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South Australian Perinatal Practice Guideline
Antepartum Haemorrhage
(including Uterine Rupture)
Department for Health and Wellbeing, Government of South Australia. All rights reserved.
INFORMAL COPY WHEN PRINTED Page 1 of 20
Public-I2-A2
Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
The use of interpreter services where necessary,
Advising consumers of their choice and ensuring informed consent is obtained,
Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant woman. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.
Purpose and Scope of Perinatal Practice Guideline (PPG)
This guideline outlines the management of bleeding from 20 weeks gestation and up to the
onset of labour, including Vasa Praevia, Placenta Praevia, Placental abruption and distal
genital tract/gynaecological bleeding. It also includes the management of uterine rupture.
Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics,
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectfully manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.
South Australian Perinatal Practice Guideline
Antepartum Haemorrhage
(including Uterine Rupture)
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Initial Management of major or massive APH
Flowchart based on the PROMPT management for major APH1
South Australian Perinatal Practice Guideline
Antepartum Haemorrhage
(including Uterine Rupture)
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Table of Contents
Initial Management of major APH .............................................................................................. 2
Summary of Practice Recommendations .................................................................................. 4
Abbreviations ............................................................................................................................. 5
Definitions .................................................................................................................................. 5
Antepartum Haemorrhage ......................................................................................................... 6
Causes, risk factors and complications ................................................................................. 6
Placenta Praevia .................................................................................................................... 7
Risk factors ........................................................................................................................ 7
Clinical features ................................................................................................................. 7
Expectant management ..................................................................................................... 7
Place of care ...................................................................................................................... 7
Bloods ................................................................................................................................ 7
Correction of anaemia........................................................................................................ 8
Ultrasound .......................................................................................................................... 8
Tocolytics ........................................................................................................................... 8
Corticosteroids ................................................................................................................... 8
Other considerations .......................................................................................................... 8
Timing, location and mode of birth ..................................................................................... 8
Active bleeding ................................................................................................................... 9
Placental Abruption or Abruptio Placenta .............................................................................. 9
Risk factors ........................................................................................................................ 9
Clinical features ................................................................................................................. 9
Diagnosis ........................................................................................................................... 9
Management ...................................................................................................................... 9
Conservative management .............................................................................................. 10
Other considerations ........................................................................................................ 10
Vasa Praevia ........................................................................................................................ 10
Risk factors ...................................................................................................................... 10
Incidence .......................................................................................................................... 10
Clinical features ............................................................................................................... 10
Management .................................................................................................................... 10
Timing of birth .................................................................................................................. 11
Ultrasonography ............................................................................................................... 11
Corticosteroids ................................................................................................................. 11
Other considerations ........................................................................................................ 11
Uterine Rupture .................................................................................................................... 11
Risk factors ...................................................................................................................... 11
Clinical features ............................................................................................................... 11
Considerations ................................................................................................................. 12
Management .................................................................................................................... 12
Additional counselling recommendations ........................................................................ 12
Distal genital tract/gynaecological bleeding ......................................................................... 12
Cervical bleeding ............................................................................................................. 12
Vaginal bleeding .............................................................................................................. 13
Vulval bleeding ................................................................................................................. 13
South Australian Perinatal Practice Guideline
Antepartum Haemorrhage
(including Uterine Rupture)
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Non-genital tract ............................................................................................................... 13
Unclassified bleeding ........................................................................................................... 13
Abnormal placentation ......................................................................................................... 13
APH Management.................................................................................................................... 15
Call for help .......................................................................................................................... 15
Immediate actions ................................................................................................................ 15
Assessment ......................................................................................................................... 15
Stopping the bleeding .......................................................................................................... 16
Preparation for Postpartum Haemorrhage .......................................................................... 16
Preparation for Neonatal Resuscitation ............................................................................... 16
Documentation ..................................................................................................................... 16
Open Disclosure, Debriefing and Ongoing Support ............................................................ 17
References ............................................................................................................................... 18
Acknowledgements .................................................................................................................. 19
Document Ownership & History ............................................................................................... 20
Summary of Practice Recommendations
Antepartum haemorrhage should be managed in a systematic manner following four main
steps:
1. Call for help
2. Immediate actions
3. Assessment
4. Stop the bleeding
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Antepartum Haemorrhage
(including Uterine Rupture)
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Abbreviations
APH Antepartum haemorrhage
BMI Body mass index
BP Blood pressure
CTG Cardiotocography
DIC Disseminated intravascular coagulation
FBC Full blood count
FFP Fresh frozen plasma
FHR Fetal heart rate
G&H Group and Hold
HR Heart rate
IU International units
IUGR Intrauterine growth restriction
IV Intravenous
mm Millimetres
PPH Post-partum haemorrhage
PROMPT Practical Obstetric Multi-Professional Training
ROTEM Rotational thromboelastometry
RR Respiratory rate
SaO2 Oxygen saturation
SAPPG South Australian Perinatal Practice Guideline
TVS Transvaginal Ultrasound scan
VE Vaginal examination
VTE Venous thromboembolism
% Percentage
Definitions
Antepartum
Haemorrhage
Any bleeding from the genital tract after twenty weeks gestation
and before the onset of labour.
Recurrent APH Episodes of APH occurring on more than one occasion
Spotting Staining, streaking or blood spotting on underwear
Minor haemorrhage Blood loss less than 50mL that has settled
Major haemorrhage Blood loss of 50-1000mL, with no signs of clinical shock
Massive haemorrhage Blood loss greater than 1000mL and/or signs of clinical shock
Placental Abruption Placental Abruption occurs when there is partial or total
detachment of the placenta prior to the birth of the baby.
Placenta Praevia Placenta Praevia occurs where the placenta covers the internal
cervical os.
Vasa Praevia Vasa praevia occurs when the fetal blood vessels transverse
the placental membranes over or near the inner cervical os.
Uterine Rupture Refers to a full thickness tear through the myometrium and
serosa and may occur in a previously intact uterus or in one
with a previous caesarean, myomectomy scar or perforation
from a previous gynaecological procedure.
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Antepartum Haemorrhage
(including Uterine Rupture)
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Antepartum Haemorrhage
Antepartum haemorrhage (APH) is any bleeding from the genital tract after twenty weeks
gestation and prior to the onset of labour, and complicates between 2-5% of all pregnancies.1
APH can contribute to maternal or neonatal morbidity/mortality.1-3 A woman s condition can
deteriorate rapidly even without external signs of blood loss.1 Difficulties identified in
management include delays in recognising the severity of the bleeding, underestimation of
the blood loss, delays in commencing fluid resuscitation, delays in gaining senior obstetric
assistance and uncertainty in knowing how to access blood products rapidly.1
APH can be concealed or revealed and management should always include the assessment
of signs and symptoms of shock and the presence of fetal compromise no matter how much
blood is visible.1,4
Causes, risk factors and complications
Causes of APH include:1
? marginal placental bleeds
? local vaginal causes: cervical ectropion, polyp, cervical dysplasia/carcinoma, trauma
? blood stained show
? placenta praevia
? placental abruption
? abnormal placentation
? abnormal placental shape
? vasa praevia
? uterine rupture
? non-gynaecological causes: urinary tract infection, urethral caruncle, haemorrhoids,
inflammatory bowel disease
The most common causes of minor APH are marginal placental bleeds, bleeding cervical
ectropion and blood-stained show. Major APH is most commonly caused by placental
abruption, placenta praevia, vasa praevia and uterine rupture.1 Women who have
experienced a previous placental abruption are at increased risk of experiencing another APH
in subsequent pregnancies.4 Other risk factors for APH include:4
? pre-eclampsia
? fetal growth restriction
? non-vertex presentations
? polyhydramnios
? advanced maternal age
? multiparity
? low BMI
? pregnancy following assisted reproduction
? intrauterine infection
? preterm rupture of membranes
? abdominal trauma (accidental and domestic violence)
? smoking and drug use (cocaine and amphetamines)
Complications of APH include:
? maternal mortality
? anaemia (see Anaemia in Pregnancy PPG available at
www.sahealth.sa.gov.au/perinatal for further information9
? infection
? maternal shock
? renal tubular necrosis
? consumptive coagulopathy
? postpartum haemorrhage
? prolonged hospital stay
? psychological sequelae
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Antepartum Haemorrhage
(including Uterine Rupture)
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? complications of blood transfusions
? fetal hypoxia
? small for gestational age and fetal growth restriction
? preterm birth
? fetal death
Placenta Praevia
Placenta praevia occurs when the placenta covers or is adjacent to the internal os.5 In cases
greater than 16 weeks of gestation and where the placental edge is less than 20 mm from the
internal os, the term low-lying placenta should be used.5
Risk factors
? Previous caesarean birth
? Assisted reproductive technology / infertility treatment
? Maternal smoking
? Multiple pregnancy
? Previous placenta praevia
? Increasing parity
? Advanced maternal age
? Previous termination of pregnancy
? Previous uterine surgery
? Maternal cocaine use
Clinical features
? Painless vaginal bleeding, usually bright red, but variable quantity
? Uterine tenderness and irritability unusual (although uterine irritability can be present
after the bleed)
? Fetal malpresentation or unusually high and mobile presenting part
? May be an incidental ultrasound finding
Expectant management
? Expectant management refers to delayed birth greater than 24 hours from the time of
diagnosis. The objective being to prolong the pregnancy to achieve fetal maturity
while minimising maternal and fetal risks.
Place of care
? If there is no or minimal bleeding the woman may be managed as an outpatient.
? If the woman is in a rural setting then liaison with metropolitan services through the
pregnancy advice line (Phone: 137 827) needs to be initiated to discuss potential
transfer to a metropolitan setting, provided that there is no urgent indication for birth
? Ensure women with active bleeding are admitted/transferred to a hospital with a
suitable level neonatal unit to care for the baby should birth be required
? Explain that the frequency and severity of recurrent bleeding is unpredictable and
carries the risk of maternal and fetal complications
? Counsel to seek urgent hospital care if contractions or vaginal bleeding occur. This
includes any form of pain, bleeding, spotting and period like cramps5
? Placenta praevia and anterior low-lying placenta increase the woman s risk for
massive obstetric haemorrhage and hysterectomy. Birth should be arranged for a
maternity unit that has access to critical care and blood transfusion services5
Bloods
? If admitted, complete a weekly blood picture (CBP) and maintain current group and
hold (G&H) as per local guidelines.
? For women with known blood group abnormalities in whom outpatient management is
planned, liaise with local blood bank regarding the frequency of taking bloods for
G&H.
? With any bleeding, the need for Anti-D in Rhesus negative women may be quantified
with Kleihauer and flow cytometry. See Anti-D Prophylaxis PPG available at
www.sahealth.sa.gov.au/perinatal
South Australian Perinatal Practice Guideline
Antepartum Haemorrhage
(including Uterine Rupture)
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Correction of anaemia
? Consider iron supplementation (oral or infusion) for correction of anaemia and
optimising haemoglobin levels.
? Stool softeners (e.g. docusate) and high fibre diets should be discussed to minimise
constipation and avoid excess straining.
? Blood transfusion may be indicated.
Ultrasound
? Ultrasound scans every 2-3 weeks are recommended to assess fetal growth and
placental location colour Doppler ultrasound of the placenta and lower segment late
in the third trimester is recommended to reassess the placental site and to exclude
Vasa Praevia.
? Transvaginal ultrasound (TVS) for the diagnosis of Placenta Praevia or low-lying
placenta is recommended over transabdominal and transperineal scans.5
? TVS can be used to measure cervical length in asymptomatic women with placenta
praevia short cervical length before 34 weeks increases the woman s risk of
preterm emergency birth and haemorrhage.5 Also see Preterm Labour and Birth PPG
available at www.sahealth.sa.gov.au/perinatal.
Tocolytics
? The use of tocolytics is debated, with some medical experts considering APH as a
contraindication to the use of tocolytics. However, when contractions are contributing
to the bleeding from placenta praevia, tocolysis may have a role in supressing
contractions. The use of tocolytics in this setting should be discussed with a
consultant obstetrician before administration.
? Tocolysis for women who are symptomatic (of vaginal bleeding) and who have been
diagnosed with either placenta praevia or low-lying placenta may be considered for
48 hours to facilitate administration of antenatal corticosteroids. See Preterm Labour
and Birth PPG available at www.sahealth.sa.gov.au/perinatal.
? If birth is indicated for maternal or fetal reasons, there is no indication for tocolytics.5
Corticosteroids
? For women with a low-lying placenta or placenta praevia and active bleeding
administration of steroids at the time of the bleed is recommended. Note: Steroids are
not indicated after 37 completed weeks of gestation.
? Refer to Preterm Labour and Birth PPG available at
www.sahealth.sa.gov.au/perinatal.
Other considerations
? With any bleeding, digital vaginal examination and sexual intercourse should be
avoided
? Clinicians are reminded of the need for a venous thromboembolism (VTE) risk
assessment for women who are managed as inpatients.5 See Thromboprophylaxis
and Thromboembolic Disease in Pregnancy PPG available at
www.sahealth.sa.gov.au/perinatal.
Timing, location and mode of birth
? Women residing in a rural location with major placenta praevia need an individual
plan made for transfer to an appropriate metropolitan setting prior to term.
? Planned late preterm birth (34+0 36+6 weeks) should be considered for those women
who present with placenta praevia or low-lying placenta with a history of vaginal
bleeding or who have other risk factors for preterm birth.5
? Timing of birth depends on the clinical scenario, but for women who present with
uncomplicated placenta praevia, birth should be planned between 36+0 and 37+0
weeks.5
? For uncomplicated low-lying placenta in the third trimester, mode of birth should
consider the woman s wishes, clinical history, distance between the placental edge
and the position of the fetal head relative to placental position based on TVS.5
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Antepartum Haemorrhage
(including Uterine Rupture)
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? Planned caesarean section for women with a placenta praevia should be performed
by an experienced practitioner and in cases of unplanned or emergency caesarean
birth for placenta praevia or low-lying placenta, a senior obstetrician and anaesthetist
should be present or easily accessible.5
? Regional anaesthesia is safe and associated with a lower risk of haemorrhage than
general anaesthesia for women experiencing placenta praevia or low-lying placenta.5
Women should provide consent for the potential to convert to general analgesia if
needed during the caesarean.5
Active bleeding
? Active bleeding should be managed as per APH management.
Placental Abruption or Abruptio Placenta
Placental abruption occurs when there is a partial or total detachment of the placenta prior to
the birth of the baby, it is usually a sudden event and is an obstetric emergency.4 Chronic
pathologic vascular processes contribute to most cases of abruption.6 Placental abruption is
most often revealed but can be concealed. Where abruption has occurred with intrauterine
fetal death there is an increased incidence of maternal coagulopathy .4
Risk factors4,6
? Previous abruption
? Pre-eclampsia
? Fetal growth restriction
? Non-vertex presentations
? Polyhydramnios
? Advanced maternal age
? Multiparty
? Low BMI
? Pregnancy following assisted reproduction
? Intrauterine infection
? Premature rupture of membranes
? Abdominal trauma
? Smoking & drug use
? Maternal thrombophilias
Clinical features4
? Continuous abdominal pain/ back pain
? Tense, woody feel on abdominal palpation, so-called Couvelaire uterus
? Fetal heart rate abnormalities
? Blood loss can vary between mild to life-threatening
? Vaginal bleeding is often dark/non-clotting
? Signs of fetal compromise or uterine irritability (contractions >5 in 10 minutes)
Diagnosis
? Many women presenting with placenta abruption are in established labour
? Diagnosis is often made on clinical presentation and assessment
? Ultrasound may be helpful if there is a large retroplacental haematoma, however
absence of ultrasound evidence of retroplacental clot does not exclude the diagnosis
(performing an ultrasound to assess for abruption should not delay clinical
management in an unstable patient)
? In mild cases the diagnosis may not be made until after the birth when a
retroplacental clot is identified on placental examination
? In severe cases the woman may present with signs of shock
? Consider concealed abruption if abdominal or back pain is present
Management
Placental abruption is an obstetric emergency and should be managed as per APH
management.
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Antepartum Haemorrhage
(including Uterine Rupture)
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Women residing in a rural location who present with a large abruption should be delivered on-
site and the woman and neonate transferred postnatally if clinically indicated. Liaison via the
Pregnancy Advice Line (Phone: 137 827) at the earliest possible stage is essential.
Conservative management
Conservative management may be appropriate in cases of small abruptions (very preterm
gestation) with no maternal or fetal compromise.
Ensure:
? administration of maternal corticosteroids (from 23 weeks gestation)
? neonatology consultation
? observation for further bleeding
? maternal haemoglobin is maintained
? maternal and fetal monitoring
? monitoring for IUGR
? discussion with the woman to determine the appropriate place for management (i.e.
home or hospital)
? Consideration of need for Anti-D in rhesus negative women
Other considerations
? Often labour is precipitous (especially if multiparous)
? Consider a urine drug toxicity screen
? Ensure placental examination for completeness, area of abruption, associated
pathological findings, document findings and sent for histopathology (see
Histopathology Management of the Placenta PPG available at
www.sahealth.sa.gov.au/perinatal)
Vasa Praevia
Vasa praevia occurs when the fetal blood vessels transverse the placental membranes.7 Type
I vasa praevia occurs when the vessel is connected to a velamentous umbilical cord and type
II occurs when the vessel connects the placenta with a succenturiate or accessory lobe.7
Vasa praevia is likely to rupture either in active labour or when rupture of membranes occurs
(especially if located near or over the cervix and under the presenting part).7 Vasa previa
should be considered where there is APH and no maternal compromise with the presence of
spontaneous or artificial rupture of membranes.4 There is high fetal mortality associated with
vasa praevia and emergency birth should be expedited in suspected cases.1,7
Risk factors
? Low-lying placenta
? Succenturiate lobe
? Velamentous cord insertion
? Multiple pregnancy
? IVF
Incidence
Vasa praevia is uncommon with incidence of somewhere between 1 in 1200 and 1 in 5000.7
Clinical features1
? Fresh vaginal bleeding after rupture of membranes
? No maternal compromise
? Fetal compromise present (sinusoidal/bradycardic FHR on CTG)
Management
? Acute antenatal bleeding should be managed as per APH management.
? Women with confirmed vasa praevia should have an individually designed care plan
where consideration has been made for prophylactic hospitalisation from 30-32
weeks and that considers factors such as singleton or multiple pregnancy, history of
bleeding and/or threatened preterm labour.7
? Fetal exsanguination occurs very quickly and the mortality is high if vasa praevia is
suspected birth must be expedited.
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Antepartum Haemorrhage
(including Uterine Rupture)
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Timing of birth
? The management goal is to plan birth prior to rupture of membranes and where the
baby is of appropriate gestation.7
? Where there has been a diagnosis of vasa praevia planned caesarean section
between 34-36 weeks is reasonable in asymptomatic women.7
Ultrasonography
? There is high diagnostic accuracy with a low false-positive rate with the use of
ultrasound to diagnose vasa praevia with the routine fetal anomaly scan.7
? The use of both transabdominal and transvaginal colour Doppler imaging
ultrasonography is recommended for diagnosis in suspected vasa praevia.7
Corticosteroids
? Consideration should be given to administration of corticosteroids from 32 weeks due
to the increased risk of preterm birth.7
Other considerations
? Ensure placental histopathological examination to confirm vasa praevia, especially if
there has been fetal death or significant fetal compromise.7
Uterine Rupture
Refers to a full thickness tear through the myometrium and serosa. Uterine rupture may occur
in a previously intact uterus or in one with a previous caesarean, myomectomy scar or uterine
perforation at a gynaecological procedure. By definition, it is associated with the following:
? clinically significant uterine bleeding
? fetal compromise
? protrusion or expulsion of the fetus and/or placenta into the abdominal cavity
? need for prompt caesarean delivery
? uterine repair or hysterectomy
Different terms may be used to describe partial separation (dehiscence) or healing defects
(windows) of uterine scars. Uterine scar dehiscence occurs when there is a separation of a
pre-existing scar that does not disrupt the overlying visceral peritoneum (uterine serosa) and
that does not significantly bleed from its edges. In addition, the fetus, placenta, and umbilical
cord must be contained within the uterine cavity.
Risk factors
? Previous uterine surgery (caesarean section, myomectomy, cornual/ectopic
pregnancy, uterine perforation)
? High parity (? 4)
? Trauma
? Oxytocin infusion during labour for women with previous uterine surgery
The risk of uterine rupture in a woman with an unscarred uterus is extremely rare (2 per
10 000 (0.02%) births) and this risk is mainly confined to intrapartum multiparous
women.8
Clinical features1
? Sudden onset of constant sharp pain
? Peritonism and tenesmus
? Abnormal or pathological CTG
? High presenting part, unreachable presenting part or loss of station of the presenting
part
? Bleeding intra-abdominal and / or vaginal unless the fetal head blocks the pelvis
(blood may be retained within the broad ligament)
? Hypovolaemic shock
? Haematuria (suggests bladder involvement)
? Contractions may stop
? Palpable fetus ex utero
? Abdominal tenderness and or distension
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Antepartum Haemorrhage
(including Uterine Rupture)
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? No fetal presentation on vaginal examination
? Maternal tachycardia
? Absent fetal heart activity
? Increasing requirement for intrapartum analgesia can indicate impending uterine
rupture8
Rupture at the site of a previous uterine scar may occur with few warning signs. If there is an
atypical pattern of pain, or pain previously controlled by analgesia (epidural or otherwise)
which becomes more severe, complete clinical reassessment by an experienced obstetrician
is required.8 Shoulder tip pain may indicate peritoneal irritation and suprapubic pain may
reflect local, including bladder irritation.
Considerations
In developing countries, lower uterine segment caesarean sections are often performed with a
midline skin incision. If this can be identified from the history, these cases can be managed in
the same manner as other lower segment caesarean sections.
Management
Management as per APH management with the additional considerations below;
? In the case of uterine rupture early involvement of senior experienced staff, including
obstetrician/gynaecologist, anaesthetist, midwife(s), paediatrician, and haematologist
and intensivist as required (if available).
? Resuscitate while arranging urgent laparotomy / caesarean section
? The most senior person should take charge and assign roles and responsibilities to
all other individuals
? If major blood loss, recruit additional staff to assist during resuscitation e.g. to record
events, medications given, someone to make urgent phone calls, to organise
transport of laboratory samples, to bring blood (products) to the site of resuscitation,
and additional staff to support family members and significant others
? Repair of the uterus is preferable, but in some cases, hysterectomy may be required
? Provide standard post-operative and post-natal care
? Provide adequate counselling as soon as possible, document this, and arrange
further follow-up
Additional counselling recommendations
? If tubal ligation was not performed at the time of laparotomy, explain the increased
risk of rupture with subsequent pregnancies, and discuss the option of permanent
contraception
? If the defect is confined to the lower segment, the risk of rupture in a subsequent
pregnancy is similar to that of someone with a previous caesarean section
? If there are extensive tears involving the upper segment, future pregnancy may be
contraindicated
? Women with a history of uterine rupture should have a planned elective caesarean
section (37 to 38 weeks gestation) in their next pregnancy.8
Distal genital tract/gynaecological bleeding
? Speculum examination is indicated to inspect the genital tract
? A colposcopy examination may be useful in cases of suspected invasive cervical
neoplasm
? Swabs for infective pathogens and cervical cytology may be helpful in diagnosis
Cervical bleeding
Clinical considerations include:
? heavy show/onset of labour
? carcinoma - requires consultation with a gynaecological oncologist to plan timing of
birth
? benign polyps
? ectropion/inflammation/infection
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Vaginal bleeding
Clinical considerations include:
? tumours (e.g. condylomata)
? inflammation
? trauma *consider domestic violence
Vulval bleeding
Clinical considerations include:
? varicosities
? trauma
? tumour
? inflammation
Non-genital tract
Clinical considerations include:
? haematuria
? rectal
Unclassified bleeding
? More often painless
? Can be due to a marginal haemorrhage from the edge of the placental insertion site
(marginal haemorrhage)
? Sometimes related to a circumvallate placenta (see below)
? Monitor fetal growth by ultrasound
Abnormal placentation
Placenta accreta spectrum refers to abnormally adherent or invasive forms of accreta
placentation.5 Women with these conditions are at increased risk of life threatening bleeding
at birth.5 Women who experience placenta accreta syndrome are more likely to birth early and
in most cases of increta or percreta there is a need for complex surgical intervention.9
PLACENTA ACCRETA
Abnormal adherence of chorionic villi to the myometrium with no plane of separation
PLACENTA INCRETA
Abnormal invasion of chorionic villi penetrating into the myometrium
PLACENTA PERCRETA
Abnormal invasion of chorionic villi through the whole thickness of myometrium up to the
serosal surface or beyond with potential involvement of surrounding structures
Causes
? Implantation over previous caesarean section scar
? Manual removal of placenta after a previous pregnancy
? Placenta praevia
? Previous vigorous or repeated curettage (particularly postpartum)
? Previously treated intrauterine synechiae (adhesions)
? Presence of submucous myomata
? Pregnancy in uterine diverticulum
Management
Management of APH is as per APH management with the following considerations:
? Caesarean section should be planned in a level 6 maternity hospital with the required
services and surgical teams to manage all potential complications (Note: Flinders
Medical Centre is the preferred referral centre for placenta accreta)
? If diagnosis is made intraoperatively and the woman and fetus are stable with no
active bleeding, close incision and transfer to a level 6 maternity hospital (if not
already there)
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? If diagnosis made intraoperatively and the woman or fetus is unstable or the woman
is actively bleeding, activate local emergency procedures with emphasis on securing
emergency blood supplies, and if necessary, appropriate external expertise, such as
a gynaecological oncologist or appropriate staff from a level 6 maternity hospital.
See Morbidly Adherent Placenta Management PPG available at
www.sahealth.sa.gov.au/perinatal for detailed information on diagnosis, plan for birth and
management following suspected adherent placenta following vaginal birth or intra-
operatively.
ABNORMAL PLACENTAL SHAPE
Circumvallate placenta
Abnormality of placental shape resulting from chorioamniotic membrane insertion toward the
centre rather than the edge of the placenta.
Features include:
? An irregular edge.
? An uplifted margin or a placental sheet or shelf resulting from the infolding of the fetal
membrane upon the fetal surface of the placenta (plication) during the middle of the
second trimester.
? The thickened ridge of tissue can be accompanied by haemorrhage or infarction.
? Associated with increased risk of APH, preterm birth, low birth weight,
oligohydramnios, congenital malformations and perinatal mortality.10
Circummarginate placenta
? Similar to circumvallate placenta but with no prominent fold or central depression.10
MULTILOBATE PLACENTAS
Bilobed placenta
? Two near equal sized placental lobes that are usually associated with velamentous
cord insertion.11
? There are always membranous vessels connecting the two lobes. If one lobe is much
smaller than the other, the placenta is said to have a succenturiate or accessory lobe.
? Associated with first-trimester bleeding, polyhydramnios, placental abruption and if
unrecognised, a retained placenta.12
Succenturiate lobe
? The presence of one or more small lobes of placental tissue located in the membrane
at a distance to the main placenta. The umbilical cord most commonly inserts into the
dominant lobe. A placental artery and vein extend from and within the membrane of
the main placenta to each lobe then divide into smaller vessels supplying individual
cotyledons.
? They differ from bilobed placentas only in the size and number of accessory lobes.
? Approximately one half are associated with infarction or atrophy of the succenturiate
lobe/s.
? Increased incidence of velamentous insertion of the umbilical cord, vasa praevia. and
retained placenta.12
? Bilobed and succenturiate lobe placentas are more common in twins and multiparous
women and in pregnancies conceived via assisted reproductive technology.
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APH Management
Major APH is an obstetric emergency that requires immediate assistance from the
multidisciplinary health care team.1 Blood loss is often underestimated but accurate
measurement can assist in earlier recognition and instigation of fluid resuscitation.1 Fluid
resuscitation is a priority in the management of obstetric haemorrhage.1 Management of
major APH is based upon the guidance provided by PROMPT and other emergency drill
training.
Call for help1
Call for help and commence emergency management response.
The emergency team includes a senor midwife, experienced obstetrician, anaesthetist and
neonatologist and additional support staff. Notify the consultant obstetrician and neonatologist
if not already aware.
Alert the haematologist, blood bank technicians, theatre and orderly staff to be aware that the
major obstetric haemorrhage protocol may be activated and theatre to be on standby.1
Immediate actions
? Lie the woman supine with left lateral tilt/uterine displacement and administer high-
flow oxygen via a non-rebreather mask
? Assess airway and breathing
? Collect clinical observations and communicate them with the health care team (blood
pressure, pulse, capillary refill, respiratory rate and oxygen saturations).
? Intravenous access x 2 (16 gauge)
? Collect urgent blood samples: full blood count, Kleihauer (to detect maternofetal
haemorrhage), coagulation studies (including fibrinogen), ROTEM, cross match 4
units of blood, renal and liver function tests
? Rapid fluid resuscitation with 2 litres of crystalloid (Hartmanns or 0.9% saline,
preferably warmed)
? Assess the need for appropriate blood products, optimally using ROTEM as
guidance.
? Use O-negative blood if there is a life-threatening haemorrhage and consider the
early use of coagulation products (particularly if operative birth indicated)
? Assess fetal wellbeing establish presence of a fetal heart rate and commence
cardiotocography (CTG) (depending on gestation). Ultrasound as a primary tool for
the assessment of fetal wellbeing is not appropriate
? If fetal demise is confirmed with an abruption, there is a high risk of a major APH and
disseminated intravascular coagulation (DIC). The woman will need critical care
management with close clinical observation. Additionally, the woman and her partner
will need bereavement support and an appropriate level of medical / MFM follow-up.
Assessment1
Rapid assessment of the maternal and fetal condition is indicated. This assessment includes:
? Determine relevant obstetric and clinical history including
o Gestational age
o Presence of previous uterine surgery/caesarean section
o Position of placenta (refer to antenatal scans)
o Presence of abdominal pain (include site, commencement, frequency, strength
and duration)
o Establish if history of blood loss in this pregnancy is present
? Examination
o Estimated blood loss, note the colour, consistency, pattern and time of bleeding.
Weigh pads, linen for more accurate measures. Document ongoing blood loss
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? Uterine palpation for tone and tenderness (soft, tense, tender or non-tender). Assess
if tightenings or contractions are present.
o Abdominal palpation for peritonism and ex-utero fetal parts
o Assess placental site using ultrasound (point of care and/or formal depending on
woman s condition and assessment)
o Once placenta praevia has been excluded a speculum exam is indicated to
assess the degree of bleeding and identify any local causes (trauma, polyps,
ectropion)
o Consider a vaginal examination to establish cervical dilatation. Do NOT perform
a vaginal examination without first excluding placenta praevia
Stopping the bleeding
In most cases of massive APH, expediting birth is an effective measure to control bleeding.1
Birth should be via Category One Caesarean Section (See Category One Caesarean Section
Standards for Management Clinical Directive and Caesarean Section PPG at
www.sahealth.sa.gov.au/perinatal) unless birth can be expedited vaginally (cervix is fully
dilated and vaginal birth can be achieved within a short timeframe).
A caesarean section that is performed for major APH requires the most experienced
obstetrician available1 Where the woman has experienced a massive abruption clinicians
should be aware that coagulopathy might be present. The maternal condition should take
precedence over fetal condition in the case of a massive APH, and birth should not be
delayed for fetal reasons.1
Preparation for Postpartum Haemorrhage
An APH is a major risk factor for a postpartum haemorrhage (PPH).1 As such, a PPH should
be anticipated and acted on immediately. Active third stage management is strongly advised,
with a low threshold for additional prophylaxis. See Postpartum Haemorrhage PPG available
at www.sahealth.sa.gov.au/perinatal for further information.
Preparation for Neonatal Resuscitation
The need for Neonatal Resuscitation following a massive APH is likely and should be
anticipated. The neonatal team should be notified early to enable the appropriate team to
assemble for optimal newborn resuscitation and preparation of neonatal resuscitation
equipment.1 Neonatal anaemia can be present in cases of APH especially where there has
been a vasa praevia or an abruption.1 See Newborn Life Support Algorithm available at
www.sahealth.sa.gov.au/perinatal for further information.
Documentation
Contemporaneous records of the emergency should be maintained. The woman s clinical
response to haemorrhage and resuscitation response documented and shared with the health
care team. If a centralised CTG monitoring system was in use (such as OBTraceVu or Philips
IntelliSpace Perinatal) the event should also be recorded in the system.
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Open Disclosure, Debriefing and Ongoing Support
All major APH cases should be managed as per the SA Health Patient Incident Management
and Open Disclosure Policy
Considerations include:
? Clear communication is vital during the emergency both to the woman, her family and
the healthcare team.
? After the birth, the woman and her support persons should be offered opportunities to
discuss the birth and the management of the emergency.
? Counselling should be offered.
? A social work referral should be offered.
? Arrange a clinical review postnatally to further debrief and discuss the recommended
approach to future pregnancy.
? All staff working in birth suites should participate in regular practical based simulated
obstetric haemorrhage training.
? Attending a major APH can be distressing for all staff involved. If possible, a staff
multidisciplinary meeting should occur after the emergency to debrief regarding the
events and discuss management of the case as a team.
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References
1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
PROMPT Course Manual Australian and New Zealand Edition. United Kingdom:
Cambridge University Press; 2020.
2. Australian Institute of Health and Welfare. Australia s mothers and babies 2018: in brief
Perinatal statistics series no. 36. Cat. no. PER 108. Canberra: AIHW; 2020.
3. Pregnancy Outcome Unit. Pregnancy Outcome in South Australia 2017. In: SA POUW,
editor. Adelaide: Prevention and Population Health Branch; 2019.
4. Royal College of Obstetricians and Gynaecologists. Antepartum Haemorrhage Green
top Guideline No. 63. United Kingdom: RCOG; 2011.
5. Jauniaux ERM AZ, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D,
Kayem G, Kingdom J, Silver R, Sentilhes L on behalf of the Royal College of
Obstetricians and Gynaecologists,. Placenta Praevia and Placenta Accreta: Diagnosis
and Management. Green-top Guideline No. 27a. BJOG. 2018.
6. Ananth, C & Kinzler, W Placental abruption: Pathophysiology, clinical features,
diagnosis, and consequences [Internet] 2020 August [cited July 22, 2020] Availbale from:
www.uptodate.com
7. Jauniaux ERM AZ, Bhide AG, Burton GJ, Collins SL, Silver R on behalf of the Royal
College of Obstetricians and Gynaecologists,. Vasa Praevia: Diagnosis and
Management Green-top Guideline No. 27b. BJOG. 2018.
8. Royal College of Obstetricians and Gynaecologists. Birth after Previous Caesarean Birth
Green-top Guideline No. 45. Royal College of Obstetricians and Gynaecologists; 2015.
9. Jauniaux E, Bunce C, Gr nbeck L, Langhoff-Roos J. Prevalence and main outcomes of
placenta accreta spectrum: a systematic review and meta-analysis. American journal of
obstetrics and gynecology. 2019;221(3):208-18.
10. Merriam A, D'Alton ME. 101 - Placenta Circumvallata. In: Copel JA, D'Alton ME,
Feltovich H, Gratac s E, Krakow D, Odibo AO, et al., editors. Obstetric Imaging: Fetal
Diagnosis and Care (Second Edition): Elsevier; 2018. p. 441-3.e1.
11. Biswas PR, Paul GK, Chowdhury M, Selim M. A Rare Shape of Placenta; Placenta
Bipartite, Bilobata, Dimidiate, Duplex: A Rare Case Report. Bangladesh Journal of
Obstetrics & Gynaecology. 2016;31(2):101-3.
12. Rathbun KM, Hildebrand JP. Placenta abnormalities. StatPearls [Internet]: StatPearls
Publishing; 2019.
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Acknowledgements
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development
process particularly:
Write Group Lead
Dr Angela Brown
Write Group Members
Dr Asha Short
Keera Laccos Barrett
A/Prof Rosalie Grivell
Dr Michael McEvoy
Dr Anupam Parange
A/Prof Chris Wilkinson
Other major contributors
Catherine Leggett
SAPPG Management Group Members
Sonia Angus
Lyn Bastian
Dr Elizabeth Beare
Elizabeth Bennett
Dr Feisal Chenia
John Coomblas
Dr Danielle Crosby
Dr Vanessa Ellison
Jackie Kitschke
Dr Kritesh Kumar
Catherine Leggett
Dr Anupam Parange
Rebecca Smith
A/Prof Chris Wilkinson
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Document Ownership & History
Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Endorsed by: Commissioning and Performance, SA Health
Next review due: 25/02/2026
ISBN number: 978-1-76083-342-8
PDS reference: CG354
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? V7
Does this policy replace another policy with a different title? Y
If so, which policy (title)? Merged with Uterine Rupture
Approval
Date
Version
Who approved New/Revised
Version
Reason for Change
25/02/21 V7
Deputy CE, Commissioning and
Performance Division, SA Department
for Health and Wellbeing
Reviewed and merged with Uterine
Rupture
29/04/13 V6
SA Health Safety & Quality Strategic
Governance Committee
Minor Update
06/08/12 V5
South Australian Maternal and
Neonatal Clinical Network
Minor Update
20/02/12 V4
South Australian Maternal and
Neonatal Clinical Network
Minor Update
17/01/12 V3
South Australian Maternal and
Neonatal Clinical Network
Reviewed in line with scheduled review
date
01/09/08 V2
South Australian Maternal and
Neonatal Clinical Network
Reviewed in line with scheduled review
date
07/06/04 V1
South Australian Maternal and
Neonatal Clinical Network
Original
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