Vaginal Bleeding (second trimester/less than 24+0 weeks gestation), maternity assessment (986)

All calls must be documented under communication on Badgernet. Please create a new record for any women without an open Badgernet record.

Obtain history:

If unbooked ensure you obtain:

• LMP and cycle length
• Date of first positive pregnancy test
• Parity, any previous uterine surgery?
• Are they already under EPAS care/ have they already contacted EPAS?
• Have they had an NHS ultrasound (USS) confirming an intrauterine pregnancy?

For all women:

• Symptoms: PVB and if so how heavy, abdominal pain, shoulder tip pain, rectal pain/pressure, gastrointestinal upset
• Any ectopic risk factors? (previous ectopic, assisted conception in this pregnancy, PID, STI’s, previous tubal damage/surgery, IUCD in situ or using progesterone only pill)

< 6 weeks by LMP

Women reporting painless bleeding who are less than 6 weeks based on their last menstrual period (LMP), and who have no risk factors for ectopic pregnancy, should be advised to repeat their high sensitivity pregnancy test after 7 days and to contact EPAS if it remains positive. 

If the home pregnancy test is negative then sadly the pregnancy has miscarried.  Women should be encouraged to report new or worsening symptoms and they should be reassessed, with consideration given to diagnoses other than miscarriage. 

Women experiencing miscarriage should be advised of available online support. Relevant websites can be found at the end of this document.

Women with mild, crampy lower abdominal pain should be advised to take paracetamol and observe the effect.  If worsening, they should be referred to EPAS for review. 

Women who seek early pregnancy advice regarding pain or bleeding on more than one occasion within 24 hours should be advised to attend.

≥ 6+0 weeks and <17+0 weeks (<20+0 weeks in Clyde)

All women referred to EPAS will be triaged (by telephone) by EPAS midwives who are experienced in assessing early pregnancy symptoms and providing advice or arranging further assessment where necessary.

Those women who require further assessment should be evaluated in EPAS where there are dedicated facilities to perform early pregnancy ultrasound scans, appropriate measurement and interpretation of serum hCG.

If the woman is rhesus negative, ensure assessment of anti D requirement is completed as per GGC guidance Anti-D Immunoglobulin Administration Following Potentially Sensitising Events and Routine Antenatal Anti-D Prophylaxis in RhD Negative Women (559) | Right Decisions

There are no available routine scan facilities out of hours. Out of hours women can call Maternity triage for advice. Women should be assessed and referred to the correct location as per appendix 1.

Women reporting heavy bleeding, severe pain or if there is a strong suspicion of ectopic pregnancy without previous confirmation of intrauterine pregnancy at < 12 weeks should be advised to attend A+E for assessment. Please refer to appendix 2 for further guidance.

Women reporting heavy bleeding or severe pain ≥12 weeks on ultrasound should be invited to attend maternity triage for assessment.

Women that are presenting with:

• A single episode of bleeding >14 days
• A second episode of bleeding in this pregnancy
• Symptoms suggestive of infection
• Ultrasound suggesting cervical ectopic

Should be referred to medical staff for a speculum. If cervical ectopic is suspected speculum should be performed by senior medical staff as findings will inform decisions regarding management.

Refer to Indications for speculum examination in early pregnancy, Gynaecology (1114) | Right Decisions for further advice.

Bleeding > 17+0 weeks (Clyde > 20+0 weeks): Refer to Maternity Triage

Women reporting bleeding should have a telephone triage assessment and invited in for review.

Assessment should include:

• Accurate history (noting amount of bleeding and any related events such as pain or intercourse). Note any risk factors for cervical incompetence (previous history/cervical surgery).
• Perform antenatal assessment including completion of MEWS and urinalysis
• Review any previous ultrasound if available.
• Auscultate fetal heart if fundus palpable.
• Medical review
• Speculum examination and LVS is indicated when:
  • No previous speculum examination has been performed this pregnancy
  • If pain/bleeding indicative of high risk of miscarriage.
  • If risk factors for, or clinical suspicion of cervical incompetence.
• Repeat speculum examination should not be a routine procedure.
• Check Rhesus status and need for Anti D
• Ultrasound is indicated when there is diagnostic uncertainty. Urgency of ultrasound depends on clinical situation.

Maternity Triage Action:

1. If bleeding settled and examination normal discharge home. Ensure Rh status is confirmed and anti D arranged if required.
2. If associated pain or continued vaginal bleeding consider admission.
3. If findings suggest cervical incompetence Middle Grade to discuss with on-call Consultant
4. If ruptured membranes refer to Preterm birth (1188) | Right Decisions
5. If any concerns re the appearance of the cervix then a more senior obstetrician should inspect cervix and consider urgent referral to Colposcopy.
6. Any administration of steroids before 24 weeks gestation should be a Consultant decision.

• Anti-D Immunoglobulin Administration Following Potentially Sensitising Events and Routine Antenatal Anti-D Prophylaxis in RhD Negative Women (559) | Right Decisions
• Anti-D Immunoglobulin Administration, RhD Negative Women, Aide Memoire (433) | Right Decisions
• Preterm birth (1188) | Right Decisions
• Indications for speculum examination in early pregnancy, Gynaecology (1114) | Right Decisions

*Ectopic risk Factors:

☐  IVF pregnancy   ☐  STI’s / PIDs ☐  IUCD in situ ☐  Previous ectopic pregnancy  ☐  Previous Tubal Surgery / Damage           

The Miscarriage Association www.miscarriageassociation.og.uk 

The British Association for Counselling and Psychotherapy www.bacp.co.uk

Relate www.relate.org.uk

The Samaritans www.samaritans.org

Tommy’s www.tommys.org