SCHOOL OF MEDICAL SCIENCES

OBSTETRICS AND GYNAECOLOGY

POSTING

CLINICAL CASE WRITE-UP

NAME : MFHI
MATRIX NO : 131449
COURSE/YEAR : MEDIC 3 (GROUP 1)
SESSION : 2017/2018
SUPERVISOR : PROF. DR. MOHD SHUKRI OTHMAN
HISTORY TAKING

Identification of data
Registration no :-
Name : NSI
Age : 33 years old
Gender : Female
Race : Malay
Occupation : Teacher
Adress : Kg. Alor Pasir, Wakaf Bharu
Date of admission : 24/6/2018
Date of clerking : 24/6/2018
Gravida/Parity : G2P1
Abortion : Nil
Last normal menstrual period (LMP) : 19/10/2017
( She was sure of date, regular menses, not breastfeeding
for 2 month, not on hormonal contraception within 3
month )
Period of gestation (POG) : 35 weeks 4 days
Expected date of delivery (EDD) : 26/7/2018
Revised Expected date of delivery : 22/7/2018
 Booking was done at Klinik Desa Kg Bukit, Wakaf Bharu.
 1st scan was done at 10 weeks 6 days at Klinik Primer Wakaf Sireh and parameter
corresponds to 11 weeks 4 days period of gestation (POG)

Chief complaint
Electively admitted for expectant management of placenta praevia major type IV

History of presenting illness (HOPI)

MSI had her booking done at Klinik Desa Kg Bukit at 10 weeks 6 days period of
amenorrhea which was on 3/1/2018 while subsequent regular antenatal care was done at Klinik
Kesihatan Wakaf Bharu. During second month of pregnancy which was around Dicember 2017,
there was a history of threatened miscarriage where she had spotting for 1 month. Usually, it
was noted in the afternoon until late evening as she comes back from work. It was brownish in
colour, measuring about new 50$ coins with no foul smelling, no abdominal pain, no fever and
no vomiting. She seek for medical advice at KK Wakaf Bharu on 15/1/2018 and ultrasound scan
done to confirm the presence of baby in uterus. She had no more spotting episode occurred
later. She attended regular Antenatal Care (ANC) at KK Wakaf Bharu until around 24-25 period
of gestation (POG) which was on April 2018 where she went to Klinik Adila, Taman Maju to do
ultrasound scan to find out the gender of her baby. During that time, she was told to have low
lying placenta. She was explained by the Dr in charge that the placenta will change in size as the
baby is growing inside the uterus. Therefore, at 32 weeks period of gestation, she went to Klinik
Primer Wakaf Bharu to do another ultrasound scan to find out either placenta has changed in
position or not. During that time, she was also prescribed with Sangobion which is iron
supplement for anemia. At 32 weeks period of gestation, MSI went to Klinik Adila again to do
another ultrasound scan and she was told to have placenta praevia type IV. Ultrasound scan
result was given to patient to be submitted to KK Wakaf Bharu. On 30/5/2018, MSI met a
specialist at KK Wakaf Bharu. During that time, urine test was done with a result of glucose 2+.
She has a risk factor of diabetes as his father was diagnosed to have diabetes mellitus. She was
then referred to HUSM due to risk factor of Gestational Diabetes and placenta praevia type IV.
She was presented at HUSM SOPD clinic on the following day which was on 31/5/2018 and
ultrasound scan was done by Dr S with similar result of placenta praevia type IV. Another scan
was done on 10/6/2018 at HUSM to re-confirm the result . After it was confirmed, she was
given a date on 18/6/2018 to be admitted for expectant management of placenta praevia type
IV. However, she didn’t showed up because she had to finish her journal as she is now doing
PhD at UMK Bachok. Another ultrasound scan was during the day of admission which was on
24/6/2018 and and the result revealed that she has placenta praevia type IV with main bulk of
posterior. It was a singleton fetus with breech presentation and presence of fetal heart beat.
On further questioning, she denied having any history of antepartum haemorrhgae, no previous
history of placenta praevia, no history of uterine abnormalities and fibroid as well. Currently,
MSI is afebrile with no contraction pain, no show fetal movement is good.

History of presented pregnancy (HOPP)

For the current pregnancy, MSI wasn’t expecting the baby as it was spontaneous
contraception. On November 2017, she suspected her pregnancy as her regular menstrual
period was delayed for 1 weeks than usual. However, there was no quickening nor abdominal
distention during that time. MSI went to Klinik Primer Lembah Sireh and Urine pregnancy test
(UPT) was done with positive result. Ultrasound scan was done which correspond to 5 weeks
period of gestation (POG). Booking was done at Klinik Desa Kg Bukit on 3/1/2018 and 1 st
antenatal care was done there as well. Several investigations was done during that time which
include:

a) Height : 160cm
b) Weight : 65.8kg
c) BMI : 25.7 (Overweight)
d) BP : 108/63mmHg (normotensive)
e) Fundal height : 10/52
f) Blood Group : B+
g) Rhesus : +ve
h) Hb : 12.9
i) Urine glucose : Nil
j) Urine protein : Nil
k) VDRL : Non-reactive
Her subsequent antenatal check up was done monthly until 28 weeks and forthnigthly until 34
week at KK Wakaf Bharu. She was admitted to the ward on 35 weeks period of gestation. There
was a history of excessive weight gain at 24 weeks period of gestation where she gained 3kg
2/53 with BP range of 108-126/63-83 mmHg. She is at risk of gestational diabetes as she has a
family history of DM. OGTT was done on 16 weeks period of gestation once and the results
turned out to be normal with reading of 5.0mmol/L (Fasting blood glucose) and 5.1mmol/L (2H
Postprandial) She attended all antenatal care check up which was around 15 times. She went to
KK Wakaf Bharu on 30/5/2018 to get her routine ANC done and urine test was done during that
time with a result of positive glucose (2+). The test was repeated again 5 days later at HUSM
with normal result. She felt the first fetal movement at 20-24 wekks period of gestation. Fetal
kick chart is usually completed at 4pm. For the current pregnancy, she had backache, breast
discomfort and engorgement. However, she didn’t experience hyperemesis gravidarum,
nausea, ankle edema or constipation. She got 1 ATT shot at 28 weeks period of gestation.

Menstrual History
MSI attained menarche at the age of 14 years old with regular cycle of 28-30 days
interval lasting for 7-8 days of bleeding. Before marriage, she’ll have heavy flow on the first 5
days of menstrual cycle. However, she’ll only have heavy flow on the first 3 days of menstrual
cycle after marriage with an amount of pad usage of 4-5/daily which is not fully soaked.
However, there’s no blood clot noticed and no dysmenorrhea.

Past Obstetric History

This is her second pregnancy. MSI got married at the age of 28 years old on 2014. The
marriage is non-consanguineous and the only marriage she had. She was gifted with 1 son who
aged 4 years old now. She gave birth to her son at HUSM on 2014 at 39 weeks period of
amenorrhea (POA). She underwent emergency lower segment caesarean section (EMLSCS) for
poor progress as she was 13 hour in labour post induction for 2 times. She gave birth to a baby
boy with a birth weight of 3.4kg and she had 1 previous scar due to poor progress. Intra-
operation was uneventful with no complication post operation and no history of blood
transfusion. Baby was admitted to 2 Nilam for 2/7 due to neonatal jaundice and allowed for
discharge on day 3. She breastfed her son for only 3 weeks as she was running out of milk and
her son refused to be fed with breast milk. She had history of late onset pregnancy induced
hypertension in previous pregnancy which was diagnosed at 37 weeks period of gestation at KK
Pasir Putih. She was started on methyldopa TDS for 4/7 consecutive days. MSI has good spacing
between her child with 4 years apart between the first child. She’s not using any contraceptive
method such as condom, oral contraceptive pills, injection, implantation or intrauterine
contraceptive device.

Past Gynaecological History

MSI doesnt have any issues such as pain during menstrual cycle (dysmenorrhea), no
heavy bleeding(menorrhagia), no intermenstrual bleeding, no postcoital bleeding and no
dyspareunia. She has never done pap smear before
Past Medical & Surgical History
MSI only sought treatment for her placenta praevia major problem. Otherwise, she has
not been diagnosed to have any chronic illnesses such as hypertension, diabetes mellitus,
asthma, heart disease, renal disease etc
She had Lower segment caesarean section (LSCS) surgery done at 39 weeks of
gestational age on 2014 at HUSM due to poor progress. It was uneventful and she gave birth to
a baby boy with a birth weight of 3.4kg

Family History
MSI’s parents are still alive and healthy. Her mother is now 57 years old, with
symptomatic anemia whereas her father is now 62 years old with hypertension, diabetes
mellitus and ischemic heart disease. She is the second child out of 7 and all her siblings are
healthy except the 4th child in the family who passed away at the age of 17 due to vaccination
overdose during infants. Otherwise, there is no family history of breast tumor, endometrial,
cervical or any other tumors related to female reproductive tract and no family history of
congenital abnormalities like Down Syndrome, cleft palate, spina bifida etc.

Personal and Social History

MSI graduated from Alexandria University, Egypt and currently she’s doing PhD at UMK
Bachok Vokasional. She works asa a teacher at SMKA Morak, Tumpat. Her husband is 37 years
old and he’s working as a Chief Operator at Loji AKSB with an average income of
RM6000/month. She and her husband currently stay in bungalow with adequate ameneties.
Since the day of admission, her husband visited her 5x to bring her food. During the admission,
her son is taken care by her sister in the daytime and will be fetched by her husband after office
hour. Her husband is a smoker and usually he’ll smoke in a distance from his family members.
MSI and her husband don’t drink alcohol nor take illicit drugs

Drug History
MSI is not on any medications before. She started to take folic acid at 5 weeks POG and
being prescribed with Ganilia by Klinik Primer Lembah Sireh and Obimin by Klinik Desa Waka
Bharu. She’s taking Arctic sea salmon oil and Absorbent C as traditional medication. She doesn’t
have any allergy to food and drugs

Diet History
MSI consumes normal adult diet 3x daily which mainly compose of rice
Systemic Review

Respiratory Shortness of breath(SOB), no cough, no hemoptysis

Cardiovascular No hypertension, no ankle swelling, no palpitation, no chest
pain
Musculoskeletal Muscle pain, joint pain, no muscle wasting, no deformity
Central Nervous System (CNS) No loss of consciousness, no tremor, no headache
Gastrointestinal tract (GIT) No nausea, no vomiting, no diarrhea, no constipation, no loss
of weight, no loss of appetite
Endocrine No neck swelling, no established Diabetes Mellitus

Summary
MSI, 33 years old Malay, Gravida 2 Para 1 at 35 week 4 days period of gestation was admitted
to HUSM for expectant management of placenta praevia major type IV. The risk factors include
passive smoker and previous caesarean section

PHYSICAL EXAMINATION

General examination
I examined MSI on 26/6/2018 at 845am.
On examination, MSI was lying flat in supine position while supported with 1 pillow. She is alert
and conscious to time, place and person. She’s not in pain nor distress. She has good nutritional
status and hydrational status was clinically adequate. She wasn’t pale nor jaundice. There was
no gross deformity nor any attachment seen on any part of the body.

Vital signs
Temperature : 370 (afebrile)
Blood pressure : 132/68 mmHg (normotensive)
Respiratory rate : 19 breath per minute (normal)
Pulse rate : 72 beat per minute (good volume and regular rhythm)
SPO2 : 100 % under room air

Upper limbs
Palms were moist, warm and not pale. Capillary refill time is less than 2 seconds. There
was no signs of clubbing, koilonychias, leukonychia, peripheral cyanosis, Palmar’s erythema,
Osler’s node, Janeway lesion, bruises, scratch mark, petechiae nor tremor seen. Wrist
tenderness and collapsing pulse was negative. No radio-radio delay nor scratch mark seen on
forearm
Head and neck
Sclera of eyes were white with pink conjunctiva. Tongue was moist and non coated. No
central cyanosis, angular stomatitis, glossitis nor high arched palate seen. Oral hygiene was
good with no dental carries. Trachea was centrally located with no palpable lymph nodes. No
abnormal swelling on area of neck. Jugular venous pressure wasn’t elevated.
On examination of the abdomen, cough impulse was negative

Lower limbs
No bilateral pitting edema seen. Dorsalis pedis and posterior tibialis was palpable. No
sacral edema

Specific examination

Cardiovascular examination
 Inspection
No gross deformity, spider nevi, gynecomastia, surgical scar, precordium bulge or any
pacemaker box noted on area of chest
 Palpation
No thrill and parasternal heave noted. Apex beat was palpable on 5th intercostal space, 1cm
lateral from midclavicular line
 Auscultation
S1 and S2 were heard with normal intensity and no murmur heard at 4 auscultatory areas
(Aortic, Pulmonary, Tricuspid and Mitral)
Impression : Physiologically normal

Respiratory examination
 Inspection
Chest rises symmetrically and bilaterally on all parts of lung with each respiration. No chest
deformity or skin discolouration seen
 Palpation
Chest expand symmetrically and bilaterally on all zones of lung. Tactile fremistus was heard
with normal intensity
 Percussion
Resonant note was heard symmetrically, bilaterally on all parts of lungs with cardiac and liver
dullness noted
 Auscultation
Equal air entry with good quality and vesicular breath sound was heard
Impression : Lung is clear
Abdominal examination
 Inspection
Abdomen was distended by gravid uterus evidenced by presence of striae gravidarum, linea
nigra and straie albicans. Abdomen rises symmetrically with each respiration while the
umbilicus was centrally located and inverted. There was scar noted over suprapubic area which
was transverse in line measuring about 10cm which was well healed with no keloid formation.
However, there was no fetal movement and no dilated vein seen
 Palpation and percussion
On palpation, abdomen was soft and non-tender over 9 region.
On deep palpation, uterus was soft, non-contractile and non-irritable.
 Leopold Maneuver
From my examination, my clinical fundal height finding is 36 weeks and symphysio-fundal
height was 32cm. The fetus was in transverse lie. There were 2 poles felt where the fetal
head is on the maternal right side which is rounded, hard and ballotable while the back was
facing superiorly which is soft and. Liquor volume is adequate
 Auscultation
Fetal heart was heard by using Pinnard stethoscope
Impression : Uterus correspond to date

Digital rectal examination and examination of external genitalia wasn’t performed

Summary
I examined MSI on Day 3 of admission. Al her vital signs were normal. On inspection ,
abdomen was distended by gravid uterus evidenced by presence of striae gravidarum, linea
nigra and striae albicans. There was scar noted over suprapubic area which was transverse in
line measuring about 10cm which was well healed with no keloid formation. On palpation,
abdomen was soft and non-tender over 9 region and on deep palpation, uterus was soft, non-
contractile and non-irritable. Clinical fundal height finding is 36 weeks and symphysio-fundal
height was 32cm. The fetus was in transverse lie. There were 2 poles felt where the fetal head
is on the maternal right side which is rounded, hard and ballotable while the back was facing
superiorly which is soft. Liquor volume is adequate. Fetal heart was hardly heard by using
Pinnard stethoscope

Diagnosis
Placenta Previa major type IV

Problem list
1. Placenta praevia major type IV
2. Risk of GDM
3. 1 previous scar
 Investigations

1) Pregnancy Test (hCG)

Rationale: To confirm that a woman is pregnant.
It measures human chorionic gonadotropin (hCG) hormone that is produced by the placenta
when a woman is pregnant.

2) mOGTT
Rationale: To screen pregnant women for signs/risk of gestational diabetes.

Results:
Date Fasting blood sugar 2 H Postprandial
27/2/2018 5.0 5.1
Impression: Blood sugar profile was well controlled

3) Full blood count

Rationale: To assess hemodynamic status of patient
I. During pregnancy, hemoglobin must transport enough oxygen to meet both her and her
fetus' needs. Women with low RBC/hemoglobin is said to be anemic.
II. White blood cells protect the body from infections and also have immune functions.
Evaluating WBCs during pregnancy can help detect infections so that it can be treated and
resolved before causing health problems to mother or her baby
III. Pregnant women with low platelet or with platelets that don't function properly to form
clots are at risk of life-threatening bleeding during labour

Result
Parameter 24/6/2018

WBC (3.4-10.1) 6.91 x 109 (Normal)

RBC (3.52-5.16) 4.41 x 1012 (Normal)
HGB (11.6-15.1) 13.1g/dL (Normal)
HCT (31.8-42.4) 39.4% (Normal)
MCV (77.5-94.5) 89.3 (Normal)
MCH (24.8-31.2) 29.7pg (Increase)
MCHC (29.4-34.4) 33.2g/dL (Increase)
PLT (158-410) 230 x 109 (Normal)

Impression : Latest FBC investigations which was done on 8/6/2018 showed all parameters are
within normal range
4) GSH (Blood group, Screen, Hold)
Rationale : To test patient’s blood sample for ABO and Rh grouping and to screen for
unexpected antibody. This is done to standby for any possibilities of blood transfusion
requirement as pre-operation measure if patient opted for Lower Segment Caeserean Section
(LSCS)

Results: B +ve

5) Renal function test (24/6/2018)

Rationale: To detect electrolyte imbalance

Results:
Parameter 24/6/2018
Na (135-145) 133 (Decrease)
K (3.5-5.0) 4.2 (Normal)
Urea (1.7-8.3) 2.4 (Normal)
Calcium (2.15-2.55) 2.16 (Normal)
Creatinine (70-130) 57 (Decrease)
TB (3.4-17.1) 6 (Normal)
Chloride (98-107) 108 (Increase)
Impression: All parameters are normal except Na which is slightly reduced, Creatinine
(decrease) and chloride(slightly increase)

6). Liver function test (27-30/4/2018)

Rationale: to assess liver function. It gives information about the state of patient’s liver

Results
Parameter 24/6/2018
Uric acid (150-350) 272 (Normal)
Phosphate (0.87-1.45) 1.32 (Normal)
Total protein (65-83) 68 (Normal)
Albumin (38-44) 32 (Decrease)
AST (5-34) 22 (Normal)
ALP (42-98) 163 (Increase)
ALT (<34) 17 (Normal)

Impression: Increase level of ALP beyond normal level may indicate a problem with patient liver
or gallbladder which include hepatitis, cirrhosis , liver cancer, gallstone or blockage in bile
ducts.
7) Transabdominal ultrasound scan (Latest on 25/6/2018)
Rationale : To confirm exact placenta location, assess for fetal well-being, determine fetal lie
and position

Results:

Biparietal diameter : 84.82

Head circumference : 305.25
Abdominal circumference : 282.65
Femur length : 62.17
Amniotic fluid index : 12 cm
Estimated fetal weight : 2kg
8) Cardiotocograph
Rationale : To assess fetal wellbeing by recording the fetal heartbeat and the uterine
contractions during pregnancy.

CTG belongs to MSI which was taken at 1240 on 24/6/2018

Fetal heart rate is in the range between 130-160 beat per minute with a baseline of 140 beat
per minute
Baseline variability is around 5-15 beats per minute
Acceleration was noted more than 2episode with an amplitude of more than 15 beat per
minutesin 20 minute strip
No deceleration noted
Impression: Reactive and fetal isnt in distress
9) Fetal growth chart
Rationale : To describe growth of prematurely born infants and create a growth chart adequate
to assess growth of infants with less than 29 completed weeks of gestation
Management

1. Antenatal management
o Patient should be well educated about placenta praevia and the complications that
might occur such as antenatal haemorrhage, still birth and hysterectomy
o The risk of bleeding must be reduced via
- avoid digital cervical examination
- avoid sexual activity
- avoid strenuous exercise
- avoid lifting heavy weight
- avoid standing for prolonged period of time
o Patient should also be counselled that if there’s any contraction or vaginal bleeding
occur, she should seek medical attention immediately
o Madam Hidayah has placenta praevia major type IV, therefore she should be admitted
on 34 weeks of gestation for expectant management of placenta praevia
o
2. In-patient management (Mccafee regime)
a) Full blood count and cardiotocograph weekly
b) Fetal heart rate, labour progress chart and fetal kick chart monitoring
c) Pad chart (to monitor presence of bleeding)
d) Prevention of thromboembolism
Patient should be adviced to put on deterrent stocking to prevent deep vein thrombosis due
to prolonged bed ridden and reduce movement
e) Blood availability (GSH)
-Should be done once in 3 days so that blood product is available at anytime as patient can
bleed massively at any time
- it includes packed cell, fresh frozen plasma and cryoprecipitate
- 2 blood product should be ready for usage at anytime
f) Antenatal corticosteroids
- this is done to enhance fetal pulmonary maturation as it promote secretion of surfactant
in fetus which will reduce the chances of fetal respiratory distress after delivery

3. Immediate caesarean section is indicated where bleeding is extensive or continuing or in

presence of fetal distress

4. Timing and mode of delivery

o Patient with placenta previa major (type III and type IV should be adviced to go to
delivery via lower segment caesarean section at 38 weeks period of gestation as
spontaneous vaginal delivery is contraindicated to prevent postpartum

5. Other general considerations

o Give anti-D immunoglobulin after each episode of PV bleed antenatally if mother is
rhesus negative
Discussion
My patient, MSI, 33 years old Malay, Gravida 2 Para 1 at 35 week 4 days period of
gestation was admitted to HUSM for expectant management of placenta praevia major type IV.
There was a history of threatened miscarriage at 10 weeks period of gestation where she had
spotting for 1 month. It was an accidental finding at 24-25 weeks of gestation when she went to
Klinik Adila to do ultrasound scan to find out the gender of her baby when the doctor
discovered that she had low lying placenta and it was confirmed at 30 weeks period of
gestation that she had placenta praevia major type IV. MSI is now having fetal complication of
placenta praevia as the baby is currently in transverse lie.

Placenta previa is a problem of pregnancy in which the placenta grows in the lowest
part of the uterus and covers all or part of the opening to the cervix. Before 28 weeks period of
gestation, it is called as low lying placenta and diagnosis of placenta praevia can only be made
after 3rd trimester via ultrasound scan. During pregnancy, the placenta moves as the womb
stretches and grows. It is very common for the placenta to be low in the womb in early
pregnancy as what has occurred to MSI. But as the pregnancy continues, the placenta moves to
the top of the womb. Most low lying placenta discovered in the second trimester eventually
migrate superiorly due to growth and development of the lower uterine segment in the 3rd
trimester such that at term, they are in normal position while a minority of low lying placenta
discovered in 2nd trimester persist to become placenta praevia in the 3rd trimester which is
similar to MSI’s case

As for MSI, the risk factor include previous caesarean section that she had on 2014 due to poor
progress post induction for 2x. Eventhough she’s not smoking, but being a passive smoker could
also be a risk factor for placenta praevia. Otherwise, she doesn’t have any history of multiple
gestation, no usage of assisted reproductive technology, no prior placenta praevia or any
previous dilatation and curettage procedure done. Placenta praevia is classified into 4 types:

Type I : Low lying placenta ( praevia minor)

Type II : Marginal placenta praevia
Type III : Praevia major (Partial)
Type IV : Complete placenta praevia

Patient with placenta praevia will usually presented to the hospital due to episode of sudden
bleeding from the vagina where it often starts near the end of the second trimester or
beginning of the third trimester. Bleeding may be severe and life threatening and labor
sometimes starts within several days of the heavy bleeding. Sometimes, bleeding may not occur
until after labor starts.

Complications of placenta praevia

1. Maternal complications
 Uncontrolled haemorrhage
- Antenatally
- Postpartum
 Abruptio placenta
 Disseminated intravascular coagulopathy
2. Fetal complications
 Fetal malpresentation (MSI’s baby is now in transverse lie)
 Preterm delivery
 Premature rupture of membrane
 IUGR
 IUFD

Diagnosis of placenta praevia

1. Clinical presentation
 Per vaginal bleeding
- Painless and sometimes associated with contraction
- 1st episode of bleed occur prior to 30 week gestation in 1/3, between 30-36 weeks in
1/3 and after 36 weeks in remaining patient
- About 10% reach term without any PV bleed
2. Investigations
 Ultrasound
- Confirm placenta site, establishing firm diagnosis of placenta praevia
- Transabdominal ultrasound is 1st line; transvaginal ultrasound used if diagnosis remains
uncertain after transabdominal scan

McAfee and Johnson regimen (Conservative management in placenta praevia)

 This consist of bed rest, tocolysis and close observation of patient
 Steroids are generally given to enhance lung maturity
 To undertake this regimen, all the 3 criteria should be fulfilled:
- Mother is haemodynamically stable
- No fetal distress
- Pregnancy should be less than 36 weeks gestation
 If any of the listed criteria isn’t met, patient should be delivered by LSCS

Almost all women with placenta previa need a C-section. If the placenta covers all or part of the
cervix, a vaginal delivery can cause severe bleeding. This can be deadly to both the mother and
baby. Patient should be admitted on 34 weeks period of gestation for expectant management.
Patient should be counselled on the risk of complication of placenta praevia. They also need to
be adviced to reduce their activities and stay in bed, pelvic rest which means no sex, no
tampons, douching, and nothing should be placed in the vagina.

Reference
1. Obstetrics by Ten Teacher

2. Hwee’s Obstetrics and Gynaecology

3. RCOG Guideline on placenta praevia management

4. The practical Labour suite management by Prof Dr Adibah Ibrahim