A Case Of Vaginal Bleeding In Third Trimester

Labor and delivery department calls you about a 27-year-old G1 P0 at 38 weeks gestation who awoke this morningcomplaining of wetness. However, when she went to the bathroom she discovered significant vaginal bleeding that had soaked her bed. She denies any cramping or abdominal pain. She is on her way to the hospital.
You would tell the nurses to initiate all of the following interventions immediately upon the patient’s
arrival EXCEPT:
A) Obtain IV access.
B) Draw blood for type and screen.
C) Perform a digital vaginal exam.
D) Initiate fetal monitoring.
E) Draw blood for complete blood count.

Discussion



The correct answer is “C.” A small-to-moderate amount of bleeding is not unexpected during labor; however, the profuse bleeding described by the patient is an obstetric emergency.

• The first priorities are to obtain IV access and ensure that the mother is hemodynamically stable. 
• Baseline laboratory evaluation will give some indication of the amount of blood loss and establish that blood is available for transfusion if necessary. 
• Monitoring of the fetal heart rate (FHR) will establish viability. 
• Also, an ultrasound should be done to evaluate for placenta previa. 
• A digital vaginal examination should NOT be performed until the diagnosis of placenta previa has been excluded. 
• A consultation with someone skilled in cesarean section should be obtained if the initial evaluation suggests that immediate fetal delivery is necessary.

Classically, placenta previa presents as painless third trimester bleeding, whereas, placental abruption classically presents as painful third trimester bleeding.
Note that these are the “classic” presentations, not pathognomonic.