Key Antepartum Haemorrhage (APH)
Messages 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.

REFERENCES

  • Buchmann, E.J. 2009. Antepartum haemorhage in Cronje, H.S. and Grobler, C.J.F. (eds), Obstetrics in Southern Africa (2nd edition), Van Schaik Publishers.
  • Royal College of Obstetricians and Gynaecologists. 2011. Updated 2014. Antepartum Haemorrhage. Green-top Guideline, No 63. [Pdf]. Available at: https://www.rcog.org.uk/. Accessed September 2019.
  • Wansink, S.K. & Vijay, N. 2015. Antepartum Haemorrhage: Causes & its effects on mother and child: an evaluation, Obstetrics & Gynecology International Journal. 3(1):00072. DOI:10.15406/ogij.2015.03.00072