DAY 3
📅 Nov 12 (Tue)
🔺 Intrapartum Hemorrhage & Inversion
DME 211: APH & Uterine Inversion
- APH: Placental abruption, Placenta previa
- Uterine Inversion: Degrees, Causes, Management
⚠️ REMEMBER: APH = After 28 weeks! Placenta previa = PAINLESS bleeding. Abruption = PAINFUL!
🔺 KEY POINT: Inversion = Uterus turns inside out. SHOCK IS DISPROPORTIONATE! REPLACE IMMEDIATELY!
"Stay calm in the storm. Your knowledge is the anchor!"
"Peace be still." - Mark 4:39
1. ANTENATAL/ANTEPARTUM HEMORRHAGE (APH) - DEFINITION
Definition: Bleeding from the genital tract from 24 weeks gestation to the onset of labor.
Incidence: 4% of women (1 in 25 pregnancies)
Importance: MAJOR CAUSE OF MATERNAL DEATH IN UGANDA! Leads to preterm delivery, fetal distress, maternal shock.
⚠️ DIPLOMA LEVEL EXAM TIP: APH is a TOP KILLER topic! Examiners test 3 things: 1) Differentiate causes, 2) Emergency actions, 3) When to refer!
📊 CLASSIFICATION BY BLOOD LOSS:
| Category | Amount | Clinical Sign | Action |
|---|---|---|---|
| Minor | < 50 ml | No shock | Observe, find cause |
| Major | 50-1000 ml | No shock yet | URGENT intervention |
| Massive | > 1000 ml | Clinical shock | EMERGENCY! |
2. MAIN CAUSES OF APH
🧠 MNEMONIC: 5 MAIN APH CAUSES
Placenta Previa (0.4-0.8%)
Abruption (5%)
Vasa Previa (rare! 0.015%)
Uterine Rupture (<1% with scar)
Local Causes (cervix, trauma, infection)
Placenta Previa (0.4-0.8%)
Abruption (5%)
Vasa Previa (rare! 0.015%)
Uterine Rupture (<1% with scar)
Local Causes (cervix, trauma, infection)
IMPORTANT: Placenta previa and abruption account for 50% of APH cases in Uganda.
💡 EXAM FOCUS: Must know Placenta Previa vs Abruptio Placentae - they ask on every exam!
3. PLACENTA PREVIA
📚 Definition:
Abnormally implanted placenta in the lower uterine segment, covering or partially covering the cervical os.
Normal placenta implants in upper uterus (fundus). In previa, it implants TOO LOW!
📊 Types (Based on Coverage):
- Complete/Total Previa: Placenta completely covers cervical os
- Partial Previa: Placenta partially covers os
- Marginal Previa: Placenta at edge of os
- Low-lying Placenta: Placenta in lower segment but not reaching os
🔴 Risk Factors:
- Previous cesarean section (scarred uterus)
- Multiple pregnancies
- Previous uterine surgery
- Age >35 years
- Smoking
📋 Clinical Features - The "P-L-A-C-E-N-T-A" Signs:
🔴 MNEMONIC: PLACENTA PREVIA SIGNS
Painless bleeding (sudden, bright red)
Late pregnancy (usually 3rd trimester)
Apparently causeless (no trauma)
Can be recurrent
Engaged head is absent (head is HIGH FLOATING)
Normal uterus (soft, non-tender)
Typically malpresentation (breech common)
Alive fetus usually (FHS present)
Painless bleeding (sudden, bright red)
Late pregnancy (usually 3rd trimester)
Apparently causeless (no trauma)
Can be recurrent
Engaged head is absent (head is HIGH FLOATING)
Normal uterus (soft, non-tender)
Typically malpresentation (breech common)
Alive fetus usually (FHS present)
⚠️ EXAM CRITICAL: NEVER do vaginal exam in suspected previa until placenta location confirmed by ultrasound! You could tear placenta and cause MASSIVE hemorrhage!
🩺 Management Principles:
- Call for HELP - Senior obstetrician, anesthetist
- No vaginal exams! Confirm with ultrasound first
- Assess maternal condition: BP, pulse, blood loss
- Assess fetal condition: FHS, CTG monitoring
- Establish IV access: 2 large bore cannulas (14G or 16G)
- Blood tests: FBC, Group & Crossmatch (4 units ready!)
- Correct anemia: Iron supplements, transfuse if needed
🏥 Conservative Management (If Stable):
🛌 MNEMONIC: BED REST & WAIT
Bed rest (hospital admission)
Emergency trolley ready
Daily FHS monitoring
Restrict movement - no ambulation
Ensure blood available
Steroids if <34 weeks (for lung maturity)
Transfuse if Hb <8g/dL
&
Wait for 37 weeks (if no further bleeding)
Avoid all digital vaginal exams
Inform patient about signs of bleeding
Timing: Plan elective CS at 37-38 weeks
Bed rest (hospital admission)
Emergency trolley ready
Daily FHS monitoring
Restrict movement - no ambulation
Ensure blood available
Steroids if <34 weeks (for lung maturity)
Transfuse if Hb <8g/dL
&
Wait for 37 weeks (if no further bleeding)
Avoid all digital vaginal exams
Inform patient about signs of bleeding
Timing: Plan elective CS at 37-38 weeks
🔪 Definitive Management:
- Delivery by Cesarean Section (CS) - ALWAYS for major previa!
- Timing: Elective CS at 37-38 weeks (before labor starts)
- Emergency CS: If massive bleeding at any gestation
- Vaginal delivery possible ONLY if: Minor marginal previa, head engaged, minimal bleeding
🚨 EXAM ALERT: The golden rule - PL CENTA PREVIA = CS DELIVERY! Never attempt vaginal delivery with complete or partial previa!
4. PLACENTAL ABRUPTION (Abruptio Placentae)
📚 Definition:
Premature separation of a normally implanted placenta after 28 weeks gestation.
The placenta detaches BEFORE the baby is born → FETAL HYPOXIA & MATERNAL HEMORRHAGE!
📊 Types Based on Bleeding:
- Revealed: Blood drains through vagina (visible)
- Concealed: Blood trapped behind placenta (hidden, more dangerous!)
- Mixed: Both revealed and concealed (most common)
🔴 Risk Factors:
🧠 MNEMONIC: ABRUPT causes ABRUPTION
Age >35 years
BP - Hypertension/preeclampsia (most common!)
Road traffic accidents/Trauma
Uterine fibroids
Polyhydramnios (excess fluid)
Twin pregnancy
&
Smoking, cocaine use
Multiparity
Oligohydramnios with IUGR
Key one: Previous abruption
Essential: PPROM (infection)
Age >35 years
BP - Hypertension/preeclampsia (most common!)
Road traffic accidents/Trauma
Uterine fibroids
Polyhydramnios (excess fluid)
Twin pregnancy
&
Smoking, cocaine use
Multiparity
Oligohydramnios with IUGR
Key one: Previous abruption
Essential: PPROM (infection)
📋 Clinical Features - The "A-B-R-U-P-T-I-O-N" Signs:
🚨 MNEMONIC: ABRUPTION DETECT
Abdomen rigid, tender, board-like
Bleeding: Painful, dark red (often concealed)
Restless mother
Uterine irritability (hypertonic)
Pain: Sudden, severe abdominal pain
Tense uterus (palpate carefully!)
Increased fundal height (concealed blood)
Oliguria (shock sign)
No FHS (especially concealed type)
&
Disproportionate shock (bleeding more than visible)
Elevated BP often (due to preeclampsia)
Tense: Mother feels like "tight band" around abdomen
Abdomen rigid, tender, board-like
Bleeding: Painful, dark red (often concealed)
Restless mother
Uterine irritability (hypertonic)
Pain: Sudden, severe abdominal pain
Tense uterus (palpate carefully!)
Increased fundal height (concealed blood)
Oliguria (shock sign)
No FHS (especially concealed type)
&
Disproportionate shock (bleeding more than visible)
Elevated BP often (due to preeclampsia)
Tense: Mother feels like "tight band" around abdomen
⚠️ EXAM CRITICAL: Abruption = PAINFUL bleeding! Previa = PAINLESS bleeding! This is the #1 exam question!
🩺 Management Principles:
- Call for HELP! - This is an emergency!
- 2 large bore IV cannulas (14-16G) - Run crystalloids fast!
- Group & Crossmatch: 4-6 units of blood
- Check bedside clotting test: May develop DIC!
- Deliver baby FAST: Maternal & fetal lives at risk
🏥 Mode of Delivery:
🔴 KEY DECISION: Delivery depends on maternal-fetal condition, NOT mode of delivery!
- Vaginal delivery: If mother stable, fetus dead, labor progressing
- Emergency CS: If live fetus, maternal compromise, fetal distress
- Give blood: Correct anemia, treat shock
- Monitor for DIC: Check clotting, fibrinogen levels
5. PLACENTA PREVIA vs ABRUPTION - MASTER COMPARISON
| Feature | Placenta Previa | Placental Abruption |
|---|---|---|
| Nature of Bleeding | Painless, bright red, causeless | Painful, dark red, continuous |
| Abdomen | Soft, relaxed, non-tender | Rigid, tense, board-like, tender |
| General Condition | Proportional to visible blood loss | Disproportionate (worse than visible) |
| Preeclampsia | Not associated | Present in 1/3 of cases |
| Malpresentation | Common (breech) | Not related |
| FHS | Usually present | Usually absent (especially concealed) |
| Diagnosis | Placenta on ultrasound | Clinical diagnosis (no placenta separation seen) |
| Management | CS delivery (except minor marginal) | Delivery (vaginal or CS, depends on condition) |
| Rule | NO vaginal exam until confirmed! | Danger of DIC! |
📊 EXAM STRATEGY: This table is GOLD! Memorize at least 5 distinguishing features. They ask: "How would you differentiate previa from abruption?"
6. OTHER APH CAUSES (Brief but Important!)
6A. VASA PREVIA
- Rare (0.015-0.04%) but dangerous!
- Definition: Fetal vessels (umbilical cord vessels) run across cervical os
- Bleeding: Fetal blood (contain fatal for baby!)
- Signs: Sudden bleeding after rupture of membranes → fetal bradycardia
- Management: EMERGENCY CS! Baby can die within minutes
6B. UTERINE RUPTURE
- Definition: Tear in uterine wall during pregnancy/labor
- Associated with: Previous CS scar, grand multiparity, malpresentation, obstructed labor, oxytocin misuse
- Clinical features: Sudden severe abdominal pain, vaginal bleeding, absent fetal heart sounds, maternal shock
- Management: EMERGENCY LAPAROTOMY! Replace blood loss, antibiotics
🚨 UGANDA CONTEXT: Uterine rupture is common in rural areas due to delayed referral and improper oxytocin use. Always monitor labor progress and refer early!
6C. VASA PREVIA
- Definition: Fetal vessels run across cervical os
- Rare but deadly: Fetal vessel rupture → massive fetal hemorrhage
- Clinical features: Painless vaginal bleeding, fetal distress
- Management: Emergency CS - baby can die in minutes!
💡 EXAM TRIGGER: Vasa praevia = FETAL vessels bleeding. Maternal condition stable but FHS absent/absent. Need emergency CS for baby!
7. PLACENTA PREVIA vs ABRUPTIO PLACENTAE - THE COMPARISON TABLE
| Feature | Placenta Previa | Abruptio Placentae |
|---|---|---|
| Nature of Bleeding | Painless, causeless, recurrent | Painful, often with pre-eclampsia/trauma, continuous |
| Type of Blood | Bright red | Dark colored (old blood) |
| General Condition | Proportionate to visible blood loss | Out of proportion (concealed bleeding) |
| Uterus | Soft, relaxed, non-tender | Tense, tender, rigid (woody hard) |
| FHS | Usually present | Usually absent (especially concealed) |
| Ultrasound | Placenta in lower segment | Placenta in upper segment |
| Vaginal Exam | Placenta felt on lower segment | No placenta felt (but NEVER do exam!) |
🧠 QUICK DIFFERENTIATION:
PREVIA = PAINLESS, BRIGHT RED, SOFT UTERUS
ABRUPTION = PAINFUL, DARK BLOOD, HARD UTERUS
PREVIA = PAINLESS, BRIGHT RED, SOFT UTERUS
ABRUPTION = PAINFUL, DARK BLOOD, HARD UTERUS
8. MANAGEMENT OF MASSIVE APH (EMERGENCY PROTOCOL)
🚨 EMERGENCY MNEMONIC: APH ALERT
Assess ABCs (Airway, Breathing, Circulation)
Place 2 large bore IV lines (14G/16G)
Hemoglobin check, Group & Crossmatch (4 units)
&
Avoid vaginal exams until placenta ruled out
Left lateral position
Emergency call for Obstetric & Anesthetic team
Replace blood loss (crystalloids then blood)
Transfer to theatre for CS (if previa)
Assess ABCs (Airway, Breathing, Circulation)
Place 2 large bore IV lines (14G/16G)
Hemoglobin check, Group & Crossmatch (4 units)
&
Avoid vaginal exams until placenta ruled out
Left lateral position
Emergency call for Obstetric & Anesthetic team
Replace blood loss (crystalloids then blood)
Transfer to theatre for CS (if previa)
💡 CRITICAL EXAM POINT: Management is NOT based on amount of bleeding but on maternal/fetal stability! Even small bleed with unstable vitals = EMERGENCY!
9. UTERINE INVERSION
🔺 Definition:
The uterus turns inside out, with fundus descending into or through cervix.
Rare but MORTALITY 15-20%!
📊 Degrees of Inversion:
- 1st Degree (Incomplete): Fundus descends but not through cervix
- 2nd Degree (Complete): Fundus extends through cervix to vagina
- 3rd Degree (Prolapse): Fundus protrudes out of vagina
- 4th Degree (Total): Both uterus AND vagina invert (extremely rare)
🔢 MNEMONIC: DEGREES OF INVERSION
1 - Inside uterus only
2 - Comes through cervix
3 - Protrudes outside vagina
4 - Total (uterus + vagina)
1 - Inside uterus only
2 - Comes through cervix
3 - Protrudes outside vagina
4 - Total (uterus + vagina)
🔴 Causes:
- Excessive cord traction (pulling placenta before separation)
- Fundal pressure (pressing on uterus)
- Short cord (placenta pulls uterus)
- Placenta accreta (abnormally adherent placenta)
- Weak uterine wall (multiparity, overdistension)
⚠️ CAUSE TO REMEMBER: Most common cause is IMPATIENT PLACENTAL DELIVERY! Always wait for signs of separation before pulling!
📋 Clinical Features:
🚨 THE SHOCK-SHAPED UTERUS
Sudden postpartum collapse
Hemorrhage (may be concealed)
Obvious mass at introitus (in 3rd degree)
Cervix not palpable on exam
K shock disproportionate to blood loss (neurogenic shock!)
-SHAPED-
Uterus absent on abdominal palpation
Tender abdomen
Excessive vaginal bleeding
Rapid maternal pulse
Unrelieved pain
Shiny red mass if prolapsed
Sudden postpartum collapse
Hemorrhage (may be concealed)
Obvious mass at introitus (in 3rd degree)
Cervix not palpable on exam
K shock disproportionate to blood loss (neurogenic shock!)
-SHAPED-
Uterus absent on abdominal palpation
Tender abdomen
Excessive vaginal bleeding
Rapid maternal pulse
Unrelieved pain
Shiny red mass if prolapsed
🩺 Emergency Management:
🚨 EMERGENCY PROTOCOL: REPLACE WITHIN 1 HOUR! Delay = death!
- CALL FOR HELP - Senior obstetrician, anesthetist
- Do NOT remove placenta if still attached! Replace with placenta attached
- Treat shock: 2 IV lines, crystalloids, blood transfusion
- Anesthesia: IV analgesia or general anesthesia
- Manual replacement: Push fundus up through cervix
- Give tocolytic: Terbutaline 0.25mg SC (relaxes constriction ring)
- After replacement: Give oxytocin to contract uterus
- Antibiotics: 3rd generation cephalosporin
- Refer to hospital: Even if replaced successfully
💡 CRITICAL EXAM POINT: Shock in inversion is DISPROPORTIONATE to blood loss - it's NEUROGENIC SHOCK from parasympathetic stimulation!
LIKELY EXAM QUESTIONS FOR DAY 3
1. FILL-IN-THE-BLANK (2 marks)
The most common cause of antepartum hemorrhage in Uganda is ______ and ______ which account for 50% of cases.
ANSWER: Placenta previa and placental abruption
2. MULTIPLE CHOICE (3 marks)
A 32-year-old woman at 34 weeks gestation presents with sudden, painless, bright red vaginal bleeding. Abdominal examination shows a soft, relaxed uterus and high floating head. The most likely diagnosis is:A) Placental abruption
B) Placenta previa ⭐ CORRECT
C) Uterine rupture
D) Vasa praevia
EXPLANATION: Painless + bright red + soft uterus + high head = CLASSIC placenta previa
3. SHORT ANSWER (5 marks)
Differentiate between placenta previa and abruptio placentae based on clinical features.
ANSWER GUIDE: Create a table with:
• Pain (previa=painless, abruption=painful)
• Blood color (previa=bright, abruption=dark)
• Uterus (previa=soft, abruption=hard/tender)
• Shock (previa=proportionate, abruption=disproportionate)
• FHS (previa=present, abruption=absent)
Each comparison point = 1 mark
• Pain (previa=painless, abruption=painful)
• Blood color (previa=bright, abruption=dark)
• Uterus (previa=soft, abruption=hard/tender)
• Shock (previa=proportionate, abruption=disproportionate)
• FHS (previa=present, abruption=absent)
Each comparison point = 1 mark
4. PRACTICAL SCENARIO (10 marks)
A multiparous woman delivers a baby at a health centre III. During delivery of placenta, the midwife pulls on the cord before signs of separation. The mother suddenly collapses with profuse bleeding. The uterus is not palpable abdominally. What is the diagnosis? Outline IMMEDIATE management.
ANSWER:
Diagnosis: Uterine inversion (likely 3rd degree)
Management:
1. Call for help immediately
2. Do NOT remove placenta (if attached)
3. 2 IV lines, start crystalloids
4. Give analgesia/consider anesthesia
5. Attempt manual replacement (push fundus up)
6. Give terbutaline 0.25mg SC if constriction ring
7. After replacement: oxytocin to contract uterus
8. Broad spectrum antibiotics
9. Refer to hospital immediately
MARKING: Diagnosis=2 marks, Each management step=1 mark, Must include "don't remove placenta" and "refer"
Diagnosis: Uterine inversion (likely 3rd degree)
Management:
1. Call for help immediately
2. Do NOT remove placenta (if attached)
3. 2 IV lines, start crystalloids
4. Give analgesia/consider anesthesia
5. Attempt manual replacement (push fundus up)
6. Give terbutaline 0.25mg SC if constriction ring
7. After replacement: oxytocin to contract uterus
8. Broad spectrum antibiotics
9. Refer to hospital immediately
MARKING: Diagnosis=2 marks, Each management step=1 mark, Must include "don't remove placenta" and "refer"
5. TRUE/FALSE (2 marks each)
a) Vaginal examination is contraindicated in suspected placenta previa.b) Uterine inversion causes hemorrhagic shock proportionate to blood loss.
c) Steroids should be given if placenta previa bleeding occurs before 34 weeks.
ANSWERS:
a) TRUE - Can cause catastrophic bleeding
b) FALSE - Causes neurogenic shock (disproportionate)
c) TRUE - For fetal lung maturity
a) TRUE - Can cause catastrophic bleeding
b) FALSE - Causes neurogenic shock (disproportionate)
c) TRUE - For fetal lung maturity
6. LIST QUESTION (8 marks)
List four risk factors for placenta previa and four for uterine inversion.
ANSWER:
Placenta Previa: Previous CS, multiple pregnancy, age>35, smoking, uterine surgery
Uterine Inversion: Fundal pressure, cord traction, short cord, placenta accreta, multiparity
Any 4 from each list = 8 marks (1 mark each)
Placenta Previa: Previous CS, multiple pregnancy, age>35, smoking, uterine surgery
Uterine Inversion: Fundal pressure, cord traction, short cord, placenta accreta, multiparity
Any 4 from each list = 8 marks (1 mark each)
📊 STATISTICS: APH appears in 95% of UHPAB midwifery exams! Uterine inversion is in 70% of exams (usually scenario-based). Master the differences and emergency management!
📚 DAY 3 SUMMARY: EMERGENCY ESSENTIALS
🎯 The 3 P's of APH:
Plaventa Previa = Painless + Painless + Painless!
Painful bleeding = Abruptio
Postpartum collapse = Think Inversion
Painful bleeding = Abruptio
Postpartum collapse = Think Inversion
🎯 Emergency Actions in 5 Steps:
- CALL FOR HELP (never manage alone!)
- 2 IV LINES (14G/16G - volume replacement)
- LEFT LATERAL (improve circulation)
- BLOOD READY (group & crossmatch)
- REFER FAST (know your limits!)
🎯 Inversion = THE DEADLY MISTAKE:
- Pulling placenta too early = DANGER
- Shock is disproportionate = NEUROGENIC
- Replace within 1 hour = SURVIVAL
- Don't remove placenta = KEY POINT
⚠️ FINAL WARNING: APH and inversion are LEADING CAUSES OF MATERNAL DEATH in Uganda. You must recognize, stabilize, and refer. Don't try to be a hero - save lives through teamwork and prompt referral!
"In emergencies, your knowledge is the mother's lifeline. Stay calm, act fast, and remember your training!"
"The Lord is my helper; I will not fear." - Hebrews 13:6