Antepartum haemorrhage is defined as bleeding from or into the genital tract occurring from 24 weeks of pregnancy up until the birth of the baby. In Nigerian clinical practice, the lower gestational limit of 24 weeks is crucial because it marks the age of fetal viability in most local tertiary centres. Bleeding occurring before 24 weeks is classified instead as early pregnancy bleeding, such as abortion or ectopic pregnancy. APH affects roughly 2 to 5 percent of all pregnancies and remains a leading cause of maternal and perinatal morbidity and mortality across West Africa. The bleeding can range from mild spotting to massive haemorrhage that rapidly compromises both maternal and fetal status.
The causes of antepartum haemorrhage are broad, originating from placental abnormalities, local genital tract conditions, or systemic disorders. Placental causes account for the most severe bleeding episodes and require immediate intervention.
Placenta praevia occurs when the placenta implants in the lower uterine segment. The classic presentation is painless, recurrent vaginal bleeding that often starts spontaneously during rest. The blood is typically bright red.
Modern classification grades the condition based on the relationship of the placental edge to the internal cervical os:
A cardinal rule in managing placenta praevia is that vaginal examination is strictly contraindicated unless performed in a fully equipped operating theatre ready for an immediate caesarean section, as digital examination can provoke catastrophic haemorrhage.
Abruptio placentae involves the premature separation of a normally situated placenta after 24 weeks of gestation. Unlike placenta praevia, abruption usually presents with sharp abdominal pain and uterine tenderness. The bleeding may be revealed, where blood escapes through the vagina, or concealed, where blood collects behind the placenta, leading to a rigid, board-like uterus and a high risk of hypovolemic shock out of proportion to visible blood loss.
Initial nursing assessment of a woman presenting with APH must be rapid, systematic, and prioritized to prevent maternal collapse. The nurse assesses maternal vital signs, estimates blood loss, and evaluates fetal well-being. Abdominal palpation is performed carefully to assess uterine tone and tenderness, noting that internal pelvic examinations must be avoided until placenta praevia is ruled out by ultrasound. Baseline laboratory investigations are promptly secured, including full blood count, blood grouping and crossmatching, coagulation profile, and renal function tests. Continuous monitoring helps detect early signs of hypovolemic shock, such as tachycardia, tachypnoea, pallor, and falling blood pressure.
Emergency management of massive APH requires a multidisciplinary team approach involving midwives, obstetricians, anaesthetists, and laboratory staff. Resuscitation follows the ABCDE protocol. Two large-bore intravenous cannulas are inserted immediately to infuse warmed isotonic crystalloids and type-specific blood products. Supplemental oxygen is delivered via a face mask to maintain fetal oxygenation. Catheterization with an indwelling catheter allows accurate hourly urine output monitoring as a sensitive indicator of renal perfusion and fluid balance. Constant monitoring of maternal blood pressure, pulse, and fetal heart rate dictates the urgency of surgical intervention, which is often an emergency caesarean section.
Antepartum haemorrhage carries significant risks for both mother and baby. Maternal complications include severe hypovolemic shock, acute kidney injury from prolonged renal hypoperfusion, disseminated intravascular coagulation (DIC), and postpartum haemorrhage. Emergency caesarean delivery also increases the risk of operative trauma and puerperal sepsis. Fetal complications stem primarily from uteroplacental insufficiency and hypoxia, leading to intrauterine growth restriction, fetal distress, preterm birth, and stillbirth. Prompt resuscitation and timely delivery remain the most effective strategies to minimize these adverse outcomes.
Preventive care and health education are vital components of antenatal care aimed at reducing APH morbidity. Antenatal nurses educate pregnant women to recognize warning signs such as vaginal bleeding or sudden abdominal pain and to report to the clinic immediately. Women with identified low-lying placenta on routine mid-trimester ultrasound are counselled on pelvic rest and advised to avoid strenuous activities and sexual intercourse. Health promotion also emphasizes regular antenatal attendance, early treatment of anaemia to build physiological reserve, and referral of high-risk cases to well-equipped facilities before bleeding occurs.