Maternity · Antepartum complications
High-Risk Pregnancy: Previa vs. Abruption, PROM/PPROM, Rh Incompatibility
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Prepared for Pass the Shift (owner: Kristina, RN). Always follow your facility’s protocols, provider orders, and current references.
1. Overview
Bleeding in the second half of pregnancy is never “normal.” The two classic causes are (the placenta is in the wrong place) and (the placenta separates too early). Rupture of membranes before labor and Rh incompatibility round out this high-yield group.
2. Placenta Previa vs. Placental Abruption
| Feature | Placenta previa | Placental abruption |
|---|---|---|
| What happens | Placenta implants low and covers or is near the cervical opening | Placenta separates from the uterine wall before birth |
| Bleeding | Painless, bright red; often sudden, may stop and recur | Dark red; may be concealed (hidden behind placenta) — bleeding seen may underestimate loss |
| Pain | None | Sudden, severe abdominal or back pain |
| Uterus | Soft, relaxed, non-tender | Firm, rigid (“board-like”), tender; may rise in height; frequent contractions with high resting tone |
| Fetus | FHR usually normal at first; malpresentation common | Fetal distress common (late decels, bradycardia, loss of variability) |
| Risk factors | Prior cesarean or uterine surgery, prior previa, multiparity, multiple gestation, smoking, advanced age | Hypertension/preeclampsia (most common), cocaine or methamphetamine, smoking, abdominal trauma (car crash, IPV), prior abruption, sudden decompression of the uterus, PPROM |
| Complications | Hemorrhage, placenta accreta spectrum (especially with previa + prior cesarean), preterm birth | DIC, hemorrhagic shock, , fetal death |
| Diagnosis | Transabdominal then transvaginal ultrasound | Clinical diagnosis; ultrasound often misses it |
| Delivery | Cesarean for complete previa (often planned ~36–37 weeks) | Depends on severity: emergent cesarean or vaginal if stable |
Key nursing rule: No vaginal exams (and nothing in the vagina — no intercourse, no tampons, no douching) with bleeding in the 2nd–3rd trimester until previa is ruled out by ultrasound. A finger in the cervix can tear the placenta and cause catastrophic bleeding.
3. Priority Nursing Care for Antepartum Bleeding
- Assess the parent: VS (tachycardia first, hypotension late), amount/color of bleeding (weigh pads), pain, uterine tone and tenderness, LOC, urine output
- Assess the fetus: continuous EFM
- Lateral positioning; bed rest as ordered
- Large-bore IV ×2, labs (CBC, type and crossmatch, coagulation, fibrinogen — low in DIC), Kleihauer-Betke test if Rh-negative to measure fetal blood in maternal circulation
- Oxygen per protocol
- Prepare for cesarean and blood products; neonatal team present
- Rh immune globulin if Rh-negative and not sensitized
- Betamethasone if < 34 weeks and delivery may be delayed
- Emotional support — these are frightening events
DIC signs to watch (abruption, HELLP, AFE, fetal demise, sepsis): oozing from IV sites, gums, or incisions; petechiae; hematuria; prolonged PT/aPTT; low platelets and fibrinogen; high D-dimer. Treat the cause; replace blood products as ordered.
4. PROM and PPROM
| Term | Meaning |
|---|---|
| (prelabor rupture of membranes) | Membranes rupture before labor begins, at ≥ 37 weeks |
| PPROM (preterm PROM) | Rupture before labor and before 37 weeks |
Why it matters: infection (chorioamnionitis, neonatal sepsis), cord prolapse or compression, preterm birth, abruption, and with very early PPROM, underdeveloped fetal lungs.
Confirming ROM: sterile speculum exam (pooling fluid), nitrazine (turns blue — alkaline), ferning under the microscope, ultrasound for fluid volume, or commercial biomarker tests. Avoid digital cervical exams in PPROM unless labor or delivery is expected (they raise infection risk).
Management:
- Term PROM: usually induce labor (often with oxytocin) rather than wait, to lower infection risk; GBS prophylaxis as indicated
- PPROM < 34 weeks (stable): expectant management in the hospital — latency antibiotics (e.g., ampicillin + azithromycin, then amoxicillin, per protocol) to prolong pregnancy and lower infection, corticosteroids, magnesium sulfate for neuroprotection if < 32 weeks and birth is imminent, fetal monitoring; delivery around 34 weeks or sooner if infection, abruption, or fetal distress
- Monitor: maternal temperature every 4 h, HR, uterine tenderness, fluid color and odor, FHR (tachycardia), WBC trend, contractions
- Pad count; no tampons or intercourse
(intraamniotic infection): maternal fever ≥ 38 °C plus fetal tachycardia, maternal tachycardia, uterine tenderness, foul or purulent fluid, high WBC. Treat with broad-spectrum IV antibiotics, antipyretics, and plan delivery; alert the neonatal team.
5. Rh Incompatibility
Pathophysiology: an Rh-negative parent carrying an Rh-positive fetus can be exposed to fetal red cells (birth, miscarriage, abortion, ectopic, trauma, bleeding, amniocentesis, external version). The parent’s immune system makes anti-D antibodies (). The first baby is usually not affected, but in later Rh-positive pregnancies those IgG antibodies cross the placenta and destroy fetal red cells → : anemia, jaundice, kernicterus, and in severe cases hydrops fetalis (heart failure, generalized edema).
Prevention — Rh(D) immune globulin (RhIG, e.g., RhoGAM):
- Give to Rh-negative, antibody-negative (unsensitized) clients — it is useless once the parent is already sensitized
- ~28 weeks routinely
- Within 72 hours after birth if the newborn is Rh-positive (dose may increase if a large fetomaternal bleed is found on Kleihauer-Betke/flow cytometry)
- After any sensitizing event: miscarriage, abortion, ectopic, molar pregnancy, bleeding, abdominal trauma, amniocentesis/CVS, external cephalic version
- IM (deltoid or gluteal), to the parent, never the infant. It’s a blood product — follow consent and verification policies
- Indirect Coombs test (on the parent) = antibodies present? Direct Coombs (on the baby’s cord blood) = antibodies coating baby’s red cells?
ABO incompatibility (parent type O, baby type A or B) also causes newborn jaundice, usually milder; can occur in a first pregnancy; RhIG doesn’t prevent it.
Sensitized pregnancy: monitor antibody titers, middle cerebral artery Doppler ultrasound for fetal anemia, intrauterine transfusion, early delivery. Newborn: phototherapy, exchange transfusion as needed.
6. Medications Summary
| Drug | Use | Key points |
|---|---|---|
| Rh(D) immune globulin | Prevent Rh sensitization | Rh-neg, antibody-neg parent; 28 wk, ≤ 72 h postpartum, after sensitizing events |
| Betamethasone | Fetal lung maturity (24–34 wk; selected later cases per guidance) | IM, 2 doses 24 h apart; may raise maternal glucose |
| Magnesium sulfate | Fetal neuroprotection < 32 wk | Same toxicity monitoring as for preeclampsia |
| Latency antibiotics | PPROM | Allergy history; complete the course |
| Tocolytics (nifedipine, indomethacin) | Short delay of preterm labor to give steroids | Generally avoided in abruption and with infection; indomethacin limited to < 32 weeks, short course |
7. Education
- Report any vaginal bleeding, fluid leakage, contractions, abdominal pain, decreased fetal movement, or fever
- With previa: nothing in the vagina; activity limits as prescribed; have a plan to reach the hospital quickly
- Abruption prevention: seat belt with lap belt below the belly and shoulder strap between breasts; stop smoking and stimulant use (offer help without judgment); BP control; screen for IPV
- Rh-negative clients: carry your blood type info; tell any provider about bleeding or trauma so RhIG can be given within 72 h
8. Memory Aids
- Previa = “Painless, Placed low, Please no exam.” Abruption = “Agonizing, Abdomen rigid, Associated with hypertension and cocaine”
- Abruption → DIC: watch for oozing
- PPROM: “Fever + fast baby = chorio until proven otherwise”
- RhoGAM: “Negative mom, positive baby, protect the next baby.” Given at 28 weeks, 72 hours (after birth or events)
- Coombs: Indirect = In mom; Direct = baby
9. NCLEX-Style Practice Questions
1. A client at 33 weeks arrives with painless bright red vaginal bleeding. Her uterus is soft and non-tender. Which order should the nurse question?
A. Continuous fetal monitoring
B. Digital cervical examination to assess dilation
C. Type and crossmatch
D. Transabdominal ultrasound
Answer: B. Painless bright red bleeding with a soft uterus suggests placenta previa. A digital exam can disrupt the placenta and cause severe hemorrhage. Ultrasound comes first.
2. A client at 36 weeks with severe preeclampsia suddenly reports intense abdominal pain. Her uterus is rigid and tender, there is minimal dark bleeding, and the FHR shows late decelerations. What does the nurse suspect?
A. Placenta previa
B. Placental abruption
C. Normal labor
D. Round ligament pain
Answer: B. Hypertension is the top risk factor for abruption. Sudden pain, a board-like uterus, and fetal distress fit; bleeding can be concealed, so visible blood underestimates the loss.
3. Which client is a candidate for Rh(D) immune globulin?
A. Rh-positive parent who delivered an Rh-negative baby
B. Rh-negative parent with a positive indirect Coombs (anti-D) titer
C. Rh-negative, antibody-negative parent at 28 weeks of gestation
D. Rh-negative parent whose newborn is Rh-negative
Answer: C. RhIG prevents sensitization in Rh-negative, unsensitized parents. It doesn’t help once antibodies exist (B), and it isn’t needed for an Rh-positive parent (A) or after birth of an Rh-negative baby (D).
4. A client at 30 weeks has PPROM and is being managed expectantly. Which findings should the nurse report immediately? Select all that apply.
A. Maternal temperature 38.4 °C (101.1 °F)
B. Fetal heart rate baseline 172 bpm
C. Clear fluid on the pad
D. Uterine tenderness
E. Foul-smelling vaginal discharge
Answer: A, B, D, E. These signal chorioamnionitis, which requires antibiotics and usually delivery. Clear fluid (C) is expected with ruptured membranes.
5. A client with a suspected abruption has bleeding from the IV site and gums. Which lab result best supports DIC?
A. Platelets 310,000/µL
B. Fibrinogen 110 mg/dL and elevated D-dimer
C. Hemoglobin 13 g/dL
D. Shortened PT
Answer: B. In DIC, clotting factors and fibrinogen are used up (low fibrinogen) while clot breakdown products (D-dimer) rise. Fibrinogen is normally high in late pregnancy, so a low value is especially worrisome. Platelets would be low and PT prolonged.
References
American College of Obstetricians and Gynecologists. (n.d.). The Rh factor: How it can affect your pregnancy [Patient FAQ]. Retrieved October 15, 2026, from https://www.acog.org/womens-health/faqs/the-rh-factor-how-it-can-affect-your-pregnancy
Anderson-Bagga, F. M., & Sze, A. (2023). Placenta previa. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539818/
Dayal, S., Jenkins, S. M., & Hong, P. L. (2024). Preterm and term prelabor rupture of membranes (PPROM and PROM). In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532888/
National Council of State Boards of Nursing. (2026). 2026 NCLEX-RN test plan. https://www.nclex.com/test-plans.page
Rosenkrans, D., Zubair, M., & Doyal, A. (2023). Rh blood group system. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK594252/
Sullivan, M., Skelly, C. L., & Rouse, C. (2025). Placental abruption. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482335/