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Spotting Before 12 Weeks. Vaginal Bleeding Before 12 Weeks. Vaginal Bleeding After 12 Weeks. Spotty or Minimal Bleeding After 12 Weeks Miscarriage Guidelines
SPOTTING BEFORE 12 WEEKS
If spotting occurs before 12 Weeks and is not associated with lower quadrant pain:
1. The client should be advised to rest and abstain from sexual intercourse for at least seven days after spotting has ceased.
2. The midwife should schedule a prenatal visit within 7 - 14 days to assess uterine growth, rule out missed spontaneous abortion (miscarriage) or ectopic pregnancy and check FHTs. Although urine pregnancy tests are fairly accurate, blood tests are valid much sooner and even more precise. A venous blood test (Beta-pregnancy test) may be considered to determine Human Chorionic Gonadotropin (HCG) levels in blood. HCG is a hormone produced by the placenta. If an intrauterine death has occurred which includes cessation of placental function, the HCG levels will rapidly fall off making this test a good non-invasive first step to diagnosing a missed abortion.
3. If the bleeding has not resolved after 2 consecutive visits, the client should consult with and/or possibly transfer care to her health care provider.
VAGINAL BLEEDING BEFORE 12 WEEKS
1. Advise client to rest and abstain from sexual intercourse for at least seven days after bleeding has ceased.
2. Schedule prenatal visit. Perform venous blood HCG - Beta Pregnancy test, if needed.
3. If bleeding persists for 5 days and cramping persists for 1 - 2 days, or uterine or fetal growth stops, client should be referred to her health care provider for further care. If the fetus has ceased viability, a dilation & curettage (D & C) may need to be scheduled to evacuate the uterus of any left over fetal material.
4. If bleeding is heavy, (more than 3 full-size pads/hour or 8 pads in 12 hours) the client should consult with her health care provider. When possible, save any tissue passed for examination by the midwife and/or health care provider.
5. The midwife should administer or have administered from a health care provider or clinic Rhogam to all unsensitized Rh-Negative women within 72 hours of spontaneous abortion (miscarriage). The midwife will need to explain the pros and cons of Rhogam and will need to have an informed consent form signed by the client before administering Rhogam.
6. If a spontaneous abortion (miscarriage) inevitable, refer to the Miscarriage Guidelines.
VAGINAL BLEEDING AFTER 12 WEEKS
1. Evaluation of the client should be done as soon as possible for possible placenta previa or abruptio placentae . An ultrasound may need to be scheduled to confirm either condition.
2. The midwife should rule out precipitating factors such as vaginal exam, intercourse, or vaginal-cervical infections, trauma or lacerations, or any other conditions.
3. If bleeding is heavy and/or painful, direct client to a medical facility immediately.
SPOTTING OR MINIMAL BLEEDING AFTER 12 WEEKS
1. A history should be taken noting time of onset, amount, duration, and activity at time of onset.
2. Assessment of maternal and fetal vital signs should be done. If fetal heart tones (FHTs) have been heard prior to bleeding incident, recheck FHTs and check for variability, frequency and intensity. If fetal movement and activity has been felt, have client take notes on number of fetal movements are felt, when and how often in a set time period. This is a non-invasive method to determine fetal well-being.
Assessment of Fetal Movement & Activity Test
3. Assessment of fetal position by abdominal exam should be done.
4. A careful speculum exam only; no vaginal exams should be done in 3rd Trimester, just in case this may be a borderline placenta previa. A vaginal exam may disrupt the edge of the placenta and may make things worse.
5. Obtain ultrasound scan if abnormal (placenta previa, abruptio placentae) is suspected to confirm diagnosis. The client should consult with her health care provider about other possible birth alternatives. A cesarean delivery may need to be considered.
6. If spotting persists despite normal ultrasound scan, the client should consult with her health care provider for further testing. This may be considered a high-risk situation.
7. If spontaneous abortion inevitable, refer to Miscarriage Guidelines.
MISCARRIAGE GUIDELINES
1. This is defined as cramping and bleeding that lead to pregnancy loss.
2. The midwife should stay in close telephone contact with the client.
3. The midwife should be sure the client and her partner have a clear understanding of what is normal and what is not. The midwife should have them write everything down and save any clots or tissue passed to be examined later.
4. Expect cramping to be quite severe and suggest complementary and support measures.
5. The midwife will need to determine if she will attend her client when the process is intensifying.
6. The midwife should refer her client to the client's health care provider if and when the following situations are present:
- The client desires to be in the hospital.
- The bleeding exceeds one pad every two hours, not counting the 3-2 hours of actually "passing" the baby and placenta.
- The heavy bleeding does not subside 2 to 3 hours after passing the baby and placenta and any alternative therapies have not worked.
7. The midwife should administer or have administered by a health care provider or clinic RhoGam to any unsensitized Rh-Negative client within 72 hours, only after the client has been informed about the pros and cons of the Rhogam and a informed consent form has been signed.
8. The midwife should schedule a two week follow-up appointment and expect to do some emotional counseling and support.
RELATED MOONDRAGON LINKS
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Dr. Cacciatore's Life and Death Blog
When a Child Dies
Changing the Way Our Culture Mourns
Dr. C's Research Page
Stillbirth Policy Advocacy
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