Vidyadhar Bangal*
Department of Obstetrics and Gynecology, India
*Corresponding author: Vidyadhar Bangal, Department of Obstetrics and Gynecology, India
Submission: October 30, 2020;Published: November 06, 2020
ISSN: 2640-9666Volume4 Issue2
On many occasions Obstetrician encounter problems or difficulties while managing cases
of placenta praevia or while performing caesarean section for placenta praevia. At times,
patients loose large amount of blood leading to shock. Excessive and unanticipated blood loss
pose the risk of severe maternal morbidity or mortality.
Following are practical tips for managing cases of placenta praevia.
a. Admit the patient and follow standard protocol of conservative management in
antenatal ward.
b. Arrange minimum two units of blood. Ask relatives to donate blood.
c. Do not perform per vaginal and frequent per abdominal examination.
d. Let everyone including nursing staff know about the admitted case, so that anyone
can start the zero-hour management, in case patient starts bleeding at any odd hour.
e. Do not change or shift the bed of the patient. Keep the bed close to passage for
prompt transfer on stretcher.
f. Allow one female relative with the patient all the time. Write emergency contact
number of the patient’s first degree relative on the case sheet front page back side.
g. Take provisional consent for Obstetric hysterectomy, internal iliac ligation, massive
blood transfusion and admission to intensive care unit before shifting patient to operation
theatre. Additional consents may be obtained during surgery as and when it is needed
depending upon intra-operative findings and some unanticipated complication.
h. Plan termination of pregnancy by appropriate method at the completion of 36/37
weeks. There is no advantage of conservative management after completed 37 weeks.
i. Rule out placental invasion by ultra-sonography by senior sonologists. Resident
must accompany the patient when patient is shifted for sonography or to operation
theatre on stretcher.
j. Reconfirm the blood and component availability before posting the case for surgery
k. Confirm the availability of responsible relative of the patient at the time of surgery.
l. Post the placenta praevia caesarean section during routine morning OT, when whole
team is available for help. Considering the unanticipated intra operative problems, never
post elective placenta praevia caesarean section at night time.
m. Arrange/confirm the availability of two faculty members/obstetrician during
surgery.
a. Secure two IV line, use No 16/18 vein flow, collect
adequate cross matching sample, start Ringers Lactate iv
solution.
b. Arrange two units of PCV and four FFP.
c. Arrange/confirm the availability of two faculty members/
Obstetrician during surgery.
d. Mobilize adequate manpower(Residents and Interns).
e. Shift patient to operation theatre after taking high risk
consent.
f. After opening the abdomen, inspect for evidence of
abnormal vascularity of the uterus, especially lower uterine
segment. See if there is any evidence of increta and percreta,
bladder involvement, prominent vessels in broad ligament.
g. Do not be in hurry to give incision on lower segment
without proper inspection of the uterus. Do not blindly believe
USG findings regarding invasion. Call for help when needed
before opening the uterus.
h. Perform surgery/caesarean as per clinical and ultrasonographic
evaluation of the case.
i. If there is evidence of increta or percreta, perform classical
caesarean section avoiding extension of vertical incision in
lower uterine segment, deliver the baby, do not disturb the
placenta, apply temporary haemostatic clamps to both cornua
and isthmus. Plan internal iliac artery ligation followed by
obstetric hysterectomy.
j. Call surgeon, if bladder invasion is anticipated or seen on
inspection before opening the uterus.
k. Inform anesthesiologists about the surgical plan or
anticipated blood loss and operation time so that they make
necessary arrangement at their end.
l. If there is un-anticipated bleeding from lower uterine
segment, then ask second assistant to apply good aortic
compression, so as to control placental site bleeding till
further preparations/planning for surgery is done. Apply
good aortic compression using fist of the hand, so that there is
disappearance of femoral pulsation.
m. Do not fiddle with the placenta, if you feel that it is
adherent. Attempts of manual separation of adherent placenta
can result into profuse torrential bleeding resulting into
hypovolemic shock and even cardiac arrest within very short
time.
n. If placenta is seen posterior and adherent, inspect the
posterior surface of the uterus externally by exteriorization.
Judge the extent of invasion and plan further actions accordingly.
It is extremely important to anticipate the complications and
thus make necessary arrangements before posting the cases
(elective as well as emergency) of placenta praevia for surgery.
Be prepared to deal with adherent placenta or placental site
bleeding. Make sure that the operating surgeon/surgeons are
well versed with the procedures like internal iliac ligation, aortic
compression and obstetric hysterectomy.
© 2020 Vidyadhar Bangal. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.