🤱 Maternity & Newborn · Lesson 3 of 6 · 6 min
Previa Versus Abruption: Painless or Painful
🩸 Bright red bleeding with no pain in the third trimester. Dark bleeding with a board-hard, agonizing abdomen. Both are emergencies, and for one of them a vaginal exam could be fatal.
💡 Key idea
Previa: painless bright bleeding, soft uterus, no vaginal exams. Abruption: painful dark bleeding, rigid uterus, shock, emergency delivery. Ectopic: one-sided pain and shoulder pain when ruptured.
🧠 Why it matters
PLACENTA PREVIA: the placenta covers or lies near the cervix, causing PAINLESS, bright red vaginal bleeding, usually after 20 weeks, with a soft, non-tender uterus. NO VAGINAL EXAMS, which can tear the placenta; diagnose by ultrasound, keep the client on bed rest with fetal monitoring, and plan a cesarean birth, done urgently at any gestational age if bleeding is heavy or continuous. ABRUPTIO PLACENTAE: the placenta separates early, causing PAINFUL, often dark bleeding (which may be concealed), a rigid, board-like, tender uterus, and signs of shock out of proportion to visible blood; risk factors include hypertension, trauma, cocaine use and smoking; it can cause fetal distress and disseminated intravascular coagulation. Treat as an emergency: large-bore IV access, oxygen, fetal monitoring, blood products and immediate delivery. ECTOPIC PREGNANCY: a missed period, one-sided lower abdominal pain, spotting, and, if ruptured, referred shoulder pain and shock; treated with methotrexate if unruptured and stable, or surgery. SPONTANEOUS ABORTION: bleeding and cramping before 20 weeks; count pads, save tissue, give Rh immune globulin to Rh-negative clients (since 2024 ACOG suggests forgoing it routinely before 12 weeks). GESTATIONAL TROPHOBLASTIC DISEASE (molar pregnancy): dark brown bleeding, a uterus larger than dates, very high hCG; follow serial hCG levels afterward and use reliable contraception throughout monitoring, which can last up to a year.
🏥 In the real world
🚫 A client at 32 weeks arrives with painless bright red bleeding. A student reaches for gloves to check cervical dilation. The nurse stops her: with bleeding of unknown cause, a vaginal exam can disrupt a placenta previa and cause a hemorrhage. Ultrasound first. The exam's wrong answer here is the one that looks like thorough assessment.
📌 Takeaways
- Painless bright red bleeding: previa; no vaginal exam
- Painful rigid abdomen with dark or hidden bleeding: abruption; DIC risk
- Ectopic rupture: one-sided pain, shoulder pain, shock
📖 Terms in this lesson
Placenta previa: A placenta covering the cervix, causing painless bright red bleeding; no vaginal exams.
Abruptio placentae: Early separation of the placenta, causing painful bleeding, a rigid uterus and risk of shock.
✅ Test yourself
A client at 34 weeks reports painless bright red vaginal bleeding. Which action is contraindicated?
- Ultrasound examination
- Bed rest with side-lying position
- Continuous fetal monitoring
- Digital vaginal examination
Answer: D · Digital vaginal examination
A vaginal exam can disrupt a placenta previa and trigger massive hemorrhage; placement is confirmed by ultrasound.
Which findings suggest abruptio placentae rather than placenta previa?
- Painless bright red bleeding with a soft, non-tender uterus
- Bright red bleeding after intercourse
- Spotting after a vaginal exam
- Sudden severe abdominal pain with a rigid, tender uterus
Answer: D · Sudden severe abdominal pain with a rigid, tender uterus
Abruption causes pain and a board-like uterus from blood accumulating behind the placenta.
A client with a positive pregnancy test reports sudden right lower abdominal pain and right shoulder pain, and her blood pressure is falling. What does the nurse suspect?
- Ruptured ectopic pregnancy
- Normal implantation discomfort
- Round ligament pain
- Hyperemesis gravidarum
Answer: A · Ruptured ectopic pregnancy
Unilateral pain with referred shoulder pain (diaphragmatic irritation from blood) and hypotension indicates a ruptured ectopic pregnancy.
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