Vaginal Bleeding

What weeks are early gestation?

0-20 weeks

What weeks are late gestation?

20-40+ weeks

What is early gestation bleeding most likely to be?

• suspected miscarriage

• ectopic pregnancy

Suspected miscarriage definition

woman with positive pregnancy tests experiencing miscarriage symptoms

Confirmed miscarriage definition

ultrasound scan in hospital confirmed pregnancy is definitely not ongoing

When can ambulance clinicians only confirm a miscarriage?

by observing a deceased baby delivered and have a pre-existing scan ruling out multiples

Miscarriage definition

spontaneous loss of pregnancy before baby reaches 24wks gestation

What proportion of pregnancies result in miscarriage?

1 in 4

When is a miscarriage most common?

in the first trimester

Miscarriage signs & symptoms

• signs of hypovolaemic shock

• maternity pad soaked within 30 mins (approx 50ml)

• total blood loss >500ml

• signif symptoms (hypotension/bradycardia)

• signs or symptoms of ectopic pregnancy

What can indicate significant bleeding?

blood under the feet or between toes

What is an ectopic pregnancy?

embryo that is implanted outside of the uterus

Signs and symptoms of ectopic pregnancy

• abdo pain

• vaginal bleeding

• delayed menstruation

• nausea

• appetite loss

What position should a ectopic pregnancy pt be kept in?

lateral position

When do symptoms of hypovolaemic shock occur?

late

When does tachycardia appear in hypovolaemic shock?

may not appear until 30% of circulating volume has been lost

When is vaginal bleeding considered time critical?

all vaginal bleeding after 20 weeks, any bleeding could result in foetal compromise

What is placenta praevia?

placenta is implanted near or covering the cervix

How painful is placenta praevia?

placenta praevia is painless - bleeding is usually painless

What can placenta praevia lead to?

haem during pregnancy or labour

When is placenta praevia identified?

After 20/40 weeks gestation

Signs and symptoms of placenta praevia

• bright red blood

• usually painless

• can be heavy

• uterus relaxed, non tender

How can bleeding with placenta praevia occur?

in late pregnancy due to contractions or sexual intercourse

How does bleeding in placenta praevia occur?

tearing of blood vessels close to cervical canal

What is placental abruption?

when the placenta detaches from the uterine wall

How can placental abruption occur?

can be a result of hypertensive disease or direct trauma

How painful is placental abruption?

constant pain and/or contractions, rarely painless

What can be seen when placental abruption occurs?

bleeding, accompanied by constant pain and/or contractions

What increases the risk of placental abruption?

• smoking doubles risk

• hypertension

• substance use

• trauma

• infection

What proportion of pregnancies have placental abruption occur?

6.5 in 1000 - <1%

Signs and symptoms of placental abruption

• severe, constant abdo pain - like a contraction

• uterus is tense, ‘woody’

• revealed bleeding may be dark in colour

Where to palpate with placental abruption?

if hx suggests abruption - don’t palpate

What may haemorrhage in placental abruption be?

• revealed - evident blood loss

• concealed - occurs within abdo/uterus

What is considered threatened preterm labour?

uterine pain/lower back pain before 37/40

How much blood does a sanitary towel hold?

100ml

How much blood does an inco sheet hold?

500ml

What position should a placental abruption pt be kept in?

lateral position

PPH

Post-partum haemorrhage

Primary PPH

• blood loss of 500ml or more

• any blood loss that results in signs of hypovolaemic shock

When does primary PPH occur?

within 24hrs of birth

Secondary PPH

• excessive bleeding from birth canal between 24hrs and 6 weeks post birth

• if maternity pad is soaked within 30 mins

4 T’s of PPH

• tone - uterine muscle needs to contract to close placental arteries

• tissue - retained tissue is leading cause of secondary PPH

• trauma - up to 90% of women tear during vaginal delivery

• thrombin - clotting disorder reduces ability to form clots

What proportion of women who give birth vaginally for the first time experience some type of tear or graze?

up to 9 in 10

When and what does perineal damage cause?

tears can occur during child birth and affects the skin and muscles of perineum

1st degree tear

superficial

2nd degree tear

involves some pelvic floor musculature

3rd degree tear

involves anal sphincter musculature

4th degree tear

complete tear of anal sphincter and partial tear of rectum

How to do fundal massage?

• single cupped hand just above umbilicus

• move in circular motion until you feel uterus tense under your hand

• don’t remove hand unless essential

EMOTIVE in PPH

• E - early recognition of PPH

• M - massage uterus

• O - oxytocic - stimulate uterus contraction

• T - TXA

• IV - IV access

• E - extricate and pre alert