Differential Diagnosis of APH and Emergency Midwifery Protocol

Clinical Presentation and Initial Assessment of Bleeding in Pregnancy

Antepartum haemorrhage (APH) is defined as bleeding from or into the genital tract occurring from 24 weeks of gestation up until the birth of the baby. When a pregnant woman presents with bleeding, the initial assessment must be rapid, calm, and systematic. Midwives must avoid immediate digital vaginal examinations until placenta praevia has been definitively ruled out by an ultrasound scan, as a finger sweep can provoke catastrophic, life-threatening haemorrhage.

• History taking: Determine gestational age, approximate blood loss volume, presence or absence of pain, and any precipitating factors like trauma or sexual intercourse.
• General condition: Assess the woman's conscious state, skin temperature, colour, and capillary refill time to detect early signs of hypovolaemic shock.
• Vital signs: Record baseline maternal pulse rate and blood pressure immediately. Tachycardia and falling blood pressure often precede overt signs of shock.

Differential Diagnosis of Late Pregnancy Bleeding

The two primary and most dangerous causes of antepartum haemorrhage are placenta praevia and placental abruption. Other less common or minor causes must also be considered during clinical evaluation to ensure appropriate management.

Local cervical or vaginal lesions, such as cervical polyps, cervicitis, or carcinoma of the cervix, can also cause bleeding and should be visualized using a speculum examination only after major placental causes are excluded.

Emergency Protocols and Immediate Resuscitation

When faced with a heavy antepartum haemorrhage, the midwife must activate the facility emergency response team immediately. Resuscitation follows the standard ABCDE framework while simultaneously addressing the failing uteroplacental unit.

1. Call for senior obstetric, anaesthetic, and paediatric help without delay.
2. Position the woman in a left lateral tilt to relieve aortocaval compression by the gravid uterus and maintain venous return.
3. Secure two large-bore intravenous cannulas (16G or 14G) in the antecubital fossae.
4. Draw blood urgently for full blood count, coagulation profile, urea and electrolytes, and cross-matching of at least four units of blood.
5. Infuse warm isotonic crystalloids rapidly while awaiting type-specific or O-negative blood products.
6. Monitor continuous fetal heart rate patterns if the fetus is viable and the mother is stabilized.

Midwifery Management and Ongoing Monitoring

Once the initial crisis is managed, continuous and meticulous surveillance is required to protect both mother and fetus. The midwife records vital signs every fifteen minutes until the patient is stable, then hourly. An indwelling urinary catheter attached to a urometer is inserted to monitor urine output strictly; output must remain above 30 millilitres per hour as a reliable indicator of adequate renal perfusion.

Accurate charting of all fluid input and estimated blood loss helps guide ongoing blood product replacement. Emotional support is vital, as the sudden gush of blood and rush of medical staff induce severe anxiety in the mother and her relatives. Explain every procedure calmly before performing it.

Indications for Urgent Obstetric Referral and Transfer

Primary health clinics and basic maternity centers in Nigeria often lack blood banking facilities and surgical theaters. Midwives working in these settings must recognize their limitations and arrange prompt, safe transfer to a comprehensive emergency obstetric care facility when complications exceed local capacity.

• Ongoing or heavy bleeding: Any episode of bleeding that does not settle quickly with conservative measures.
• Signs of shock: Maternal tachycardia, falling blood pressure, pallor, or confusion.
• Fetal compromise: Abnormal fetal heart rate tracing indicating hypoxia or distress.
• Suspected major placental abruption or complete placenta praevia.

Before transfer, ensure an IV line is running securely, accompany the patient with a trained midwife, and send all clinical notes along with a written referral summary.