Antepartum Haemorrhage

• Communication can be impaired under stress. (PROMPT, 2017) advises the SBAR format is succinct and effective, especially in emergencies when prompt decision making and action is required (Siassokos et al, 2010). 
• The message should be 
• formulated
• addressed to specific individuals
• delivered
• acknowledged
• acted upon 

Communication should utilise non-verbal communication, accurate terminology and respect, being clear concise and calm. 

Women and birth partners should also be communicated with. If possible, a staff member should be allocated to convey messages to them; the cause, the condition of the baby, and immediate and ultimate aims of treatment. (Bristowe et al, 2012). 

Definition

• Complicates 2-5% of all pregnancies.
• Unpredictable, can cause rapid deterioration of condition before during or after external evidence of haemorrhage
• Bleeding from or in the genital tract from 24 weeks and prior to birth of baby (RCOG, 2011) 

Spotting – staining, streaking or blood spotting noted on underwear or sanitary protection Minor haemorrhage – blood loss less than 50 ml that has settled
Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.

Symptoms

• Vaginal bleeding (concealed or revelealed) 
• Signs or symptoms of shock/ collapse
• Uterus tone/tenderness 
• Fetal condition 
• Location of placenta 
• Pain (or absence of)
• Peritonism 
• Presenting part/ lie

• Obstetric emergency; potential for rapid deterioration of both maternal and fetal condition.
• Blood loss often underestimated due to concealment especially in cases of uterine rupture or placental abruption. (RCOG, 2011)

Requires multiple rapid actions

• swift assessment of maternal and fetal condition 
• stabilise maternal condition 
• specific treatment dependant on cause; fetal condition, needs of mother, resources available. 

Call for Help 

• Emergency buzzer 
• senior midwife
• experienced obstetrician 
• experienced anaesthatist
• experienced neonatologist
• additonal support staff
• alert haematologist, blood bank, theatre, porter, MOH protocol may be activated
• Consultant obstetrician and anaesthatist to be informed 

Immediate actions

• Lie woman left-lateral; high flow oxygen with non rebreathe mask 
• clinical observations; pulse, bp, capillary refill, resp rate, O2 saturation 
• Site 2 large bore cannulae 
• Urgent bloods; FBC, kleihauer for materno-fetal haemorrhage, coag inc. fibrinogen, Xmatch 4 units, renal and LFTs 
• Rapid fluid resuscitation with 2 litres crystalloid (warmed)
• asess need for blood products

Prior to arrival

• Ascertain relevant obstetric and clinical history; 
• gestational age
• previous uterine surgery, C/S 
• position of placenta
• abdominal pain 

Examination 

• estimate blood loss 
• palpate uterus - tone and tenderness
• abdominal palpation for peritonism and ex-utero fetal parts
• assess placental site using USS
• once placenta & vasa praevia excluded, perform speculum to assess bleeding and possible causes (trauma, polyps, ectropion) 
• consider VE for stage of labour

• Massive APH (>1000ml and/or signs of shock) expediting birth of baby and placenta is most effective method; irrespective of cause, can be life saving (Charbit et al, 2007). Coagulopathy may occur
• Major APH (50-1000ml no shock) likely to expedite birth by EM/CS unless fully dilated in labour. Likely to be technically challenging and should be performed by most experienced obstetrician available. 
• If APH due to uterine rupture; dehiscence must be identified and repaired and prep for hysterectomy if required. 
• APH major risk factor for PPH, all should be prepared
• Maternal condition always takes precedence. birth indicated at any gestation; mother should be resuscitated, birth expedited. Neonatal team should be called early to prepare equipment. associated with neonatal anaemia, particularly Vasa praevia or abruption.

• Communication can be impaired under stress. (PROMPT, 2017) advises the SBAR format is succinct and effective, especially in emergencies when prompt decision making and action is required (Siassokos et al, 2010). 
• The message should be 
• formulated
• addressed to specific individuals
• delivered
• acknowledged
• acted upon

Role of midwife: Midwives are ideally placed to recognise any changes that may lead to complications. The midwife is responsible for immediate emergency response and first line management and in ensuring timely collaboration with and referral to interdisciplinary and multiagency colleagues. The midwife has specific responsibility for continuity and coordination of care, providing ongoing midwifery care as part of the interdisciplinary team, and acting as an advocate for women and newborn infants to ensure that they are always the focus of care (NMC standards of proficiency for midwives, 2019)

Documentation

of difficult and potentially traumatic birth essential. It should include a clear explanation of actions undertaken as they are reproducable by another. Pro formas can be used. This must include: 

blood loss, cause, amount, actions performed timing and sequence, vital signs, time of birth of baby, staff in attendance and time they arrived, condition of baby, umbilical cord blood acid-base measurements (cord pH or lactate), 

Debriefing

Frightening and potenitally traumatic experience. Parents should be informed about what is happening and what is being done to help, and give clear instructions during emergency. contemperaneous communication if possible increases patients feeling of safety. (Sissakos et al, 2011). Communication and explanation essential - Birth afterthoughts and datix 

Most common minor: 

·      marginal placental bleeds 

·      bleeding from ectropion

·       show  

Most common major: 

•    Placental abruption 
• Placenta praevia 
• Uterine rupture (due to forces of labour or abdominal trauma 
• Vasa praevia (fetal rather than maternal 

Placenta praevia 

-       Shock

-       Painless bleeding – visible

-       High presenting part or transverse lie

-       Non – tender/ soft uterus

Risk factors

-       Previous c/s 

-       Low lying on USS 

-       IVF

Uterine Rupture 

-       Shock

-       Sudden onset of constant sharp pain

-       Potentially concealed blood loss

-       Condition of fetus dependent on blood loss and timing of abruption

-       Peritonism

-       Abnormal/path CTG

-       High/unreachable presenting part 

-       Haematuria

-       Cease contraction

-       Fetus palpated ex-utero

-       IOL / Augmentation

-       Prev uterine surg/ C/s

-       >4 parity

-       Trauma

Vasa praevia 

-       Visible Blood loss after ROM 

-       Pathological CTG – acute foetal compromise Sinusoidal/bradycardic 

-       Normal uterus 

-       No shock 

-       Low lying placenta 

-       Succenturiate lobe 

  Placental abruption 

-       Pain constant

-       Woody tender abdomen 

-       Irritable uterus

-       Pathological/abnormal CTG

-       Bleeding (concealed or visible)

-       Shock

-       Trauma 

-       Grand multip 

-       Prev abruption 

-       Pre-eclampsia or hypertension 

-       Fetal Growth Restriction 

-       Cocaine use and smoking 

• use O- if life threatening haemorrhage and consider early use of conagulaiton products (esp. if birth will be expedited) 
• Assess fetal wellbeing; auscultate or commene CTG if gestation appropriate
• If fetal demise with abruption, high risk of >1000ml and Disseminated Intravascular Coagulation 
• Provide close clinical observation, critical care, emotional support 
• USS will miss 75% of abruption cases (RCOG, 2011)

• Awareness of limitations and referral to MDT – obstetricians seniority in understanding of deviations from the norm. 
• Communicating clearly with MDT, woman and family.
• Continuous risk assessment.
• Know national and local guidelines and policies. 
• Assess and monitor maternal and neonatal wellbeing and take necessary observations. 
• Document all aspects of history taken, immediate actions taken, procedures carried out, maternal response to all interventions, neonatal wellbeing and/or compromise, staff members present and time of arrival, outcome and plans for ongoing care.  Discuss implications for future pregnancies on discharge. 
• Uphold the principles of the code.