Womens & Childrens Services Clinical Guidelines SDMS ID: P2010/0499-001 Ref No 2.

12-06WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: Vaginal bleeding in late pregnancy is one of the leading causes of antenatal hospitalisation, maternal morbidity and operative intervention. Perinatal outcomes include an increase rate of prematurity and perinatal death than in pregnancies without bleeding. Definition: Antepartum haemorrhage (APH) is defined as any bleeding into or from the genital tract after the twentieth week of pregnancy. The primary causes of APH are placental abruption (30%) and placenta praevia (20%). Assessment: Notify registrar, RMO and/or consultant Degree of resuscitation and urgency will depend upon the clinical findings. If the women is haemodynamically unstable call CODE OBSTETRIC and commence resuscitation. Obtain and document history: onset of vaginal bleeding spontaneous, trauma or post coital amount and type of loss current amount and rate of loss associated pain and or uterine activity Baseline maternal observations and consider ABCs - pregnant women can lose up to 30% of their circulating blood volume prior to showing signs and symptoms of shock. Abdominal palpation noting fundal height, lie, presentation, uterine tenderness, activity and tone. Auscultate fetal heart rate and commence CTG if: actively bleeding any uterine activity or tenderness concern about the fetal heart rate on auscultation Obtain large bore IV access and take blood for FBC and group and hold. If placental abruption suspected consider coagulation studies. Check blood group and consider Kleihauer and Anti D Avoid vaginal examination unless placental location is known.

Antepartum Haemorrhage
Assessment of bleeding in late pregnancy Midwifery and Medical Staff, Queen Victoria Maternity Unit Antepartum haemorrhage, APH, vaginal bleeding

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Following initial assessment of severity: If severe and continuing to bleed: resuscitate (resuscitation of the mother should always take precedence over resuscitation and delivery of the fetus) deliver/empty the uterus If mild/moderate and settling or stopped: establish cause with examination and investigation specific management of the cause

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: November 2006

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Performance Indicators: Review Date:

Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Developed By: Stakeholders:

AUTHORISED BY CHIEF EXECUTIVE OFFICER ..30 November 2006 Dr Stephen Ayre Date

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REFERENCES American Academy of Family Physicians 2000 Advanced life support in obstetrics (ALSO) course syllabus (4th edn). American Academy of Family Physicians, Kansas Enkin M, Keirse J, Neilsen J et al 2000 A guide to effective care in pregnancy and childbirth. Oxford University Press, London Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia Womens Hospital Australasia Clinical Practise Guidelines 2005 Cord Prolapse Online: http://www.wcha.asn.au/index.cfm/spid/1_47.cfm

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