Painless Bleeding at 36 Weeks With Transport Delayed
A 32-year-old G4P3 at 36 weeks is brought to a health center at 02:00 with sudden painless bright red vaginal bleeding. She has soaked one maternity pad in 30 minutes and continues to trickle. Her blood pressure is 100/60, pulse 118, respiratory rate 20, and she feels dizzy when sitting. The uterus is soft and non-tender, fundal height is 36 cm, and the fetal heart rate is 150. She has no contractions. She has never had an ultrasound. Her three previous deliveries were vaginal at home. The health center has no ultrasound, blood bank, or operating theatre. The referral hospital is 90 minutes away; the ambulance has a flat tyre and the nearest taxi is 20 minutes away. Her husband wants to wait until morning because the last birth was normal and he fears the cost.
1. What is your immediate assessment, and why is vaginal examination contraindicated?
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My first assessment is ABC and maternal stability: airway, breathing, circulation, blood pressure, pulse, capillary refill, mental status, and estimated blood loss. I would check the fetal heart rate, palpate the uterus and fundal height, and ask about pain, contractions, and previous ultrasound. I would not perform a vaginal examination because painless bright red bleeding at 36 weeks is placenta praevia until ultrasound proves otherwise, and a digital examination can provoke catastrophic haemorrhage. I would also avoid a speculum examination unless the woman is in a facility with theatre and blood available. The soft, non-tender uterus and absence of contractions fit placenta praevia more than abruption, but abruption can also present with bleeding, so I would keep both in mind. Her dizziness and pulse of 118 suggest she may be developing shock even though her BP is still 100/60.
2. What pre-referral actions and transport arrangements would you make?
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I would establish two large-bore IV lines if possible and start crystalloid, keep her warm, and monitor BP, pulse, respiratory rate, urine output, and fetal heart rate. I would not give oxytocin or perform a vaginal examination. I would call the referral hospital to announce a woman with antepartum haemorrhage at 36 weeks, arrange urgent transport, and ask the hospital to prepare blood and theatre. I would send the MCH handbook and a referral note with the estimated blood loss, vital signs, fundal height, fetal heart rate, and the fact that no ultrasound is available. I would accompany her if possible, bring emergency drugs and fluids, and continue monitoring for shock during transfer. The 90-minute journey and the flat ambulance tyre make early transport essential; waiting for morning could allow her to bleed further and become unstable.
3. How would you counsel the husband and document if he refuses transfer?
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I would explain that the bleeding is coming from the birth canal or placenta, that a vaginal examination could cause heavy bleeding, and that the health center has no ultrasound, blood, or operating theatre. I would say clearly that waiting until morning risks her life and the baby's life, and that the cost of transfer is less than the cost of emergency surgery or death. I would involve the husband, the VHSG, and the health center chief, and offer the Health Equity Fund or emergency referral fund. If he still refuses, I would document the time, who was present, the risks explained, and the advice to return immediately if bleeding increases, she feels faint, the baby stops moving, or labour starts. I would continue monitoring and call the referral hospital and ambulance again rather than simply accepting the refusal.