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Haemorrhage Ante Partum

Look To the maternal status

(General condition, Pulse,
BP, CBC, Bleeding time)


IN SPECULO Correct shock/anemia

To decide whether With IVFD, Blood Transfusion
Bleeding come from
placenta/ non placenta
Success Failed

Non Placenta Placenta

(exclude Abruptio/
Placenta Previa USG

Placenta Previa Abruptio Placenta

Placenta Previa

Full term Preterm

Active * Expectative *
Management Management
Failed Success

IE under Double Setup 1

Wait until full term
with closed observation
3 To recurrent bleeding

Vaginal Delivery CS * If there is recurrent bleeding

Active Management
Indication :
- Full term pregnancy(> 36 weeks) and viable baby(> 2500
- In labor
- Continuous bleeding or severe maternal condition due to
- There is fetal distress
- After 72 hours of expectative management and the bleeding
tends to severe than before.
- In the expectative management, there is recurrent bleeding
- After vaginal toucher is done
Including :
- Internal Examination In Operation Room(if delivery is
- CS without Internal Examination
1(Foot Note)
CS must be performed without Double Setup in
condition of:
- Poor maternal condition
- Primigravide
- There is sign of fetal distress
- The bleeding still profuse/progressively
- USG shows posterior placenta
- Central placenta previa
- Total Placenta Previa in primigravide
2 (Foot Note)
Internal Examination (IE) under Double Setup only
can be done in operation room with all necessary
requirements needed to CS delivery.
Indication to do IE under Double Setup :
- Maternal General condition is stable
- There is no fetal distress
- Multiparity with partial, marginal, or
high/low lying placenta previa as seen by
- The bleeding tends to minimal or stop
2 (Foot Note) continued
IE under Double Setup start with in speculo
examination to decide whether the bleeding is still
profuse or not. If there is no bleeding, palpation of
fornix can be done to decide whether there is
placenta that locate at the lower segment of
uterine. Then, continue with palpation through the
cervical canal to palpate the placenta directly.
Beware of sudden bleeding and never continue to
palpate the whole placenta because it can
damaged the artery sinus in placenta so not only
mother but the baby is in danger situation.
3 (Foot Note)
Indication to do Vaginal Delivery after IE under Double
Setup :
Partial Placenta previa in multigravide with cervical dilatation > 5
The bleeding tends to minimal after amniotomy/ oxytocin is done
There is no CPD
There is no fetal distress after IE under Double Setup
Fetal head can act as a tamponade so the bleeding is decreased
as the delivery progress continued

If one of those conditions are not fulfilled then CS delivery should
be done promptly.
Caesarian Section
Indicated in :
- Primigravide
- Placenta previa totalis
- The bleeding is still progressive after the
amniotomy is done.
- Cervical dilatation is less than 5 cm when
IE under Double Setup is done.
- There is contraindication to vaginal delivery
Expectant management
Indication :
- preterm pregnancy or non-viable baby(< 36 weeks or <
2500 grams)
- not in labor
- normal or moderate bleeding with the tendency to
- mother condition is well/stable
- Fetal is alive without fetal distress
Including :
- Bed rest with close observation to bleeding, fetal monitor,
and maternal condition.
- improve maternal condition and provide blood
- Tocolytics and corticosteroid
- USG to determine the localization of placenta
- mobilization after 72 hours and there is not bleeding
Abruptio Placenta

Assure the fetal heart beat

Fetal Alive Fetal Death

Non Fetal Fetal

Distress Distress

Preterm Full term

Open* Closed* 2
Active * Caesarean
Management Sectio
Expectant *
Management(72 h)

Success Failed
Vaginal Delivery
Wait until Full term
With closed observation
to recurrent bleeding,
Fetal distress, or poor
Maternal condition.
Open and Closed bleeding
Clinical manifestation of open hemorrhage :
- Uterine pain is not too severe.
- Maternal general condition is relevant to the level of
- Fetal condition is not too bad
Clinical manifestation of closed hemorrhage :
- There is mild or minimal bleeding.
- Usually, maternal general condition is very bad
and it is not relevant to the level of bleeding.
- Fetal condition is poor or death.
- Uterine pain is severe and abdominal muscle is very
Expectative Management
Especially in a preterm labor( <36 weeks of gestation or < 2500
grams in weight) and no signs of fetal distress. This, should be
continued with close observation on fetal and maternal condition.
Including :
- Bed rest
- Provide 2 bags of fresh blood
- Urine catheterization
- Corticosteroid
- observation of maternal condition
- fetal heart monitor
If in the observation :
- Bleeding is still permanently or progressively
- clinical manifestation more clearly, or
- fetal distress happens
Active Management
Especially in moderate to severe abruptio
placenta, in a full term pregnancy or if the
expectative management fails.
Including :
- amniotomy
- oxitocyn to induced labor
* The delivery in active management is immediate
per vaginam but if the delivery is not done within 6
hours since clinical manifestation happens than
SC should be considered.
1 (Foot Note)
Indication for vaginal delivery :
- Maternal general condition is stable
with minimal bleeding.
- There is no sign of fetal distress
- After amniotomy is done, the bleeding
tends to minimal or stop.
- The delivery should be done in 6 hours
since the clinical symptoms appeared.
2 (Foot Note)
Indication to Caesarean Section :
- There is sign of fetal distress
- Maternal condition is unstable
- The bleeding tends to progress or
permanently even after the amniotomy.
- After 6 hours since the clinical findings
and the delivery is not done yet.

OPEN Hemorrhage CLOSED Hemorrhage

Pre Term Full term

No Sign of
Fetal distress Fetal Distress/Death

Expectative * Active Management *


1 2
Wait until Full term
With observation to
Recurrent bleeding or Vaginal Caesaren
Fetal distress, or Delivery Sectio *
Maternal shock