This document provides information on the management of antepartum haemorrhage (vaginal bleeding occurring after 24 weeks of pregnancy). It defines antepartum haemorrhage and explains that it is a serious condition that requires prompt management. The initial steps in managing antepartum haemorrhage involve assessing the mother's condition, evaluating the fetus, diagnosing the cause of bleeding, and deciding on definitive treatment. Specific causes of antepartum haemorrhage discussed include abruptio placentae.

1. 4
Antepartum
haemorrhage
Before you begin this unit, please take the ANTEPARTUM
corresponding test at the end of the book to
assess your knowledge of the subject matter. You HAEMORRHAGE
should redo the test after you’ve worked through
the unit, to evaluate what you have learned.
4-1 What is an antepartum haemorrhage?
An antepartum haemorrhage is any vaginal
Objectives bleeding which occurs at or after 24 weeks
(estimated fetal weight at 24 weeks = 500 g) and
before the birth of the infant. A bleed before 28
When you have completed this unit you
weeks is regarded as a threatened miscarriage as
should be able to: the fetus is usually considered not to be viable.
• Understand why an antepartum
haemorrhage should always be regarded NOTE A fetus is viable from 28 weeks, or an
estimated weight of 1000 g, if the duration
as serious.
of pregnancy is uncertain. Antepartum
• Provide the initial management of a haemorrhage before the fetus is viable has
patient presenting with an antepartum the same serious complications as that with a
haemorrhage. viable fetus. In both cases, the management
is the same except for fetal monitoring, which
• Understand that it is sometimes is only done from 28 weeks (or 1000 g).
necessary to deliver the fetus as soon as
possible, in order to save the life of the 4-2 Why is an antepartum haemorrhage
mother or infant. such a serious condition?
• Diagnose the cause of the bleeding 1. The bleeding can be so severe that it can
from the history and examination of the endanger the life of both the mother and
patient. fetus.
• Correctly manage each of the causes of 2. Abruptio placentae is a common cause
antepartum haemorrhage. of antepartum haemorrhage and an
important cause of perinatal death in
• Diagnose the cause of a blood-stained
many communities.
vaginal discharge and administer
appropriate treatment. Therefore, all patients who present with an
antepartum haemorrhage must be regarded as

2. ANTEPAR TUM HAEMORRHAGE 101
serious emergencies until a diagnosis has been 2. Assess the condition of the fetus. If the
made. Further management will depend on fetus is viable but distressed, an emergency
the cause of the haemorrhage. delivery is needed.
3. Diagnose the cause of the bleeding,
taking the clinical findings into account
Any vaginal bleeding during pregnancy may be and, if necessary, the results of special
an important danger sign that must be reported investigations.
immediately.
The initial management and diagnosis of a
patient with vaginal bleeding is summarised in
4-3 What advice about vaginal bleeding Flow diagram 4-1.
should you give to all patients?
Every patient must be advised that any vaginal 4-5 What symptoms and signs indicate that
bleeding is potentially serious and told that this the patient is shocked due to blood loss?
complication must be reported immediately.
1. Dizziness is the commonest symptom of
shock.
4-4 What is the management of 2. On general examination the patient
an antepartum haemorrhage? is sweating, her skin and mucous
The management consists of four important membranes are pale, and she feels cold
steps that should be carried out in the and clammy to the touch.
following order: 3. The blood pressure is low and the pulse
rate fast.
1. The maternal condition must be evaluated
and stabilised, if necessary.
4-6 How should you manage a shocked
2. The condition of the fetus must then be
patient with an antepartum haemorrhage?
assessed.
3. The cause of the haemorrhage must be When there are symptoms and signs to
diagnosed. indicate that the patient is shocked, you must:
4. Finally, the definitive management of an
1. Put up two intravenous infusions (‘drips’)
antepartum haemorrhage, depending on
with Balsol or Ringer’s lactate, to run in
the cause, must be given.
quickly in order to actively resuscitate the
It must also be decided whether the patient patient.
should be transferred for further treatment. 2. Insert a Foley catheter into the patient’s
bladder to measure the urinary volume
and to monitor further urine output.
THE INITIAL EMERGENCY 3. If blood is available, take blood for cross-
matching at the time of putting up the
MANAGEMENT intravenous infusion and order two or
OF ANTEPARTUM more units of blood urgently.
4. Listen to the fetal heart:
HAEMORRHAGE • If fetal distress is present and the fetus
is assessed to be viable (28 weeks or an
The management must always be provided in estimated weight of 1000 g or more),
the following order: then deliver by the quickest possible
1. Assess the condition of the patient. If the method, usually by Caesarean section.
patient is shocked, she must be resuscitated • If fetal distress is excluded, if the fetus
immediately. is too preterm to be viable, or if there
is an intra-uterine death, then more
attention can be given to the history

3. 102 MATERNAL CARE
History of
vaginal Maternal condition? Not shocked
bleeding
Resuscitate Shocked
No Yes
A life-threatening Refer for urgent
haemorrhage? Fetal stress? delivery
Yes No
Refer for urgent What type of Antepartum Speculum
Caesarean section bleed? haemorrhage examination
Blood mixed with No local
mucus, or blood- Local cause, eg.
cause
stained discharge vaginitis or local
found
lesion
Treat local Decide between:
‘Show’ or 1. Placenta praevia
vaginitis cause of
bleeding 2. Abruptio placentae
and refer
Flow diagram 4-1: Initial management of a patient with vaginal bleeding

4. ANTEPAR TUM HAEMORRHAGE 103
and examination of the patient in If the maternal and fetal conditions are
order to make a diagnosis of the cause satisfactory, then a careful speculum
of the bleeding. examination should be done to exclude a
local cause of the bleeding. Do not perform a
4-7 What must you do if a patient presents digital vaginal examination, as this may cause
with a life-threatening haemorrhage? a massive haemorrhage if the patient has a
placenta praevia.
The maternal condition takes preference
over that of the fetus. The patient, therefore,
is actively resuscitated while arrangements Do not do a digital vaginal examination until
are made to terminate the pregnancy by placenta praevia has been excluded.
Caesarean section.
4-9 How does a speculum examination help
you determine the cause of the bleeding?
DIAGNOSING THE CAUSE
1. Bleeding through a closed cervical os
OF THE BLEEDING confirms the diagnosis of a haemorrhage.
2. If the cervix is a few centimetres dilated
with bulging membranes, or the presenting
4-8 Should you treat all patients part of the fetus is visible, this suggests that
with antepartum haemorrhage in the bleed was a ‘show’.
the same way, irrespective of the 3. A blood-stained discharge in the vagina,
amount and character of the bleed? with no bleeding through the cervical os,
No. The management differs depending on suggests a vaginitis.
whether the vaginal bleeding is diagnosed 4. Bleeding from the surface of the cervix
as a ‘haemorrhage’ on the one hand, or a caused by contact with the speculum (i.e.
blood-stained vaginal discharge or a ‘show’ contact bleeding) may indicate a cervicitis
on the other hand. A careful assessment of or cervical intra-epithelial neoplasia (CIN).
the amount and type of bleeding is, therefore, 5. Bleeding from a cervical tumour or
very important. an ulcer may indicate an infiltrating
carcinoma.
1. Any vaginal bleeding at or after 24 weeks
must be diagnosed as an antepartum
haemorrhage if any of the following are 4-10 Can you rely on clinical findings to
present: determine the cause of a haemorrhage?
• A sanitary pad is at least partially In many cases the history and examination of
soaked with blood. the abdomen will enable the patient to be put
• Blood runs down the patient’s legs. into one of two groups:
• A clot of blood has been passed.
1. Abruptio placentae.
A diagnosis of a haemorrhage always suggests 2. Placenta praevia.
a serious complication.
There are some patients in whom no reason
1. A blood-stained vaginal discharge will for the haemorrhage can be found. Such a
consist of a discharge mixed with a small haemorrhage is classified as an antepartum
amount of blood. haemorrhage of unknown cause.
2. A ‘show’ will consist of a small amount
of blood mixed with mucus. The blood-
stained vaginal discharge or ‘show’ will be
present on the surface of the sanitary pad
but will not soak it.

5. 104 MATERNAL CARE
4-11 What is the most likely cause of the other hypertensive disorders of
of an antepartum haemorrhage pregnancy.
with fetal distress? 3. Intra-uterine growth restriction.
4. Cigarette smoking.
Abruptio placentae is the commonest cause
5. Poor socio-economic conditions.
of antepartum haemorrhage leading to fetal
6. A history of abdominal trauma, e.g. a fall
distress. However, sometimes there may be
or kick on the abdomen.
very little or no bleeding even with a severe
abruptio placentae.
4-15 What symptoms point to a
diagnosis of abruptio placentae?
An antepartum haemorrhage with fetal distress
1. An antepartum haemorrhage which
or fetal death is almost always due to abruptio
is associated with continuous severe
placentae. abdominal pain.
2. A history that the blood is dark red with
4-12 What is the most likely cause of a life- clots.
threatening antepartum haemorrhage? 3. Absence of fetal movements following the
bleeding.
A placenta praevia is the most likely cause
of a massive antepartum haemorrhage that
threatens the patient’s life. 4-16 What do you expect to find
on examination of the patient?
1. The general examination and observations
ANTEPARTUM BLEEDING show that the patient is shocked, often
CAUSED BY ABRUPTIO out of proportion to the amount of visible
blood loss.
PLACENTAE 2. The patient usually has severe abdominal
pain.
3. The abdominal examination shows the
4-13 What is abruptio placentae? following:
Abruptio placentae (placental abruption) • The uterus is tonically contracted, hard
means that part or all of the normally and tender, so much so that the whole
implanted placenta has separated from the abdomen may be rigid.
uterus before delivery of the fetus. The cause of • Fetal parts cannot be palpated.
abruptio placentae remains unknown. • The uterus is bigger than the patient’s
dates suggest.
• The haemoglobin concentration is low,
4-14 Which patients are at increased
indicating severe blood loss.
risk of abruptio placentae?
4. The fetal heartbeat is almost always absent
Patients with: in a severe abruptio placentae.
1. A history of an abruptio placentae in a These symptoms and signs are typical of a
previous pregnancy. (There is a 10% chance severe abruptio placentae. However, abruptio
of recurrence after an abruptio placentae placentae may present with symptoms and
in a previous pregnancy and a 25% chance signs which are less obvious, making the
after two previous pregnancies with an diagnosis difficult.
abruptio placentae.)
The management of abruptio placentae is
2. Pre-eclampsia (gestational proteinuric
summarised in flow diagram 4-2.
hypertension) and, to a lesser extent, any

6. ANTEPAR TUM HAEMORRHAGE 105
Antepartum
haemmorhage with
symptoms or signs of
abruptio placentae
Shocked Maternal condition? Not shocked
Fetal heart No Rupture
Resuscitate Vaginal delivery
present? membranes
Yes
Yes No
Vaginal
Fetus viable?
examination
Cervix 9 cm or
more dliated and No Caesarean
fetal head section
engaged?
Yes
Vaginal
delivery
Flow diagram 4-2: Management of a patient with an abruptio placentae

7. 106 MATERNAL CARE
4-19 What should you do if the
The diagnosis of severe abruptio placentae can
fetal heartbeat is absent?
usually be made from the history and physical
examination. 1. Active resuscitation of the mother is a
priority and should have been started as
part of the initial emergency management:
4-17 What would you do if the fetal
• Two intravenous infusion lines are
heartbeat was still present?
usually needed, one of which can be a
If the fetal heartbeat is still present with an central venous pressure line inserted in
abruptio placentae, there will usually be signs the antecubital fossa.
of fetal distress. The infant will die in utero if • Two units of fresh frozen plasma,
not delivered immediately. and at least four units of whole blood
are usually needed for effective
4-18 How should you decide on resuscitation.
the method of delivery if the fetal 2. A Foley catheter is inserted into the
heartbeat is still present? bladder.
3. The pulse rate and blood pressure must
1. If the symptoms and signs are typical of an be checked every 15 minutes until the
abruptio placentae, a vaginal examination patient’s condition stabilises, and half-
should be done. hourly thereafter. The urinary output must
2. If the cervix is at least 9 cm dilated, and the be recorded hourly.
presenting part is well down in the pelvis, 4. The membranes are then ruptured,
then the membranes should be ruptured following which cervical dilatation and
and the infant delivered vaginally. If these delivery of the fetus usually occur quickly.
conditions are not present, an emergency 5. Pain relief in the form of pethidine or
Caesarean section should be done. morphine and promethazine (Phenegan)
3. If the fetus is not viable, it should be or hydroxyzine (Aterax) should be given
delivered vaginally if the diagnosis is once the patient is adequately resuscitated.
abruptio placentae.
4. While preparations for delivery are being
4-20 Why is it important to remember that
made, the mother must be resuscitated
many patients with abruptio placentae
and intra-uterine resuscitation of the fetus
have underlying pre-eclampsia?
started. However, salbutamol or nifedipine
must not be given to a patient who shows 1. Signs of shock may be present even with
any evidence of shock. a normal blood pressure. These patients,
5. When there is doubt about the diagnosis, nevertheless, need active resuscitation.
specifically when placenta praevia cannot 2. After resuscitation a hypotensive patient
be excluded on history and examination, may become hypertensive, so much so that
then a digital vaginal examination should dihydralazine (Nepresol) may have to be
not be done. If fetal distress is present and given parenterally or nifedipine (Adalat)
the fetus is viable, a Caesarean section orally.
must be done. If there is neither fetal 3. Magnesium sulphate must be given if the
distress nor severe vaginal bleeding, the patient develops imminent eclampsia.
possibility of a placenta praevia must be
investigated. An ultrasound examination NOTE These patients are haemodynamically very
or vaginal examination in theatre must unstable. Although initially they also require
active resuscitation, they quickly become
then be done.
fluid overloaded, resulting in pulmonary
oedema. Renal complications, such as
acute tubular necrosis, commonly occur.

8. ANTEPAR TUM HAEMORRHAGE 107
4-21 At your initial assessment of • Are grande multiparas, i.e. who are
the patient, how would you know para 5 or higher.
whether or not there is underlying • Have had a previous Caesarean section.
pre-eclampsia present? 2. With regard to their present obstetric
history, patients who:
By finding protein in the patient’s urine.
• Have a multiple pregnancy.
• Have had a threatened abortion,
Abruptio placentae with pre-eclampsia is a serious especially in the second trimester.
condition with a high risk of maternal death. • Have an abnormal presentation.
4-22 What complication should 4-26 What in the history of the bleeding
you watch for after delivery? suggests the diagnosis of placenta praevia?
Postpartum haemorrhage, as this is common 1. The bleeding is painless and bright red in
after abruptio placentae. colour.
2. Fetal movements are still present after the
bleed.
4-23 What action should you take to
prevent postpartum haemorrhage?
4-27 What are the typical findings
1. Syntometrine 1 ampoule should be given on physical examination in a
intramuscularly, if the patient is not patient with placenta praevia?
hypertensive. Only oxytocin is used in a
hypertensive patient. 1. General examination may show signs that
2. In addition, 20 units of oxytocin are put in the patient is shocked, and the amount
the intravenous infusion bottle. of bleeding corresponds to the degree
3. The uterus is rubbed up well. of shock. The patient’s haemoglobin
4. The patient is carefully observed for concentration is normal or low depending
bleeding. on the amount of blood loss and the time
interval between the haemorrhage and the
haemoglobin measurement. However, the
ANTEPARTUM first bleed is usually not severe.
2. Examination of the abdomen shows that:
BLEEDING CAUSED BY • The uterus is soft and not tender to
PLACENTA PRAEVIA palpation.
• The uterus is not bigger than it should
be for the patient’s dates.
4-24 What is placenta praevia? • The fetal parts can be easily palpated,
and the fetal heart is present.
Placenta praevia means that the placenta is
• There may be an abnormal
implanted either wholly or partially in the lower
presentation. Breech presentation or
segment of the uterus. It may extend down to,
oblique or transverse lies are commonly
or cover the internal os of the cervix. When
present.
the lower segment starts to form or the cervix
• In cephalic presentations, the head is
begins to dilate, the placenta becomes partially
not engaged and is easily balottable
separated and this causes maternal bleeding.
above the pelvis.
4-25 Which patients have the
highest risk of placenta praevia? The diagnosis of placenta praevia can usually be
1. With regard to their previous obstetric
made from the history and physical examination.
history, patients who:

9. 108 MATERNAL CARE
4-28 Do you think that engagement 4-32 What is the further management after
of the head can occur if there is making the diagnosis of placenta praevia?
a placenta praevia present?
1. If the patient is not bleeding actively,
No. If there is 2/5 or less of the fetal head further management depends on the
palpable above the pelvic brim on abdominal gestational age:
examination, then placenta praevia can be • With a gestational age of less than 38
excluded and a digital vaginal examination can weeks, the patient is hospitalised and
be done safely. The first vaginal examination managed conservatively until 38 weeks
must always be done carefully. or until active bleeding starts.
• If the fetus is viable (28 weeks or
more) but the gestational age is less
Two fifths or less of the fetal head palpable than 34 weeks, steroids must be given
above the pelvic brim excludes the possibility of to stimulate fetal lung maturity as
placenta praevia. delivery may become necessary within
a few days.
4-29 What do you understand • With a gestational age of 38 weeks or
by a ‘warning bleed’? more, the fetus should be delivered.
The further management of a patient
This is the first bleeding that occurs from a when her pregnancy has reached 36 weeks
placenta praevia, when the lower segment depends on the grade of placenta praevia.
begins to form at about 34 weeks, or even 2. A patient who is actively bleeding must be
earlier. delivered irrespective of the gestational age,
because this is a life-threatening condition
4-30 Are there any investigations that can for the patient. An emergency Caesarean
confirm the diagnosis of placenta praevia? section or hysterotomy must be done.
1. If the patient is less than 38 weeks pregnant The management of a patient with a placenta
and not bleeding actively, an ultrasound praevia is summarised in flow diagrams 4-3
examination must be done in order to and 4-4.
localise the placenta.
2. If the patient is 38 or more weeks pregnant, 4-33 When a patient with placenta
and not bleeding actively: praevia is less than 38 weeks pregnant
• If ultrasonology is available, an and is being managed conservatively,
ultrasound examination can be done in what amount of bleeding would indicate
order to localise the placenta. that you should deliver the fetus?
• If ultrasonology is not available, a
digital vaginal examination can be done 1. Any sudden, severe haemorrhage.
in theatre with everything ready for a 2. Any continuous, moderate bleeding, such
Caesarean section. that the drop in the patient’s haemoglobin
concentration requires a blood transfusion.
4-31 What action should you take if a
routine ultrasound examination early in 4-34 How will you further manage a patient
pregnancy shows a placenta praevia? who has been treated conservatively?
In most cases, the position of the placenta 1. With a grade 3 or 4 placenta praevia, a
moves away from the internal os of the Caesarean section should be done at 36
cervix as pregnancy continues. A follow-up weeks.
ultrasound examination must be arranged at a 2. With a grade 2 placenta praevia, a
gestational age of 32 weeks. Caesarean section should be done at 38
weeks.

10. ANTEPAR TUM HAEMORRHAGE 109
Antepartum
haemorrhage with
Maternal condition?
symptoms or signs of
placenta praevia
Resuscitate Shocked Not shocked
Caesarean Yes No
section if fetus ltrasound
Fetal distress? examination
viable
Continuing Yes
Caesarean Yes lacenta
bleeding with a ospitalise
section praevia?
fall in b?
No
No
A of No ocal
See flow ed rest to unknown cause?
diagram V weeks cause
Yes
reat local cause
Flow diagram 4-3: Management of a patient with a placenta praevia before 36 weeks

11. 110 MATERNAL CARE
lacenta praevia
of weeks
or more
rade of
placenta praevia?
rade with rade or
bleeding or rade
with engaged head and rade of placenta placenta
unengaged head praevia uncertain covering internal
or rade no bleeding
cervical os
ait for ait for Caesarian
weeks or spontaneous section
bleeding onset of labour
Careful vaginal
examination
lacental tissue
palpable in lower
segment?
Yes No
Caesarean Rupture membranes
section and deliver vaginally
Flow diagram 4-4: Management of a patient with a placenta praevia at 36 weeks or more

12. ANTEPAR TUM HAEMORRHAGE 111
3. With a grade 1 placenta praevia which ability as the upper segment to contract
bleeds now, and a presenting part that and retract after delivery. Therefore,
remains high above the pelvis, a Caesarean the same measures taken with abruptio
section should be done at 38 weeks. placentae must be taken to prevent
4. With a grade 1 placenta praevia, which postpartum haemorrhage.
does not bleed and where the fetal head
is engaged (2/5 or less palpable above the
brim), you can wait for the spontaneous ANTEPARTUM
onset of labour. The first vaginal
examination must be done very carefully. HAEMORRHAGE OF
UNKNOWN CAUSE
4-35 How do you go about doing a
vaginal examination in theatre?
4-38 When would you suspect
1. The theatre sister must be scrubbed up an antepartum haemorrhage
with her trolley ready. of unknown cause?
2. The anaesthetist must be ready with his
drugs drawn up so that, if necessary, he can In patients who fulfill all the following
proceed immediately with the induction of requirements:
anaesthesia. 1. Less severe antepartum bleeding, without
3. A careful digital examination must be signs of shock, and when the fetal
done. First feel in all four vaginal fornices: condition is good.
• If there is soft tissue between the 2. When the history and examination do not
examining finger and the fetal skull, suggest a severe abruptio placentae.
then placenta praevia is diagnosed. 3. When local causes have been excluded on
• If the fetal skull is easily felt in all four speculum examination.
fornices, then a careful examination is 4. When placenta praevia has been excluded
done through the cervix. by an ultrasound examination.
• If placental tissue is felt, then a
Caesarean section should be done. If 4-39 What should you do to exclude
not, the membranes can be ruptured other causes of bleeding if you do
with the aim of allowing a vaginal not have ultrasound facilities ?
delivery.
1. Abruptio placentae can usually be excluded
on history and examination.
4-36 If the fetus is alive, why is urgent 2. Local causes are excluded on speculum
delivery of less importance in placenta examination.
praevia than in abruptio placentae? 3. With a gestational age of 38 weeks or more,
Compared with abruptio placentae, intra- a vaginal examination is done in theatre to
uterine death is uncommon in placenta confirm or exclude placenta praevia.
praevia. However, a serious vaginal bleed due 4. If the gestational age is less than 38
to placenta praevia may still necessitate an weeks, the patient must be admitted to
immediate delivery to save the mother’s life. hospital and close attention paid to fetal
movements, especially in the first 24 hours.
4-37 Why do patients with a placenta
NOTE If available, antenatal fetal heart
praevia have an increased risk of
rate monitoring should be done on
postpartum haemorrhage? admission to hospital and every six
1. The placenta was implanted in the lower hours during the first 24 hours.
segment which does not have the same

13. 112 MATERNAL CARE
4-40 What is the most likely cause NOTE Antepartum haemorrhage could also be
of an antepartum haemorrhage due to vasa praevia. This rare cause of antepartum
of unknown cause? haemorrhage occurs when the vessels of the
umbilical cord cross the membranes near to
A small abruptio placentae that does not cause the internal os. When the membranes rupture, a
any other signs or symptoms. If the placental small amount of continuous bright red bleeding
separation is going to extend, it will usually occurs. The blood is from the fetal circulation
happen within the first 24 hours following and, therefore, the fetus can bleed to death.
the bleed. Therefore, the patient must be If the cervix is almost fully dilated, the fetus
can be delivered vaginally. If not, a Caesarean
hospitalised and closely observed during this
section must be done. The presence of fetal
period for signs of fetal distress. blood is confirmed by performing the sodium
hydroxide (Apt) test: Add one drop of blood to
4-41 How should you manage nine drops of 1% sodium hydroxide in a glass
a patient with an antepartum test tube. Read at one minute. If the blood is
haemorrhage of unknown cause? fetal, the mixture remains pink. However, if the
blood is maternal, the mixture becomes brown.
1. The patient must be hospitalised.
2. Careful attention must be given to fetal
movements, especially during the first 24 REFERRAL OF A PATIENT
hours.
WITH AN ANTEPARTUM
NOTE If available, a cardiotocogram must
be recorded on admission and then every
HAEMORRHAGE
six hours during the first 24 hours.
3. If there is no further bleeding in the next 4-43 How should you decide whether
48 hours, the patient can be discharged. a patient can be managed locally or
She must abstain from coitus for the rest of whether she should be transferred?
her pregnancy.
4. As a high-risk pregnancy, the patient must 1. Clinics and level 1 hospitals which do not
have weekly follow-ups and is advised to have blood available must refer all patients
report immediately if there is any decrease with an antepartum haemorrhage.
in fetal movements, or further bleeding. No 2. Level 1 hospitals which have blood
digital vaginal examination must be done. available, and level 2 hospitals, must manage
5. The patient must be allowed to go into patients with the following problems:
spontaneous labour at term. • A life-threatening bleed from placenta
praevia.
• Fetal distress present with a viable fetus.
A patient with an antepartum haemorrhage of • Abruptio placentae with a live, viable
unknown cause must be closely observed for fetal fetus.
distress during the first 24 hours after the bleed. 3. Abruptio placentae with a dead fetus must
be managed in at least a level 2 hospital,
because of the risk of clotting defects.
4-42 Why is an antepartum 4. A patient with abruptio placentae and
haemorrhage of unknown cause pre-eclampsia must be referred to a level 3
always regarded in a serious light? hospital as this patient is at high risk of
There is the possibility that abruptio placentae pulmonary oedema and acute tubular
may be present. If the abruptio placentae necrosis.
is going to extend, intra-uterine death may 5. A patient with a grade 3 or 4 placenta
result. The risk of such an event is greatest praevia and a viable fetus of less than
during the 24 hours following the bleed. 34 weeks, who is going to be managed

14. ANTEPAR TUM HAEMORRHAGE 113
conservatively, should be managed in at 4. A ‘show’ is the most likely cause of the
least a level 2 hospital with a neonatal discharge if the cervix is a few centimetres
intensive care unit, or a level 3 hospital. dilated with bulging membranes, or if the
presenting part of the fetus is visible.
4-44 When you refer a patient, what 5. A vaginitis is the most likely cause, if a
precautions should you take to ensure blood-stained discharge is seen in the
the safety of the patient in transit? vagina.
1. A shocked patient should have two
4-48 How should you treat a blood-stained
intravenous infusion lines with
discharge due to vaginitis in pregnancy?
Plasmalyte B or Ringer’s lactate running
in fast. A doctor should accompany 1. If a microscope is available, make a wet
the patient if possible. If not possible, a smear of the discharge. The specific
registered nurse should accompany her. organism causing the vaginitis can then be
2. A patient who is no longer bleeding should identified and treated.
also have an intravenous infusion and
be accompanied by a registered nurse NOTE A wet smear of the discharge is
whenever possible. made, in both saline and 2% potassium
hydroxide and examined.
2. If a microscope is not available:
A BLOOD-STAINED • Organisms identified on the cervical
VAGINAL DISCHARGE cytology smear are the most likely
cause of the vaginitis.
• If no organisms are identified on the
4-45 How would a patient generally cytology smear, or a smear was not
describe a blood-stained vaginal discharge? done, then Trichomonas vaginalis is
most probably present.
A patient would probably describe a blood-
stained vaginal discharge as a vaginal To treat a Trichomonal vaginitis, both the
discharge mixed with a small amount of blood. patient and her partner should receive a single
dose of 2 g metronidazole (Flagyl) orally.
4-46 How would a patient generally
describe a ‘show’? 4-49 Should metronidazole be
used during pregnancy?
A patient would probably describe a ‘show’
as a slight vaginal bleed consisting of blood Metronidazole should not be used in the first
mixed with mucus. trimester of pregnancy, unless absolutely
necessary, as it may cause congenital
4-47 How should you manage a patient abnormalities in the fetus. The patient and her
with a history of a blood-stained partner must be warned that metronidazole
vaginal discharge or a ‘show’? causes severe nausea and vomiting if it is
taken with alcohol. The risk of congenital
1. After getting a good history and abnormalities caused by alcohol may also be
ensuring that the condition of the increased by metronidazole.
fetus is satisfactory, a careful speculum
examination should be done.
4-50 How do you manage a patient
2. The speculum is only inserted for 5 cm,
with contact bleeding?
carefully opened, and then introduced
further until the cervix can be seen. 1. When there is normal cervical cytology
3. Any bleeding through a closed cervical os (Papanicolaou smear), the contact bleeding
indicates an antepartum haemorrhage.

15. 114 MATERNAL CARE
is probably due to a cervicitis. If it is 4. What should be done once the
troublesome, the patient should be given condition of the patient and her
a course of oral erythromycin 500 mg fetus have been assessed, and the
six-hourly for seven days. patient resuscitated, if necessary?
2. With abnormal cervical cytology, the
The cause of the antepartum haemorrhage
patient should be managed correctly.
must be sought and managed.
Cervical intra-epithelial neoplasia causes
contact bleeding.
4-51 What action should you take when the
CASE STUDY 2
bleeding is from a cervical ulcer or tumour?
A patient who is 32 weeks pregnant,
The patient most probably has an infiltrating according to her antenatal card, presents
cervical carcinoma and should be correctly with a history of severe vaginal bleeding and
managed. abdominal pain. The blood contains dark
clots. Since the haemorrhage, the patient has
NOTE When there is doubt about the
not felt her fetus move. The patient’s blood
diagnosis, a cytology smear and biopsy
pressure is 80/60 mm Hg and the pulse rate
of the lesion must be taken. The results
should be obtained as soon as possible. 120 beats per minute.
1. What is your clinical diagnosis?
CASE STUDY 1 The history is typical of an abruptio placentae.
A patient who is 35 weeks pregnant presents 2. If the clinical examination confirms the
with a history of vaginal bleeding. diagnosis, what should be the first step
in the management of this patient?
1. Why does this patient need
The patient’s blood pressure and pulse rate
to be assessed urgently?
indicate that she is shocked. Therefore, she
Because an antepartum haemorrhage should must first be resuscitated.
always be regarded as an emergency, until a
cause for the bleeding is found. Thereafter, the 3. What is the next step that
correct management can be given. requires urgent attention in the
management of the patient?
2. What is the first step in the
As the fetus is viable, it is of great importance
management of a patient with an
to establish whether the fetus is still alive.
antepartum haemorrhage?
Therefore, it must be urgently established
The clinical condition of the patient must whether the fetal heartbeat is present or not.
be assessed. Special attention must be
paid to signs of shock. If shock is present, 4. How should you manage the patient
resuscitation must be started urgently. if a fetal heartbeat is heard?
A vaginal examination must be done. If
3. What is the next step in the
the cervix is 9 cm or more dilated and the
management of a patient with an
fetal head is on the pelvic floor, then the
antepartum haemorrhage?
membranes should be ruptured and the fetus
The condition of the fetus must be assessed. delivered vaginally as quickly as possible.
The presence of fetal distress will influence the Otherwise, an emergency Caesarean section
choice of management. must be done as soon as the patient has been

16. ANTEPAR TUM HAEMORRHAGE 115
resuscitated. Immediately before starting the 3. How should the patient be managed
Caesarean section, make sure that the fetal if she should have a severe bleed?
heartbeat is still present.
An emergency Caesarean section must
be done, as soon as the patient has been
5. Should the above patient be adequately resuscitated.
transferred to a level 2 or 3 hospital
for delivery, if the fetus is still alive?
4. What investigations should be done
The patient should be delivered in any hospital if the patient is not bleeding actively
which has facilities for doing a Caesarean during your initial clinical examination?
section. Moving the patient because the fetus
A ultrasound examination must be done to
is regarded as preterm may result in an intra-
confirm the clinical diagnosis. After placenta
uterine death during transport. If necessary,
praevia has been excluded, a careful speculum
the newborn infant can be transported to a
examination should be done to exclude any
level 2 hospital with a neonatal intensive care
local cause for the bleeding.
unit. The risk of a clotting defect is low if the
fetus is still alive.
5. How should the patient be managed
if she has had no further severe
6. How should you manage this patient
bleeding after the initial bleed?
if a fetal heartbeat is not heard?
She should be hospitalised and managed
The membranes should be ruptured and the
conservatively until 36 or 38 weeks gestation,
fetus delivered vaginally, if possible.
or until she starts to bleed actively again.
Depending on the degree of placenta praevia,
a Caesarean section should be done at 36 or 38
CASE STUDY 3 weeks or spontaneous labour can be awaited.
A patient is seen at the antenatal clinic at 35
weeks gestation with a breech presentation. CASE STUDY 4
The patient is referred to see the doctor the
following week, for an external cephalic
A patient books for antenatal care at 30 weeks
version. That evening she has a painless, bright
gestation. When you inform her of the danger
red vaginal bleed.
signs during pregnancy, she says that she has
had a vaginal discharge for the past two weeks.
1. What is your diagnosis? At times the discharge has been blood stained.
The history and the presence of an abnormal
lie suggest that the bleeding is the result of a 1. Has this patient had a
placenta praevia. antepartum haemorrhage?
The history suggests a blood-stained vaginal
2. What should the initial discharge rather than an antepartum
management of the patient be? haemorrhage.
The condition of the mother should first
be assessed and the patient resuscitated, if 2. What is the most probable cause of
necessary. Then the fetal condition must be the blood-stained vaginal discharge?
assessed. The patient’s abdomen should also be
A vaginitis. This can usually be confirmed by a
examined, to determine whether the clinical
speculum examination.
signs support the diagnosis of placenta praevia.

17. 116 MATERNAL CARE
3. How can the cause of the vaginalis is presumed to be the cause of the
vaginitis be determined? vaginitis.
During the speculum examination, a sample of
the discharge should be taken and a wet smear 5. How should you treat a patient
made. Organisms seen on the wet smear are with Trichomonal vaginitis?
probably the cause of the vaginitis. A single dose of 2 g metronidazole (Flagyl)
is given orally to both the patient and her
4. What is the most likely cause of a partner. Both must be warned against
vaginitis with a blood-stained discharge? drinking alcohol for a few days after taking
metronidazole.
Trichomonas vaginalis. Therefore, if a
microscope is not available, Trichomonas