Assessment of Antepartum Haemorrhage
How are we supposed to approach a patient with Antepartum hemorrhage?
1. History
The following questions are useful to ask in the assessment of antepartum haemorrhage:
Amount: How much bleeding was there and when did is start?
Color/texture: Was it fresh red or old brown blood, or was it mixed with mucus?
Amniotic fluid: Could the waters have broken (membranes ruptured?)
Induced/provoked: Was it provoked (post-coital) or not?
Associated symptoms: associated Is there any abdominal pain?
Fetal activity: Are the fetal movements normal?
Risk of placental Abruption: Are there any risk factors for abruption? e.g. Cocaine use, smoking, etc.
ABC assessment and resuscitation is CRUCiAL If the bleeding doesn’t stop, or if there has already been a significant
vaginal bleed (leading to hemorrhagic stroke). Proceeding to examination is only done if the patient is
hemodynamically stable.
2. General Examination
On general examination, the following should be looked for:
Signs of shock/anemia : Pallor, distress, Capillary refill time.
Tenderness: Is the abdomen tender?
Signs of placental abruption: Hypertonic, woody uterus.
Presence of palpable contractions?
lie and presentation of the fetus: Ultrasound can be used to help.
Fetal status: Check fetal wellbeing with a CTG (Cardiotocograph) which can be done after 28 weeks of
pregnancy (yet most commonly done at ~32 weeks and onward) or by just auscultating fetal heart sounds if
younger than that.
3. Assessment of Bleeding
Lastly, the bleeding itself should be assessed:
1. Externally e.g. by having a look at the pads.
2. Cusco speculum examination: Rule out Placenta Previa First; thus Ultrasound scan is done.
Speculum examination helps in that it gives us an idea about:
- Blood Color?
- Amount of blood? The presence of any clots?
- Are there any cervical lesions? Is there any cervical dilatation, or any chance that the membranes have
ruptured?
3. Take triple genital swabs to exclude infection if the bleeding is minimal
4. Digital vaginal examination: A digital vaginal examination is Contraindicated in Placenta Previa cases. Also,
Avoid digital VE if the membranes have ruptured. Doing digital VE helps us in deciding whether the cervix has
started dilating or not. Especially if the amount of bleeding is minimal.
How are we supposed to approach a patient with Antepartum hemorrhage?
1. History
The following questions are useful to ask in the assessment of antepartum haemorrhage:
Amount: How much bleeding was there and when did is start?
Color/texture: Was it fresh red or old brown blood, or was it mixed with mucus?
Amniotic fluid: Could the waters have broken (membranes ruptured?)
Induced/provoked: Was it provoked (post-coital) or not?
Associated symptoms: associated Is there any abdominal pain?
Fetal activity: Are the fetal movements normal?
Risk of placental Abruption: Are there any risk factors for abruption? e.g. Cocaine use, smoking, etc.
ABC assessment and resuscitation is CRUCiAL If the bleeding doesn’t stop, or if there has already been a significant
vaginal bleed (leading to hemorrhagic stroke). Proceeding to examination is only done if the patient is
hemodynamically stable.
2. General Examination
On general examination, the following should be looked for:
Signs of shock/anemia : Pallor, distress, Capillary refill time.
Tenderness: Is the abdomen tender?
Signs of placental abruption: Hypertonic, woody uterus.
Presence of palpable contractions?
lie and presentation of the fetus: Ultrasound can be used to help.
Fetal status: Check fetal wellbeing with a CTG (Cardiotocograph) which can be done after 28 weeks of
pregnancy (yet most commonly done at ~32 weeks and onward) or by just auscultating fetal heart sounds if
younger than that.
3. Assessment of Bleeding
Lastly, the bleeding itself should be assessed:
1. Externally e.g. by having a look at the pads.
2. Cusco speculum examination: Rule out Placenta Previa First; thus Ultrasound scan is done.
Speculum examination helps in that it gives us an idea about:
- Blood Color?
- Amount of blood? The presence of any clots?
- Are there any cervical lesions? Is there any cervical dilatation, or any chance that the membranes have
ruptured?
3. Take triple genital swabs to exclude infection if the bleeding is minimal
4. Digital vaginal examination: A digital vaginal examination is Contraindicated in Placenta Previa cases. Also,
Avoid digital VE if the membranes have ruptured. Doing digital VE helps us in deciding whether the cervix has
started dilating or not. Especially if the amount of bleeding is minimal.
