Seed of Life Birthing Services

Taylor Rackey
Revised 09/2021

Evaluation and management of VAGINAL BLEEDING IN PREGNANCY

1. Definition or Key Clinical Information: Vaginal bleeding in the first trimester of pregnancy is a fairly
common occurrence, with approximately 15-25% of pregnant individuals being affected; of these
individuals, around 50% do not have a miscarriage (Tharpe, Farley, & Jordan, 2017); University of
Michigan Health, 2020). Vaginal bleeding during pregnancy is referenced as any discharge of blood from
the vagina during pregnancy (Frye, 2010). This time of pregnancy can be an emotionally difficult time if
the pathophysiology of vaginal bleeding is unknown, especially during the first and second trimester as
there are limited effective treatments, particularly for those non-viable fetuses. The midwife can
continue to provide support and education while the viability of a fetus is determined (Tharpe, Farley &
Jordan, 2017)
2. Assessment
i. Risk Factors
● Pelvic inflammatory disease, pelvic surgery, STI’s (especially chlamydia), IVF, smoking, Hx
of ectopic pregnancy, abnormal cervical cytology, vaginal infections, infertility, Hx of
cesarean section, risk exposures: physical abuse, trauma (Tharpe, Farley, & Jordan,
2017).
ii. Subjective Symptoms
● Bleeding or discharge at the vaginal introitus
iii. Objective Signs
● Visualization of external genitalia
○ trauma, lesions, varicosities, hemorrhoids, blood or discharge at the vaginal
introitus
● Speculum exam
○ blood or discharge from the vaginal vault or cervix, cervical dilation, presence of
products of conception (POC) at the vaginal os or vaginal vault, presence of
erosion, polyps, or other cervical cause of bleeding
● Bimanual exam
○ Uterine s=d, uterine tenderness or pain, presence of adnexal mass or pain,
presence of cervical motion tenderness
iv. Clinical Test Considerations
● First trimester
○ Serial quantitative hCG testing 48 hrs apart, complete blood count (CBC), ABO
and Rh status, antibody screen (microdose RhoGAM may be indicated), infection
screening (if indicated), urinalysis (UA) with culture, serum progesterone levels
(low levels are associated with increased risk of miscarriage; lower miscarriage
risk with levels > 12 ng/mL
○ Ultrasound; transvaginal approach preferred and serial studies may be
necessary. Measurements include crown-rump length (CRL), observation of fetal
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 heart motion, evaluation of placenta previa or abruption, confirmation of
intrauterine (IUP) or ectopic pregnancy
● Second/Third trimester
○ CBC, ABO and Rh status (if unknown), antibody screen (RhoGAM may be
indicated), infection screening (if indicated), UA with culture
○ Ultrasound; transvaginal and/or abdominal may be used depending on
gestational age. Observation for fetal heart motion, growth scan/evaluation of
s=d, BPP (depending on gestational age), confirmation of placenta location (if
unknown), r/o placenta previa, abruption, or vasa previa.
3. Management plan
i. Therapeutic measures to consider
● First trimester: triage and Tx is based on the amount of vaginal bleeding and definitive
differentiation between a viable IUP and non-viable IUP. An hCG rise of < 35% in 48 hrs
before medication treatment is started can reduce the likelihood of terminating a
potentially viable fetus (Tharpe, Farley, & Jordan, 2017).
○ Threatened miscarriage 6-10 wks gestation: progesterone therapy
○ RhoGAM immunoglobulin for those who are Rh negative
○ Iron-replacement therapy for those with anemia or experienced antenatal
hemorrhage
● Second/Third trimester: triage and Tx is based on the amount of vaginal bleeding and
definitive differentiation between a viable IUP and non-viable IUP. If vaginal bleeding is
due to cervical change before viability, a cerclage may be placed in the cervix.
ii. Complementary measures to consider
● Bleeding during pregnancy with rising hCG levels
○ Red raspberry leaf, false unicorn, wild yam root, black haw
● Pelvic rest
● Concerns of placenta abruption
○ Oral Vitamin E 2,000 IU and Vitamin C with bioflavonoids 1,000 mg daily for 2
weeks (Frye, 2010)
iii. Considerations for pregnancy, delivery and lactation Light bleeding or spotting may occur 1-
2 weeks after fertilization occurs, when the egg implants into the lining of the uterus (Tharpe,
Farley, & Jordan, 2017). During the second half of pregnancy, bleeding is often much more
serious and can be caused by a number of potential reasons. Those who present with vaginal
bleeding in the second half of pregnancy should be assessed via ultrasound. The most common
cause of minimal third trimester bleeding is due to normal cervical change, in addition to normal
spotting after intimacy or penetration. In the rare cases of non-cervical bleeding, about half will
be due to placenta abruption, while the other have with no undetermined (Frye, 2010).
iv. Client and family education Education around when to call MW with s/s of labor, increased
bleeding heavy enough to fill a pad within an hour, strong stomach cramps that may also radiate
around the back and down the legs, passing clots or clumps of tissue, vaginal pressure, bleeding
that has an offensive odor, feeling dizzy or unwell, fever.
v. Follow-up Need for serial evaluation (hCG levels or ultrasound), after SAB, or cerclage
removal

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4. Indications for Consult, Collaboration or Referral Indication for consultation - antepartum: second or
third trimester bleeding (Oregon Health Authority, 2020).
5.References
Frye, A. (2010). Holistic midwifery: A comprehensive textbook for midwives in homebirth practice (Vol. 1).
Portland, Oregon: Labrys Press.

Oregon Health Authority. (2020, October 20). Board of Direct Entry Midwifery - Oregon Administrative
Rules (Unofficial Copy). Retrieved from https://www.oregon.gov/oha/PH/HLO/Rules/DEM-Rules.pdf

Tharpe, N., Farley, C., & Jordan, R. (2017). Clinical practice guidelines for midwifery & womens health
(5th ed.). Burlington, Massachusetts: Jones & Bartlett Learning

University of Michigan Health. (2020, October 08). Vaginal Bleeding During Pregnancy. Retrieved from
https://www.uofmhealth.org/health-library/tm6611

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