Painless Bleeding at 34 Weeks: The Examination That Must Not Be Done
A 29-year-old woman in her third pregnancy, about 34 weeks by her antenatal card, is brought to a rural sub-centre at 9.30 p.m. Her saree and the cloth she was carried on are soaked with bright red blood. She says the bleeding started about an hour ago, is painless, and she has felt the baby move since. She has had two previous deliveries, the second by caesarean section because "the baby would not come down". She looks pale; BP is 100/70 mmHg, pulse 96 per minute, respiratory rate 20 per minute. The sub-centre has no ultrasound, no blood bank and no operating theatre. The block PHC is 14 km away, with a doctor on call but no blood bank; the district hospital, with a blood bank and caesarean facility, is 40 km away. The 108 ambulance will take about 25 minutes to reach. Her husband insists that the ANM should do an internal examination at once, "as was done last time", so they know how far labour has progressed.
1. Why is an internal examination dangerous in this situation, and what is your leading suspicion?
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Leading suspicion: placenta praevia - the placenta lying over or near the cervical opening - until it is excluded by ultrasound. The pointers are painless, bright red bleeding in late pregnancy, a previous caesarean scar, and a uterus that is not contracting.
Why vaginal examination is dangerous: in placenta praevia the placenta sits between the examining finger and the birth canal. A vaginal examination can dislodge it from the cervix and start torrential, painless bleeding that cannot be stopped by pressure. At a sub-centre with no blood bank or theatre, that bleeding can kill the woman before she reaches the district hospital.
Important distinction: in placental abruption the bleeding is usually painful and the uterus is hard and tender; here she has no pain. But the rule is the same - no vaginal examination for any late-pregnancy bleeding until the placenta's position is known.
Therefore: the husband's request must be refused, not because of rudeness, but because the examination itself is the danger.
2. Set out your priorities for the next 60 minutes, separating what can be done at the sub-centre from what needs the district hospital.
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At the sub-centre, in this order:
- Call 108 immediately - do not wait to see whether the bleeding settles. Ask for the district hospital, not the PHC, because she may need caesarean section and blood.
- Position her lying down, tilted to the left side, head low, to keep blood flowing to the heart and brain and to reduce pressure on the large vein.
- Keep her warm, loosen tight clothing, and keep her calm; cold increases shock.
- Nothing by mouth - no food, no water - in case surgery is needed.
- Record blood loss objectively: count and keep every soaked pad or cloth, note the time, colour and any clots.
- Monitor BP, pulse, respiratory rate and level of consciousness every 15 minutes, and look for pallor, restlessness and cold skin, which indicate shock.
- No vaginal examination, no enema, no intramuscular injection (poor absorption in shock and risk of bleeding).
- Inform the Medical Officer/ANM-in-charge and telephone the district hospital so that blood can be arranged before she arrives.
At the district hospital: ultrasound, blood grouping and cross-match, blood transfusion and caesarean section. Send her antenatal card and the pad count with her.
3. How would you explain this to the husband, and how would you measure blood loss objectively for the receiving hospital?
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Explaining it: "Your wife is bleeding from inside, and the bleeding is not painful, which tells us the placenta may be lying in front of the baby's exit. If we examine inside, we can tear it and she may bleed so much that we cannot save her on the way. The safest thing is to keep her lying down and take her straight to the district hospital, where they can do an ultrasound, give blood and operate if needed. That is why we are not doing the examination you asked for."
Measuring loss objectively:
- Count every soaked pad or cloth and record the number with the time each was changed.
- Weigh pads if a weighing scale is available: 1 gram of added weight is roughly 1 mL of blood.
- Note colour (bright red or dark), presence of clots and whether bleeding continues between changes.
- Record the time bleeding started, the mother's pulse and BP at each check, and whether the baby is moving.
Why it matters: a soaked saree means little to a receiving doctor, but "six soaked pads in 50 minutes, pulse rising from 96 to 112" tells the team exactly how urgent she is and how much blood to prepare.