby is old enough to be delivered, a caesarean section is usually performed. The baby may need to be monitored in intensive care to make sure all is well. The mother will undergo a range of tests, including tests to check her blood cell counts and the clotting ability of her blood.

Where to get help

• 'Placenta praevia' [online], in The Merck Manual of Diagnosis and Therapy, Section 18, Gynaecology and Obstetrics, Chapter 252, Abnormalities of Pregnancy. Eds R. Berkow, M. Beers, A. Fletcher & R. Bogin. Merck & Co. Inc., Whitehouse Station, NJ, USA.

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This page has been produced in consultation with and approved by:

This page has been produced in consultation with and approved by:

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The loss of a baby through miscarriage can be very distressing. A miscarriage generally occurs for reasons outside your control and nothing can be done to prevent or stop it from happening. Most women who have had a miscarriage will go on to have a healthy pregnancy in the future.

What is a miscarriage?

A miscarriage is the loss of your baby before 20 weeks of pregnancy. The loss of a baby after 20 weeks is called a stillbirth.

Up to 1 in 5 confirmed pregnancies end in miscarriage before 20 weeks, but many other women miscarry without having realised they are pregnant.

Common signs of miscarriage include:

• cramping tummy pain, similar to period pain
• vaginal bleeding

If you think you are having a miscarriage, see your doctor or go to your local emergency department.

Many women experience vaginal spotting in the first trimester that does not result in pregnancy loss.

What are the types of miscarriage?

There are several types of miscarriage — threatened, inevitable, complete, incomplete or missed.

Other types of pregnancy loss include an ectopic pregnancy, molar pregnancy and a blighted ovum.

Threatened miscarriage

When your body is showing signs that you might miscarry, that is called a 'threatened miscarriage'. You may have light vaginal bleeding or lower abdominal pain. It can last days or weeks and the cervix is still closed.

The pain and bleeding may resolve and you can go on to have a healthy pregnancy and baby. Or things may get worse and you go on to have a miscarriage.

There is rarely anything a doctor, midwife or you can do to prevent a miscarriage. In the past bed rest was recommended, but there is no scientific proof that this helps at this stage.

Inevitable miscarriage

Inevitable miscarriages can come after a threatened miscarriage or without warning. There is usually a lot more vaginal bleeding and strong lower stomach cramps. During the miscarriage your cervix opens and the developing fetus will come away in the bleeding.

Complete miscarriage

A complete miscarriage has taken place when all the pregnancy tissue has left your uterus. Vaginal bleeding may continue for several days. Cramping pain much like labour or strong period pain is common — this is the uterus contracting to empty.

If you have miscarried at home or somewhere else with no health workers present, you should have a check-up with a doctor or midwife to make sure the miscarriage is complete.

Incomplete miscarriage

Sometimes, some pregnancy tissue will remain in the uterus. Vaginal bleeding and lower abdominal cramping may continue as the uterus continues trying to empty itself. This is known as an 'incomplete miscarriage'.

Your doctor or midwife will need to assess whether or not a short procedure called a ‘dilatation of the cervix and curettage of the uterus’ (often known as a ‘D&C’) is necessary to remove any remaining pregnancy tissue. This is an important medical procedure done in an operating theatre.

Missed miscarriage

Sometimes, the fetus has died but stayed in the uterus. This is known as a 'missed miscarriage'.

If you have a missed miscarriage, you may have a brownish discharge. Some of the symptoms of pregnancy, such as nausea and tiredness, may have faded. You might have noticed nothing unusual. You may be shocked to have a scan and find the fetus has died.

If this happens, you should discuss treatment and support options with your doctor.

Recurrent miscarriage

A small number of women have repeated miscarriages. If this is your third or more miscarriage in a row, it’s best to discuss this with your doctor who may be able to investigate the causes, and refer you to a specialist.

What are the signs of a miscarriage?

A miscarriage can occur suddenly or over a number of weeks. The symptoms are usually vaginal bleeding and lower tummy pain. It is important to see your doctor or go to the emergency department if you have signs of a miscarriage.

The most common sign of a miscarriage is vaginal bleeding, which can vary from light red or brown spotting to heavy bleeding. If it is very early in the pregnancy, you may think that you have your period.

Other signs may include:

• cramping pain in your lower tummy, which can vary from period-like pain to strong labour-like contractions
• passing fluid from your vagina
• passing of blood clots or pregnancy tissue from your vagina

What should I do if I think I’m having a miscarriage?

If you are concerned that you are having a miscarriage, call your doctor or midwife for advice and support.

Keep in mind that many women experience vaginal spotting in the first trimester of pregnancy that does not result in a miscarriage.

If you are alone, consider calling your partner or a friend for help and support.

If you have very heavy bleeding, strong pain or feel unwell, call triple zero (000) or have someone take you to your nearest emergency department.

How is a miscarriage managed?

Unfortunately, nothing can prevent a miscarriage from happening once it has begun. What happens now depends on your own health and what is happening to you.

Each approach has benefits and risks. You should discuss these with your doctor.

Expectant or natural management

Also called ‘watch and wait’, expectant management may be recommended in early pregnancy. This involves going home and waiting until the pregnancy tissue has passed from your womb by itself. This can happen quickly, or it may take a few weeks.

Medical management

You may be offered medication that speeds up the passing of the pregnancy tissue. You may be asked to stay in hospital until the tissue has passed, or you may be advised to go home.

Surgical management

You may be advised to have a form of minor surgery called a 'dilatation and curettage' (also called a D&C or a curette). This procedure is often recommended if you have heavy bleeding, significant pain or signs of infection. It may also be recommended if expectant or medical management has failed. You may also decide that you prefer this option.

This procedure is done under general anaesthesia in an operating theatre. It takes 5-10 minutes once you are asleep. The doctor opens the cervix and removes the remaining pregnancy tissue.

How is a miscarriage treated?

Once it is confirmed that you are having a miscarriage, your doctor may offer or recommend treatment. There are many options. All have benefits and risks — discuss these with your doctor.

If the miscarriage is complete

If it seems the miscarriage is complete, you should still see your doctor for a check-up. You may be advised to have an ultrasound to make sure your uterus is empty.

If you go to hospital

If you go to your hospital’s emergency department, you will be seen first by a triage nurse, who will assess how urgently you need to be seen by a doctor. Depending on your symptoms, you will either be taken in to see a doctor immediately, or you will be asked to wait.

If you are waiting to be seen and your symptoms become worse or you feel like you need to go to the toilet, let the staff know immediately.

What happens if I miscarry at home?

Some women miscarry at home before they have a chance to see their doctor or get to the hospital.

If this happens, then:

• use pads to manage the bleeding
• if you can, save any pregnancy tissue that you pass, as your doctor may recommend it is tested to see why your miscarriage happened
• take medications such as paracetamol if you have pain
• rest
• call your doctor or midwife

There is a chance you may see your baby in the tissue that you pass, but often the baby is too small to recognise, or may not be found at all. It is normal to want to look at the remains, but you may decide you do not want to. There is no right or wrong thing to do.

Some women miscarry while on the toilet. This can also happen if you are out and about, or in hospital. There is no right or wrong way to handle this.

Why do miscarriages happen?

Many women wonder if their miscarriage was their fault. In most cases, a miscarriage has nothing to do with anything you have or have not done. There is no evidence that exercising, stress, working or having sex causes a miscarriage.

Most parents do not ever find out the exact cause. However, it is known that miscarriages often happen because the baby fails to develop properly, usually due to a chromosomal abnormality that was spontaneous, not inherited.

Occasionally, miscarriage is caused by:

• hormonal abnormalities
• immune system and blood clotting problems
• medical conditions such as thyroid problems or diabetes
• severe infections causing high fevers (not common colds)
• physical problems with your womb or cervix

What are the risk factors for miscarriage?

Women are more likely to have miscarriages if they:

• are older
• smoke
• drink alcohol in the first trimester
• drink too much caffeine in coffee, tea or energy drinks
• have had several previous miscarriages

Can you prevent a miscarriage?

Living healthily — no cigarettes, no alcohol and little to no caffeine — can decrease your risk of miscarriage. It’s a good idea to avoid contact with people who have a serious infectious illness when you’re pregnant.

Who can I talk to for advice and support?

Talk to your doctor or midwife for information and advice on what do and how to look after yourself if you experience a miscarriage.

Your hospital should be able to provide details of available support services, such as bereavement support.

SANDS is an independent organisation that provides support for miscarriage, stillbirth and newborn death. You can call them on 1300 072 637 or visit www.sands.org.au.

You can also call Pregnancy, Birth and Baby on 1800 882 436, 7am to midnight (AET) to speak to a maternal child health nurse for advice and emotional support.

Last reviewed: March 2022