ANTEPARTUM HAEMORRHAGE

Antepartum haemorrhage is defined as bleeding from the genital tract after the 28th week of
pregnancy and before the birth of the baby. The bleeding is often due to premature separation
of the placenta. Lesions of the cervix or trauma along the genital tract may also cause
bleeding and there is no means of telling where the bleeding is coming from by merely
looking at the patient. As such, a midwife should regard any vaginal bleeding as coming from
the placental site until otherwise proved. Bleeding before the 28th week of pregnancy should
be regarded as a sign of abortion.

CLASSIFICATION

Antepartum haemorrhage is classified according to the site of the placenta. (1) Accidental
antepartum haemorrhage is bleeding from premature

separation of a placenta situated in the upper uterine segment. (2) Antepartum haemorrhage
due to placenta praevia or unavoidable antepartum haemorrhage is bleeding from a placenta
situated partially or wholly in the lower uterine segment. The term 'unavoidable' explains the
fact that the placenta is bound to separate prematurely following the contraction of the lower
uterine segment and subsequent dilatation of the cervix.

(3) Unclassified antepartum haemorrhage; in this group of patients there is neither evidence
of placenta praevia nor of accidental haemorrhage. The cause of the bleeding may not be
determined even after delivery. Usually such bleeding may be due to incidental findings such
as cervical erosion, vascular ulcerated polypus, and, rarely, carcinoma of the cervix.

Management of patient with unclassified bleeding

The midwife may not be faced with the responsibility of diagnosing this type of antepartum
haemorrhage but she has a duty to see that the patient does not lose her life and that of her
baby. As such, she gives the best first aid treatment she can, before transferring the patient to
a good modern hospital with facilities to cope with massive antepartum haemorrhage. The
patient is kept warm and calm in bed, the foot of which may be raised to prevent shock.
Intramuscular injection of pethidine (100 mg) is given if available, otherwise choral hydrate
(2 g) is given to allay anxiety. The patient's general noting her pulse, presence of pallor,
blood condition is quickly assessed by noti pressure and oedema. A gentle abdominal
examination is carried out to determine the lie of the foetus and the engagement of the
presentation. Presence of pain, tenderness, uterine consistency and malpresentation are also
noted. On no account should a vaginal examination be done. Vaginal examination may
provoke further haemorrhage which could endanger the patient's life. A rough estimation of
blood loss is made by the midwife and patient's filed pads removed from the patient should
be kept for the doctor allcloth quarter-hourly record of the blood pressure, pulse and
respirator to see Auld be kept. The midwife should pay particular attention to signso shock
such as marked increase in the pub arate hypotension, perspiration cold clammy skin and,
sometimes, signs of air hunger. old clampossible and practicable, medical aid should be sent
for, but in most circumstances it is much better and practical to transfer the patient without
delay to hospital by ambulance, or suitable public transport if an ambulance is not available.
The nurse should accompany the patient to the hospital to give an account of her observations
and treatment. The patients relatives should accompany her to donate blood. In remote rural
areas where the midwife is working single-handed, the patient may have to be accompanied
by her relative while the midwife writes a detailed account of her examination findings and
treatment given in a letter to be taken by the patient's relatives to the hospital to which the
patient is being transferred.

Medical and If the patient is first seen in the hospital, the midwife should inform the doctor
immediately of the patient's arrival. She may still have to give the prescribed first aid
management where the doctor's arrival is delayed. In some rural maternity centres there are
no doctors to send for, or it may not be easy to get in touch with a doctor. In such a situation,
the midwife should do her utmost to get the patient into a fit state to travel to the nearest
hospital.

Management in the hospital

The management of antepartum haemorrhage in the hospital depends on the severity of the
bleeding and the duration of pregnancy. On the patient's arrival the midwife puts her to bed,
informs the doctor and carries out the first aid treatment if necessary and also prepares for the
investigation and treatment of the patient by the doctor. (a) taking blood for A, B, O and
Rhesus blood grouping and cros matching of the blood;

Equipment is got ready for:

(b) haemoglobin or packed cell volume estimation; (c) haemoglobin genotype determination;

(d) clotting time and fibrin index;

(e) intravenous therapy with dextrose, blood and Pitocin; (f) injection of pethidine, atropine,
etc.;

g) oxygen. ( Tore midwife then shaves the patient's pubic and vulval hair, tests her urine for
sugar, albumin, acetone and sets up Esbach's quantitative albuminuria. Abdominal
examination as previously described is carrie patie Permission for patient or her next of kin.
Blood banks are few and blood available in most hospitals in therefore persuade and explain
to the patient's relatives to come forward test if there and donate blood. In some cases
arrangement could be made to bleed the developing countries.

Severe antepartum haemorrhage

Active treatment or termination of pregnancy is indicated when the bleeding is severe and
there is great danger of maternal collapse and foetal bleeding such circumstances, the
following should be done.

(a) steps are taken to recitate the patient immediately by giving intravenous infusion while
blood is being procured, but intravenous dextrans should not be given before the blood
specimen for grouping and cross-match is obtained from the patient.

(b) maternal pulse, blood pressure and foetal heart rate are recorded at quarter-hourly
intervals.

(c) oxygen is administered by mask.

(d) blood is taken for grouping and cross-matching and haemoglobin estimation.

(e) the theatre is prepared for caesarean section.

the anaesthetist is called.

(g) the patient is prepared for examination under anaesthesia.

Slight antepartum haemorrhage

When bleeding is slight and the patient is in good condition, conservative treatment is given.
This entails resting the patient, observing her closely and making some investigations with a
view to prolonging the pregnancy until the baby is mature and preventing further bleeding.
The patient is confined to bed and not allowed up for any purpose. Her vulva is shaved and
washed and sterile perineal pads are worn. To ensure complete rest and relaxation,
phenobarbitone (30 to 60 mg) is given twice daily and sodium amytal (200 mg) at night.
Blood investigations, described under 'Management in the hospital,' are carried out and one to
two litres of blood are cross-matched and kept ready in case the patient bleeds profusely. The
perineal pad should be inspected at least four times daily noting evidence of fresh bleeding. If
such is present, the pads are kept for inspection by the doctor. Vulval toilet is done twice
daily since the patient is confined to bed and cannot clean herself. A gentle abdominal
examination, noting pain, tenderness, foetal heart sounds, and the size of the baby is done
twice daily. The blood pressure, pulse, temperature and respiration are also recorded twice
daily. Routine urine testing is done daily to exclude albuminuria. Magnesium hydroxide (30
ml) may be given daily to avoid constipation and straining at defaecation. Drugs such as
daraprim (25 mg weekly), folic acid (5 mg daily) and ferrous sulphate (200 mg) are given to
prevent anaemia and promote good health. Diet The patient's food should be rich in protein
and vitamins. In non- catering hospitals, the relatives must be instructed on what kinds of
food to bring. Such food must be inspected by the midwife before delivery to the patient.

Investigations

1) The doctor often does a speculum examination 48 to 72 hours after all ( bleeding has
stopped. This is to exclude cervical lesions such as 182 Antepartum carcinoma of the cervix
and other incidental causes of antepartum haemorrhage.

(2) Pre-eclampsia and hypertension are excluded by the routine recording of blood pressure,
urine testing and examination of the patient for oedema.

(3) Packed cell volume e is estimated at least twice weekly.

(4) An attempt at placental localization is done by way of placentrography or angiography.

Chest x-ray may be done in unbooked patients to tuberculosis. exclude pulmonary tub

(5) Ultrasound scanning is a helpful diagnostic tool where facilities are available. The patient
is allowed up five days after cessation of bleeding, but she must be kept under close
observation. The decision to keep the patient in hospital or discharge her is the doctor's.
Usually it is wise to keep the patient in hospital until examination under anaesthesia, even if
placentography or ultrasound scanning fails to reveal placenta praevia.

Placenta praevia

In this condition the placenta is situated, wholly or partially in the lower uterine segment. The
stretching and dilatation of the lower uterine segment during the later weeks of pregnancy
causes premature separation of the placenta and subsequent bleeding. The bleeding is not
associated with any pain or exertion. The first few episodes of bleeding are usually slight but
subsequent episodes may be profuse and may endanger the patient's life.

The small painless haemorrhages are often called warning haemorrhages and the patient
usually ignores the first two or three episodes of bleeding. It is the profuse bleeding that
brings many of our illiterate patients to the hospital. Diagnosis

The most reliable method of diagnosing placenta praevia is by feeling the placenta through
the cervical os. However, such an examination should only be carried out in an operating
theatre ready for caesarean section with some amount of blood available for transfusion. The
diagnosis of placenta praevia may be based on:

(1) History of painless recurrent haemorrhages.

(2) The fact that the general condition of t of the patient is directly proportional

(3) The following findings on abdominal examination: made to enter the pelvic brim to the
amount of vaginal bleeding.

(a) a high presenting part which cannot be aleasily;

(b) abnormal lie of the foetus, e.g. transverse lie;

(c) the uterus is neither hard nor tender on palpation as is found in concealed accidental
haemorrhage;

d) the foetal parts are easily felt and the foetal heart sounds are usually heard;

(4 ) x-ray examinations: these are aimed at localization of the placenta. The

methods commonly employed are: a) placentography. A soft tissue x-ray is taken with the
patient in standing position. Her bladder must have been emptied Placentography is useful
after the 34th week of pregnancy when the lower segment is being formed;

(b) angiography. this is an x-ray examination involving the injection of radio-opaque

substance into the blood vessels. This method is reliable, especially if the patient is less than
34 weeks pregnant. Preparation for the procedure entails starving the patient for 10 hours, a
pre-medication of Largactil (50 mg), and pethidine (50 mg) is given an hour prior to the
procedure. A catheter is inserted into the femoral artery and 60 per cent Urografin is injected
via the catheter. The x-ray will show the radio-opaque substance in the intervillous spaces.
Pelvic angiographic diagnosis of placenta praevia is not to be recommended as a routine
procedure. Diagnosis using radio-active isotopes is not without hazards. Ultrasound scanning
is a safe and efficient diagnostic method. Causes The cause of implantation of a placenta in
the lower uterine segment is not clearly understood. It is more common in multiparous
women. In multiple pregnancy the large placental site may encroach into the lower uterine
segment.

Types of placenta praevia

The following types of placenta praevia have been described.

(1) Lateral or type I placenta praevia. In this type the placenta is situated mainly in the upper
uterine segment with only a tip of it encroaching on the lower uterine segment. T The
placenta is not easily reached through the undilated cervical os by the examining finger.

(2) Marginal or type II placenta praevia. A greater part of the placenta is attached to the lower
uterine segment in such a way that its lower margin extends to the undilated internal cervical
os.
(3) Complete or type III placenta praevia. In this variety, the placenta completely covers the
undilated internal os, but its lower margin is still within reach of the examining finger. As
such it covers the os when it is only 6 cm dilated but not when it is fully dilated."

14) Central or type IV placenta praevia. In this case, the placenta completely covers the
undilated internal cervical os and the margin cannot be reached by the examining finger. It
completely cove covers the entire os, even at full dilatation. An anterior or posterior variety is
described for each of the four types of placenta praevia.

Management

The management of placenta praevia when the diagnosis is established depends on the
amount of blood loss, the maturity of the foetus and the degree of the place am praevia. The
aim is to control haemorrhage and save the mother and her foetus from excessive blood loss.

This immediate termination of the pregnancy is referred to as active treatment. This is indate
termination of the pregnanre of the patient fails to respond to eservative treatment; that is,
there is an onset of further brisk loss or intra- uterine dive is, there is an treatment, the patient
is managed as described of the foetus. For the acum haemorrhage. An urgent vaginal
amination under a revere antepartum fine foetal heart sound is present, a lower uterine
stranaesthesia is medioff is carried out. If the baby is dead, the membranes are ruptured and a
leg is brought down and a 450 gram weight is attached to the baby's foot to compress the
placenta and control bleeding. If types II posterior, III or IV placenta praevia are diagnosed
caesarean section is performed to avoid massive haemorrhage and consequent foetal
exsanguination and death.

Diagram showing the Types of placenta Praevia

At about the 38th week of gestation an examination under anaesthesia is carried out in the
operating theatre which is set for caesarean section inhe patient should be having blood
transfusion at the time of the examination and another 1 or s theatre. Equipment litres of
blood are kept handy in an ice box in the for resuscitation of a collapsed patient and
asphyxiated baby should also be ready.

Dangers of placenta praevia

The main danger of placenta praevia is haemorrhage. The risk from antepartum and
postpartum haemorrhage is great. Postpartum haemorrhage occurs because the lower uterine
segment does not contract and retract efficiently. The mother may die of shock secondary to
massive haemorrhage. Puerperal sepsis consequent on haemorrhage, anaemia, and debility
are also serious risks to the mother. Failure to replace blood loss or grossly inadequate
replacement of the massive blood loss in the patient may lead to supression of urine resulting
from acute tubular necrosis of the kidney. Foetal hypoxia and stillbirth are likely if more than
one-third of the placenta has separated before treatment. In conclusion, the prognosis for the
mother and foetus is good if active steps are taken to control the bleeding and resuscitate the
patient.

Accidental haemorrhage

Accidental haemorrhage is bleeding from premature separation of a placenta situated in the

upper uterine segment. The term abruptio placentae means to tear apart and it describes the
situation better than accidental haemorrhage.

Causes

Abruptio placentae may be associated with severe hypertension, pre-eclampsia and

eclampsia. A strenuous physical effort or acute emotional stress may precipitate the
occurrence of accidental haemorrhage. Abruptio placentae has been known to occur
following external cephalic version and artificial rupture of membranes. The bleeding of
abruptio placentae is usually associated with pain due to uterine contractions. The bleeding
may escape through the cervix and vagina, it may be retained in the uterus with very little
vaginal bleeding, and there may be a combination of both types. The terms revealed,
concealed and mixed respectively are used to describe these varieties of bleeding.

Revealed haemorrhage

The bleeding may be slight or profuse but the patient's condition is proportional to the
amount of blood she has lost. Revealed haemorrhage following abruptio placentae is fairly
common and may be confused with bleeding due to placenta praevia except for the presence
of pain. Moreover, the heavy bleeding of placenta praevia has in many cases been preceded
by small recurrent haemorrhages.

Concealed accidental haemorrhage

Concealed accidental haemorrhage is the most severe variety of accidental haemorrhage. The
bleeding is concealed and there is a wide area of placental large retro-placental blood clot.
The separation with the formation of a large sanical picture is typical. The patient is usually
in a state of shock because of clinical sive concealed bleeding and her condition is far out of
proportion to the masount of external bleeding if any. The pulse rate is rapid and the volume
is ssmall. The blood pressure is e is low. The patient looks ill and anxious There may be signs
of pre-eclampsia. There is a constant excruciating abdominal pain. The abdomen is woody
hard and tender to touch. The every difficult to palpate and the foetal heart sounds are absent
foetal parts are v because the separation of the greater part of the placenta might have resulted
in intra-uterine death of the foetus. The blood coming from the vagina may fail to clot due to
hypofibrinogenaemia.

Mixed haemorrhage

The majority of cases of concealed accidental haemorrhage present as mixed haemorrhage for
there is usually some revealed bleeding even in the so- called concealed haemorrhage. The
patient may be shocked, depending on the amount of blood lost, and the degree of shock is
usually out of proportion to the amount of external bleeding.

Management of accidental haemorrhage

It is imperative that all cases of accidental haemorrhage be sent to a big hospital with
facilities for urgent blood transfusion. The first aid treatment given under management of
unclassified antepartum haemorrhage is given before the patient is transferred to hospital. All
urine passed should be measured and tested for albumin and acetone. The midwife should
accompany the patient to the hospital, taking some of the patient's relatives to donate blood.
Records kept, including that of the total blood loss, are taken to the hospital.

In the hospital, the patient is admitted and a good history of the patient's previous health,
onset of the bleeding and any resuscitative measures already given is obtained. The patient's
general condition is assessed including abdominal examination, but vaginal examination is
avoided. Pethidine (100-150 mg) is given by intramuscular injection and oxygen is
administered if necessary. Blood is taken for haemoglobin estimation or packed cell volume,
grouping and cross-matching. Clotting time and fibrinogen index are estimated. Intravenous
infusion of 5 per cent glucose may be given pending the arrival of blood transfusion. Fresh
blood, which is rich in fibrinogen, should be given after due cross-matching. About 3 litres of
fresh blood may be needed so the patient's relatives should be asked to donate blood. The first
litre of blood is run in rapidly (depending on the degree of shock). The blood coming from
the vagina is examined for evidence of clotting. In small hospitals, some blood is withdrawn
in a glass capillary tube and held in the palm for the clotting time to be determined.
Transfusion of triple strength plasma is given if there is evidence of hypofibrinogenaemia.
Fresh blood and fibrinogen are also given if available. Usually the obstetrician solicits the
assistance of a haematologist who carries out full investigations an attempt is made to treat
hypofibrinogenaemia.
The midwife should keep accurate records of blood loss, the pulse rate, respiratory rate and
blood pressure of the patient. A fluid chart is kept and urinary output is carefully observed.
This ought to be 30 ml per hour. specimens of urine should be rested for albumin. The patient
is prepared for operation and asked to sign a consent form. She is then taken to the operating
theatre where in the amination under anaesthesia is done to exclude placenta praevia. In the
absence of placenta praevia the membranes are ruptured and an intravenous Pitocin infusion
is set up. Caesarean section is not done because the foetus often dies in utero and the risk of
bleeding from hypofibrinogenaemia is increased. Postpartum haemorrhage is common after
concealed antepartum haemorrhage. Further blood loss should therefore be prevented by the
prophylactic use of intravenous ergometrine given with the delivery of the anterior shoulder
if the presentation of the foetus is cephalic, or with the crowning of the head if the
presentation is breech. If no doctor is available at the time of delivery, the midwife should
give intramuscular syntometrine with the delivery of the anterior shoulder or crowning of the
head. After delivery the placenta must be examined for evidence of retro-placental blood
clots which are found on the maternal surface of the placenta. These blood clots must be
weighed and the weight recorded.

A patient with concealed accidental haemorrhage is usually not out of danger until several
hours after delivery. So she must be watched for evidence of further vaginal bleeding. The
pulse rate and blood pressure should be checked at half-hourly and two-hourly intervals
respectively, and this is done during the first 24 hours after delivery. It is very important to
record the urinary output and keep an accurate fluid chart because oliguria or anuria due to
acute renal failure is not uncommonly seen in cases of severe concealed accidental
haemorrhage. Once good urinary output has been maintained and the pulse rate and blood
pressure have remained normal for 48 hours, the patient does not need more than the usual
routine observations.

Unclassified antepartum haemorrhage

In this variety of antepartum haemorrhage, there is usually no evidence of placenta praevia or

accidental haemorrhage. However, this does not mean that such haemorrhage should be taken
lightly. It can be massive and can expose the patient to the risk of shock and death. The
midwife's management is the same as described under the general management of placenta
praevia or accidental haemorrhage.