DAY 4
📅 Nov 13 (Wed)
🩸 Antepartum Hemorrhage
DME 121: Bleeding in Pregnancy
- APH Definition & Causes (Placenta previa, Abruptio placenta)
- Management (Stabilize mother, deliver baby)
- DIC Risk (Consumptive coagulopathy)
- Rhesus Incompatibility (Anti-D prophylaxis)
🩸 REMEMBER: Placenta previa = PAINLESS bleeding. Abruptio = PAINFUL bleeding. Both EMERGENCIES!
🚨 KEY POINT: APH = never do vaginal exam until US excludes previa. Prepare for massive bleed!
"APH is life-threatening. Your rapid response saves TWO lives!"
"When I am afraid, I put my trust in You." - Psalm 56:3
1. APH: DEFINITION & EMERGENCY PRINCIPLES
Definition: Bleeding from the genital tract from 24 weeks gestation to onset of labor.
Key Concept: Every APH is POTENTIALLY LIFE-THREATENING until proven otherwise!
⚠️ CERTIFICATE LEVEL EXAM TIP: APH management questions appear in EVERY exam! Focus on: ABC approach, NO vaginal exam, and rapid referral.
🚨 The "APH KILLER" Mnemonic - Emergency Actions:
🚨 APH = ACT PREVENT HEMORRHAGE
Assess: Airway, Breathing, Circulation
Position: Left lateral (improve placental flow)
Help: Call senior midwife/doctor immediately
Prepare: 2 wide-bore IV cannulas (14G/16G)
Replace: Crystalloids (1-2L fast) then blood
Evaluate: Blood loss (always MORE than visible)
Vitals: BP, pulse, RR every 5 minutes
Equipment: Emergency trolley ready
No vaginal exam until placenta location confirmed!
Transfer: Theatre ready for CS
Hemoglobin: Send for FBC, crossmatch (4 units)
Emergency CS: If unstable or fetal distress
Monitor: Fetal heart rate continuously
Oxytocin: After delivery ONLY (not before!)
Rh status: Check and give Anti-D if negative
Refer: Always refer to hospital level III+
Assess: Airway, Breathing, Circulation
Position: Left lateral (improve placental flow)
Help: Call senior midwife/doctor immediately
Prepare: 2 wide-bore IV cannulas (14G/16G)
Replace: Crystalloids (1-2L fast) then blood
Evaluate: Blood loss (always MORE than visible)
Vitals: BP, pulse, RR every 5 minutes
Equipment: Emergency trolley ready
No vaginal exam until placenta location confirmed!
Transfer: Theatre ready for CS
Hemoglobin: Send for FBC, crossmatch (4 units)
Emergency CS: If unstable or fetal distress
Monitor: Fetal heart rate continuously
Oxytocin: After delivery ONLY (not before!)
Rh status: Check and give Anti-D if negative
Refer: Always refer to hospital level III+
⚠️ UGANDA CONTEXT: At HC IIs and IIIs, DO NOT ATTEMPT MANAGEMENT BEYOND STABILIZATION! Your role is: IV line, fluids, monitoring, and RAPID REFERRAL to HC IV or Regional Referral Hospital.
📊 Classification - The "Blood Loss Ladder":
| Grade | Blood Loss | Maternal Signs | Fetal Signs | Action Level |
|---|---|---|---|---|
| Grade I (Minor) | < 50 ml | Stable vitals | Normal FHS | Observe & investigate |
| Grade II (Major) | 50-1000 ml | Tachycardia (>100) | FHR variability | URGENT action |
| Grade III (Massive) | > 1000 ml | Shock (BP <90/60) | Fetal distress/absent | EMERGENCY! |
2. CAUSES OF APH - "The Big 5"
🧠 MEMORY AID: PAVUL
Placenta Previa (0.4-0.8%) - Painless
Abruption (5%) - Painful
Vasa Previa (0.015%) - Rare & fetal
Uterine Rupture (<1%) - Catastrophic
Local causes (cervix, vagina) - Minor
Placenta Previa (0.4-0.8%) - Painless
Abruption (5%) - Painful
Vasa Previa (0.015%) - Rare & fetal
Uterine Rupture (<1%) - Catastrophic
Local causes (cervix, vagina) - Minor
3. DIC (DISSEMINATED INTRAVASCULAR COAGULATION)
🔴 Definition:
Consumptive coagulopathy where clotting factors are depleted due to massive bleeding and tissue thromboplastin release.
In APH: Deadly complication of abruption! Blood can't clot → uncontrolled bleeding.
🚨 CRITICAL PATHOPHYSIOLOGY: In abruption, thromboplastin from placenta enters maternal circulation → widespread clotting → uses up all clotting factors (fibrinogen) → MASSIVE HEMORRHAGE!
📋 Clinical Features - "The DIC Triad":
- Bleeding: From IV sites, gums, nose, uterus (oozing)
- Clotting: Blood doesn't clot in bedside test
- Organ failure: Kidney injury (oliguria), confusion
🧠 DIC DETECTION: "CL O T T I N G"
Clotting time prolonged (>10 min)
Low fibrinogen (<1g/L)
Oozing from sites
Thrombocytopenia (low platelets)
Tachycardia, tachypnea
Increased PT/INR
No clot formation
Generalized bleeding
Clotting time prolonged (>10 min)
Low fibrinogen (<1g/L)
Oozing from sites
Thrombocytopenia (low platelets)
Tachycardia, tachypnea
Increased PT/INR
No clot formation
Generalized bleeding
🩺 Management of DIC in APH:
STEP 1: RECOGNIZE EARLY
• Bedside clotting test: 2ml blood in tube → no clot in 10 min = DIC
• Lab: FBC, PT/INR, fibrinogen, D-dimer
STEP 2: REPLACE WHAT'S LOST
• FRESH FROZEN PLASMA (FFP): 4 units STAT (replaces clotting factors)
• CRYOPRECIPITATE: 10 units (rich in fibrinogen)
• PLATELETS: If <50,000
• BLOOD: O-negative if desperate, crossmatched if time
STEP 3: TREAT THE CAUSE
• DELIVER BABY FAST! (remove thromboplastin source)
• Emergency CS if needed
STEP 4: SUPPORT ORGANS
• IV fluids, monitor urine output (>30ml/hr)
• Oxygen therapy
• ICU admission if possible
• Bedside clotting test: 2ml blood in tube → no clot in 10 min = DIC
• Lab: FBC, PT/INR, fibrinogen, D-dimer
STEP 2: REPLACE WHAT'S LOST
• FRESH FROZEN PLASMA (FFP): 4 units STAT (replaces clotting factors)
• CRYOPRECIPITATE: 10 units (rich in fibrinogen)
• PLATELETS: If <50,000
• BLOOD: O-negative if desperate, crossmatched if time
STEP 3: TREAT THE CAUSE
• DELIVER BABY FAST! (remove thromboplastin source)
• Emergency CS if needed
STEP 4: SUPPORT ORGANS
• IV fluids, monitor urine output (>30ml/hr)
• Oxygen therapy
• ICU admission if possible
💡 EXAM HIGH-YIELD: Question pattern: "A woman with abruption continues bleeding despite uterus contracting. Bedside clot test shows no clot after 10 minutes. Diagnosis? Management?" Answer: DIC - give FFP and deliver baby!
4. RHESUS INCOMPATIBILITY & ANTI-D PROPHYLAXIS
🩸 The Problem:
If Rh-negative mother is exposed to Rh-positive fetal blood during APH → mother develops antibodies → attacks future Rh-positive babies (hydrops fetalis).
🔍 Who Needs Anti-D?
🧠 ANTI-D GIVE: "R H N E G"
Rh-Negative mother
Has bleeding (APH, PPH, ectopic)
No antibodies on screening
Even minor bleed (>12 weeks gestation)
Give within 72 hours (ideally within 24hrs)
Rh-Negative mother
Has bleeding (APH, PPH, ectopic)
No antibodies on screening
Even minor bleed (>12 weeks gestation)
Give within 72 hours (ideally within 24hrs)
💉 Dosage Guidelines:
| Gestational Age | Bleeding Type | Anti-D Dose |
|---|---|---|
| < 12 weeks | Miscarriage, evacuation | 250 IU (50mcg) IM |
| > 12 weeks | APH, amniocentesis, ECV | 500 IU (100mcg) IM |
| > 20 weeks | Massive bleed, traumatic | 625 IU (125mcg) or more IM |
⚠️ CRITICAL: In Uganda, check Rh status at first ANC visit! Many mothers don't know. If unsure and it's an emergency - GIVE ANTI-D anyway! Better safe than sorry.
🎯 Administration Protocol:
- Check mother's blood group: Must be Rh-negative (D-negative)
- Screen for antibodies: If already sensitized, Anti-D won't help
- Calculate fetal bleed: If massive bleed, may need higher dose
- Give IM injection: Deep intramuscular in deltoid or gluteus
- Document: Dose, time, batch number in mother card
📋 EXAM ALERT: MCQ often asks: "How soon must Anti-D be given?" Answer: Within 72 hours (but ideally within 24 hours)!
5. APH MANAGEMENT ALGORITHMS
🚨 Scenario 1: Stable Patient, Minor Bleed
IF: Mother stable (BP >100/60), FHS normal, bleeding light
1. Admit for observation (hospitalization mandatory!)
2. Strict bed rest, no ambulation
3. Ultrasound within 24 hours (confirm placenta location)
4. Daily FHS monitoring
5. Hb check every 3 days
6. Iron supplements (ferrous sulfate 200mg TDS)
7. If no further bleeding: Discharge after 48-72 hrs
8. Counsel: Return immediately if any bleeding
9. Plan: Elective CS at 37-38 weeks if placenta previa
1. Admit for observation (hospitalization mandatory!)
2. Strict bed rest, no ambulation
3. Ultrasound within 24 hours (confirm placenta location)
4. Daily FHS monitoring
5. Hb check every 3 days
6. Iron supplements (ferrous sulfate 200mg TDS)
7. If no further bleeding: Discharge after 48-72 hrs
8. Counsel: Return immediately if any bleeding
9. Plan: Elective CS at 37-38 weeks if placenta previa
🚨 Scenario 2: Unstable Patient, Major Bleed
🚨 THIS IS AN EMERGENCY - NO TIME FOR ULTRASOUND!
IF: BP <90/60, pulse >110, FHS absent or distressed, bleeding heavy
1. CALL FOR HELP - Obstetrician, anesthetist, theater staff
2. 2 IV lines (14G) - run crystalloids wide open
3. Left lateral position
4. Oxygen via mask (4-6L/min)
5. Blood: Group & crossmatch 4 units
6. Bedside clot test: Check for DIC
7. Urinary catheter: Monitor output (>30ml/hr)
8. Theatre: Prepare for emergency CS
9. DO NOT WAIT: Deliver baby within 30 minutes
10. Rh status: Give Anti-D if mother Rh-negative
1. CALL FOR HELP - Obstetrician, anesthetist, theater staff
2. 2 IV lines (14G) - run crystalloids wide open
3. Left lateral position
4. Oxygen via mask (4-6L/min)
5. Blood: Group & crossmatch 4 units
6. Bedside clot test: Check for DIC
7. Urinary catheter: Monitor output (>30ml/hr)
8. Theatre: Prepare for emergency CS
9. DO NOT WAIT: Deliver baby within 30 minutes
10. Rh status: Give Anti-D if mother Rh-negative
🎯 The Decision Matrix: Vaginal Delivery vs CS
| Condition | Vaginal Delivery Allowed? | Requirements |
|---|---|---|
| Complete Previa | ❌ NEVER | CS only |
| Partial Previa | ❌ NEVER | CS only |
| Marginal Previa | ⚠️ RARELY | Minimal bleed, head engaged, senior supervision |
| Low-lying | ✓ MAYBE | >2cm from os, minimal bleed |
| Abruption (stable) | ✓ YES | Mother stable, no DIC, labor progressing |
| Abruption (unstable) | ❌ NO - CS | Maternal compromise or fetal distress |
| Uterine Rupture | ❌ NEVER | Emergency laparotomy |
🧠 VAGINAL DELIVERY RULE: "ONLY IF LOW & SLOW"
LOW: Low-lying placenta (>2cm from os)
SLOW: Slow, minimal bleeding
+ Mother stable + Fetus okay + Senior present
LOW: Low-lying placenta (>2cm from os)
SLOW: Slow, minimal bleeding
+ Mother stable + Fetus okay + Senior present
💡 EXAM TIP: The most common wrong answer is attempting vaginal delivery with partial previa. Remember: If it covers the os = CS ONLY!
6. POST-DELIVERY CARE AFTER APH
🩸 Watch for: The "4-Hour Danger Window"
- Primary PPH: Uterus may be atomic from overdistension
- Secondary PPH: Retained clots or infection
- Anemia: Check Hb before discharge
- Thrombosis: From prolonged bed rest
🧠 POST-APH CARE: "M O N I T O R"
Massage uterus (ensure contraction)
Oxytocin infusion (maintain for 4 hours)
No ambulation until stable
Iron therapy (correct anemia)
Temperature monitor (infection)
Output: Urine >30ml/hr
Rh status: Anti-D if needed
Review before discharge (Hb >9g/dL)
Massage uterus (ensure contraction)
Oxytocin infusion (maintain for 4 hours)
No ambulation until stable
Iron therapy (correct anemia)
Temperature monitor (infection)
Output: Urine >30ml/hr
Rh status: Anti-D if needed
Review before discharge (Hb >9g/dL)
7. LIKELY EXAM QUESTIONS FOR DAY 4
1. LONG ANSWER (10 marks)
A Rh-negative mother at 32 weeks gestation presents with sudden vaginal bleeding after a minor road accident. Outline your immediate management including Rh prophylaxis.
ANSWER GUIDE:
Immediate (7 marks):
• Assess ABCs, IV access x2, left lateral
• Monitor vitals & FHS
• Group & crossmatch blood
• Ultrasound to confirm placenta location
• Prepare for emergency CS if needed
Rh Prophylaxis (3 marks):
• Give Anti-D 500 IU IM within 72 hours
• Document batch number
• Test for antibodies first
• Repeat in 6 weeks if ongoing sensitization risk
Immediate (7 marks):
• Assess ABCs, IV access x2, left lateral
• Monitor vitals & FHS
• Group & crossmatch blood
• Ultrasound to confirm placenta location
• Prepare for emergency CS if needed
Rh Prophylaxis (3 marks):
• Give Anti-D 500 IU IM within 72 hours
• Document batch number
• Test for antibodies first
• Repeat in 6 weeks if ongoing sensitization risk
2. SHORT ANSWER (5 marks)
Explain the pathophysiology of DIC in placental abruption and its management.
ANSWER:
Pathophysiology (3 marks):
• Placental thromboplastin enters maternal circulation
• Widespread clotting consumes clotting factors
• Fibrinogen depleted → bleeding
Management (2 marks):
• Replace clotting factors (FFP, cryoprecipitate)
• Deliver baby urgently
• Monitor for organ failure
Pathophysiology (3 marks):
• Placental thromboplastin enters maternal circulation
• Widespread clotting consumes clotting factors
• Fibrinogen depleted → bleeding
Management (2 marks):
• Replace clotting factors (FFP, cryoprecipitate)
• Deliver baby urgently
• Monitor for organ failure
3. MULTIPLE CHOICE (3 marks)
The single most important initial step in managing massive APH is:A) Ultrasound scan
B) Vaginal examination
C) Establishing IV access ⭐ CORRECT
D) Giving Anti-D
EXPLANATION: ABC protocol - Circulation comes first. You can die from hypovolemia while waiting for ultrasound.
4. PRACTICAL SCENARIO (8 marks)
You are the only midwife at a HC III. A woman at 36 weeks arrives with heavy bleeding and abdominal pain. BP 80/50, pulse 120. FHS absent. What do you do?
ANSWER:
1. Call for help (radio senior midwife/doctor) - 1 mark
2. 2 IV lines, crystalloids fast - 1 mark
3. Left lateral position - 1 mark
4. Keep woman warm - 1 mark
5. Monitor vitals - 1 mark
6. Group & crossmatch blood - 1 mark
7. REFER IMMEDIATELY to HC IV/RRH - 1 mark
8. Document everything - 1 mark
DO NOT: Do vaginal exam, attempt delivery, or waste time on ultrasound at HC III.
1. Call for help (radio senior midwife/doctor) - 1 mark
2. 2 IV lines, crystalloids fast - 1 mark
3. Left lateral position - 1 mark
4. Keep woman warm - 1 mark
5. Monitor vitals - 1 mark
6. Group & crossmatch blood - 1 mark
7. REFER IMMEDIATELY to HC IV/RRH - 1 mark
8. Document everything - 1 mark
DO NOT: Do vaginal exam, attempt delivery, or waste time on ultrasound at HC III.
5. TRUE/FALSE (2 marks each)
a) Anti-D is effective if given within 5 days of sensitizing event.b) DIC is uncommon in placenta previa.
c) Every APH patient needs at least 2 units of blood crossmatched.
ANSWERS:
a) TRUE - 72 hours is ideal, up to 10 days may have some effect
b) TRUE - More common in abruption (thromboplastin release)
c) FALSE - Major APH needs 4 units minimum crossmatched
a) TRUE - 72 hours is ideal, up to 10 days may have some effect
b) TRUE - More common in abruption (thromboplastin release)
c) FALSE - Major APH needs 4 units minimum crossmatched
6. LIST QUESTION (6 marks)
List three signs of DIC and three indications for giving Anti-D prophylaxis.
DIC SIGNS:
• Prolonged bleeding from IV sites
• Blood not clotting in 10 minutes
• Oozing from gums/nose
• Petechiae, purpura
(Any 3 = 3 marks)
ANTI-D INDICATIONS:
• Rh-negative mother with APH
• Rh-negative mother after delivery of Rh+ baby
• After procedures (amniocentesis, ECV)
• Miscarriage >12 weeks
(Any 3 = 3 marks)
• Prolonged bleeding from IV sites
• Blood not clotting in 10 minutes
• Oozing from gums/nose
• Petechiae, purpura
(Any 3 = 3 marks)
ANTI-D INDICATIONS:
• Rh-negative mother with APH
• Rh-negative mother after delivery of Rh+ baby
• After procedures (amniocentesis, ECV)
• Miscarriage >12 weeks
(Any 3 = 3 marks)
8. COMMON EXAM MISTAKES TO AVOID
❌ DON'T: Order vaginal exam before ultrasound
❌ DON'T: Give oxytocin before delivery in APH
❌ DON'T: Attempt vaginal delivery in complete previa
❌ DON'T: Forget Anti-D in Rh-negative mothers
❌ DON'T: Underestimate concealed bleeding
✅ DO: Always think "What if this is abruption with DIC?"
✅ DO: Call for help early
✅ DO: Prepare for the worst-case scenario
❌ DON'T: Give oxytocin before delivery in APH
❌ DON'T: Attempt vaginal delivery in complete previa
❌ DON'T: Forget Anti-D in Rh-negative mothers
❌ DON'T: Underestimate concealed bleeding
✅ DO: Always think "What if this is abruption with DIC?"
✅ DO: Call for help early
✅ DO: Prepare for the worst-case scenario
📚 DAY 4 SUMMARY: APH EMERGENCY COMPETENCIES
🎯 The "A-B-C-D" of APH Management:
A = Assess & Activate (ABCs, call help)
B = Bleeding control (no exam, replace fluids)
C = Circulation support (2 IV lines, blood products)
D = Delivery decision (CS vs vaginal) + DIC prevention
B = Bleeding control (no exam, replace fluids)
C = Circulation support (2 IV lines, blood products)
D = Delivery decision (CS vs vaginal) + DIC prevention
🎯 DIC vs Anti-D - Don't Confuse!
| Feature | DIC | Anti-D Prophylaxis |
|---|---|---|
| What is it? | Bleeding disorder | Prevention of antibody formation |
| When? | After massive bleed (esp. abruption) | Rh-negative mother exposed to Rh+ blood |
| Treatment | FFP, cryoprecipitate, platelets | Anti-D immunoglobulin IM |
| Timing | Urgent replacement | Within 72 hours |
| Prevention | Rapid delivery | Never skip in Rh-neg mothers! |
🎯 Key Numbers to Memorize:
- >24 weeks: When APH is defined
- >1000ml: Massive hemorrhage threshold
- >100 pulse: Tachycardia indicating shock
- <90/60 BP: Hypotension requiring emergency action
- >30ml/hr urine: Adequate perfusion
- <10 min clotting: DIC screen
- <1g/L fibrinogen: Severe DIC
- <72 hours: Anti-D administration window
- >4 units blood: Crossmatch for major APH
🎯 The "Golden Hour" Rule:
From arrival to definitive management (CS) should be <60 minutes in major APH. Every minute counts for maternal and fetal survival!
"APH is not just bleeding - it's a race against time. Your rapid recognition, resuscitation, and referral saves two lives. You are the frontline!"
"She is clothed with strength and dignity; she can laugh at the days to come." - Proverbs 31:25