Key Antepartum Haemorrhage (APH)
Messages For Midwives

APH evidence-based action checklist for midwives

  • Ensure you have the woman’s full history – previous miscarriage, termination or C-section; bleeding in first trimester; suspicion of placenta praevia, abruption or anatomical disorders; if she is in premature labour.
  • If a pregnant woman presents with spotting, but is no longer bleeding, and placenta praevia has been excluded after a reassuring clinical assessment, she can go home.
  • All women with vaginal bleeding, which is on-going or heavier than spotting, should remain in hospital at least until the bleeding has stopped.
  • Stay calm and think on your feet.
  • Call for immediate help and transfer to a Level 3 hospital if applicable.
  • Assess the blood loss by visualisation.
  • Observe for signs of clinical shock and commence emergency treatment protocols.
  • Reassure your patient.
  • Assess for abdominal tenderness with gentle palpation – contractions will be revealed; a tense or ‘woody’ feel to the uterus indicates a significant abruption; a soft, non-tender uterus may suggest a lower genital tract cause or bleeding from placenta or vasa praevia.
  • Avoid vaginal examination if there is any suspicion of placenta praevia – scan evidence, a high presenting part on abdominal examination, or the bleed has been painless.

More Research-Based Information for Midwives and Associated Professionals

  • Vaginal bleeding is not always serious especially in the first trimester and can be linked to:
  • Hormonal changes to the cells of the cervix
  • Placenta implantation spotting
  • Local treatable infections or lesions (cancer of the cervix is serious and requires specialist care)
  • Spotting after sexual intercourse due to puffier membranes

Placental bleeding after mid-gestation does not always pose a threat. For instance:

  • A placental edge bleed will stop after a few hours and the baby mostly won’t be affected (due to uterine stretching with slight separation of parts of the outer perimeter from the endometrium)
  • In the hours or days before active labour, benign spotting is quite common (monitor regularly)

Three main causes of APH account for almost 50% of cases, are:

  • Placenta praevia
  • Placental abruption
  • Anatomical placental abnormalities, including vasa praevia

Important APH pointers

  • Definitions of APH are inconsistent
  • Often volume of blood lost is underestimated – imperative to assess for signs of clinical shock too
  • Fetal distress or demise are important indicators of volume depletion
  • Royal College of Obstetricians and Gynaecologists (RCOG) APH classification:
  • Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection
  • Minor haemorrhage – blood loss less than 50ml, that has settled
  • Major haemorrhage – blood loss of 50–1000ml, with no signs of clinical shock
  • Massive haemorrhage – blood loss greater than 1000ml and/or signs of clinical shock

Avoiding complications is key

  • Inform all pregnant women during antenatal care of vaginal bleeding’s potentially serious risks
  • Provide excellent antenatal care with the principles of BANC Plus in mind
  • Be aware of the challenges of transportation for women from outlying areas to emergency care centres
  • Improved nutritional status can prevent or lessen the impact of APH

The complications of APH include:

  • Maternal complications such as malpresentation, premature labour, postpartum haemorrhage, shock, retained placenta, anaemia, higher rates of C-section, peripartum hysterectomy, coagulation failure, puerperal infections and even death.
  • Fetal complications such as premature delivery, low birth weight, intrauterine death, congenital malformations and birth asphyxia leading to NICU admission.

The complications of APH include:

  • Maternal complications such as malpresentation, premature labour, postpartum haemorrhage, shock, retained placenta, anaemia, higher rates of C-section, peripartum hysterectomy, coagulation failure, puerperal infections and even death.
  • Fetal complications such as premature delivery, low birth weight, intrauterine death, congenital malformations and birth asphyxia leading to NICU admission.

REFERENCES

  • Buchmann, EJ, ‘Antepartum haemorhage’ in Cronje, HS and Grobler, CJF (eds), Obstetrics in Southern Africa (2nd edition), Van Schaik Publishers, 2009
  • Royal College of Obstetricians and Gynaecologists, ‘Antepartum Haemorrhage’, Green-top Guideline, November 2011, 63. Accessed at: https://sydneynorthhealthnetwork.org.au/wp-content/uploads/2016/03/gtg63_05122011aph.pdf
  • Wansink, SK and Vijay, N, ‘Antepartum Haemorrhage: Causes & its effects on mother and child: an evaluation’, Obstetrics & Gynecology International Journal, 2015, 3(1): 00072. DOI:10.15406/ogij.2015.03.00072
2019-04-26T13:47:48+00:00