MRCOG PART II ESSAY 277 - APH

A healthy 23 year old woman presents at 30 weeks gestation with fresh vaginal bleeding. Anomaly scan at 21 weeks showed an anterior low-lying placenta. (a) Discuss your initial assessment [7 marks]. (b) Placenta previa is confirmed and she experiences heavy bleeding at 35 weeks gestation. BP = 80/45, pulse = 120 / min and fetal heart rate is normal. Justify your management [13 marks].

i will reveiw the notes . i will ask about previous episodes of bleeding . i will ask about general wellbeing . i will ask about fetal movements..i will ask about giddiness /dizziness to assess her general wellbeing and blood loss.i will ask about abdominal pain/ contractions. i will ask previous caesarian sections as it increases risk of placenta previa .i will ask how bleeding started ? is there any history of abdominal trauma that points towards placenta abruption. if bleeding starts after sexual intercourse , placenta previa and cervical lesions ,polyps are more likely causes. 

examination will include  BP , pulse , temperature to know the condition of woman. i will check fundal height , presentation  and note any contractions /tightenings . tense abdomen or woody feel indicates placenta abruption. soft , non tender uterus may indicate cervical cause or placenta previa /vasa previa. if woman is stable  ,   CTG will be performed to know fetal wellbeing and document uterine contractions. per speculum examination to exclude cervical polyps ,cervical lesions and assess amount of bleeding.per speculum examination will help to assess cervical dilatation also.   per vaginal examination should not be performed until placental previa ruled out by ultrasound. 

I.V line should be maintained and blood sent for full blood count , group and cross matching 4 units of blood if massive bleeding .liver function tests , U &E  should be performed .coagulation screen is also needed to assess coagulopathy   . ultrasound should be performed to look for placental localization , placental separation/ abruption. large abruption may be  seen . placental abruption is a clinical diagnosis , ultrasound has limited sensitivity in identification of retroplacental hemorrhage.klehauser test in Rh negative woman to quantify fetomaternal hemorrhage for calculation of  dose of anti D .  

b:  multidisciplinary team involving consultant obstretrician , consultant anesthetist , experienced neonatologist , experienced midwife will be needed. haematologist advice may be needed in cases of massive hemorrhage  and atypical antibodies.

woman 's life is priority regardless of the gestation. communication , monitoring , investigations , resuscitation all steps should be simultanouesly performed in this emergency situation. woman should be kept in left lateral position , airway checked and O2 inhalation started via facemask. crystalloids /colloids started for fluid replacement  after maintaining I.V access . blood grouping and cross match sent to laboratory and urgent blood transfusion may be needed in massive hemorrhage . if cross matched blood is not available , O-ve blood can be given. in life threatening hemorrhage , factor VII  can be given after consultation with haematologist. continous fetal electronic monitoring should be done. 4 units of FFP and 10 units of cryoprecipitate can be given in massive hemorrhage while awaiting results of coagulation screen and platelets.liver function tests , renal function tests and coagulation screen should be preformed. 

Caesarian section under general anesthesia  is needed with arrangements for critical care level 2 beds. general anesthesia facilites the control of  resusciation and expedite delivery of baby .opening the uterus away from placenta and delivering the baby without disturbing the placenta is associated with less blood loss during surgery.

 local protocols should be followed if morbidily adherent placenta found . active mangement of third stage to reduce risk of PPH.nepnate should be assesses by senior neonatologist as risk of fetal anemia and fetal compromise of associated with placenta previa.thrombopropylaxsis is needed after risk assessment. 

incident reporting and debriefing by senior member of MDT should be done. psychological support to prevent post traumatic disorder. 

A) Antepartum haemorrhage can be associated with significant maternal and fetal morbidity and mortality. I would establish the amount of bleeding the patient is having as there is a wide spectrum of conditions including women who bleed small amounts and remain haemodynamically stable, and women who lose a large amount of blood and need involvement from a multidisciplinary team including obstetricians, anaesthetists, specialist midwives and haematologists.

I would take a history and ask about the amount and type of bleeding she is having – if the blood is bright red in colour it is more likely to be a fresh bleed. If she is passing clots, flooding or soaking pads regularly I would be more concerned as it is likely her bleeding is heavy and could cause her to be anaemic and hypovolaemic. I would ask about pain as pain is more common with placental abruption however if it is painless this is more likely to be from a placenta praevia or cervical or vaginal pathology. I would ask about any cervical abnormalities she had in the past as cervical cancer can be missed in pregnancy. I would enquire about other antenatal problems she has had as placental abruption can be associated with gestational hypertension and pre-eclampsia. I would also ask about previous pregnancies as placenta praevia is more common in women with previous caesarean sections and abruption is more common in women who have had abruptions in the past. I would take previous medical history including previous sexually transmitted diseases or vaginal infections as Chlamydia can cause irregular bleeding in pregnancy. I would establish whether there were any factors which have provoked the bleeding as sexual intercourse can cause bleeding if the patient has a cervical erosion and also in cases of placental praevia. I would ask if the patient was having any contractions as bleeding can provoke preterm labour.

I would take observations including pulse, temperature and blood pressure as this will enable me to assess how well she is and in some cases the extent of the bleeding. If she is tachycardic I would be more concerned that the blood loss is significant and if she is hypotensive this would concern me most as this is a late feature of hypovolaemia. I would assess the extent of her bleeding – if the blood was running down her legs or soaking through her clothes this would be associated with significant blood loss usually over 1 litre. I would do an abdominal examination feeling for uterine tenderness or a woody hard uterus consistent with abruption. I would also assess the lie of the fetus at this point and listen to the fetal heart though these finding would not necessarily change my management as it is important to stabilise the mother first. I would assess the fundal height as in concealed abruption the fundal height is likely to measure large for dates. I would do a speculum examination to identify any cervical erosion or polyp which could be causing the bleeding. I would also consider a vaginal examination to exclude preterm labour depending on my findings. I would scan this patient for placental localisation performing a transvaginal scan which is more accurate than transabdominal in establishing placental site. 

B) I would manage this lady with input from teams including the obstetric consultant, specialist midwives, anaesthetists, the haematology department and haematologist, and paediatricians to optimise her management. I would ensure she was managed in a high dependency room on the labour ward in a hospital which has 24 hours access to the haematology and blood products and an obstetric theatre ideally with access to a cell saver thus ensuring there were the facilities to deliver if necessary and stabalise her with blood products if needed.

I would manage her using an ABC approach, assuming she was conscious and maintaining her airway I would commence her on high flow oxygen in the left lateral position to improve venous return and increase cardiac output then concentrate on her circulatory compromise as she is tachycardic and hypotensive indicating hypovolaemic shock. I would ensure she had two large bore cannulae for adequate fluid replacement. At the time of siting the cannualae I would take bloods for full blood count to check if her haemoglobin had fallen and to help with decisions regarding blood replacement, platelets to potentially guide anaesthetic management as she is likely to need delivery, clotting as if her clotting factors are depleted she could need blood products including cryoprecipitate and fresh frozen plasma along with a blood transfusion to prevent or reverse disseminated intravascular coagulation. I would also check urea and electrolytes to ensure the fluid lost had not caused her to go in to renal failure secondary to hypovolameia, I would cross-match her for four units of blood initially due to her probable massive obstetric haemorrhage and liaise with haematology to ensure the appropriate blood products are ready. Initially I would fluid resuscitate her with colloids followed by crystalloids whilst waiting for blood products, during this time I would ask one of the midwives to continue taking observations every 15 minutes and write these on a high dependency chart so we could monitor her condition. I would insert a urinary catheter to more accurately measure fluid input and output and if there were any concerns I would discuss with an anaesthetist the pros and cons of siting an arterial line or central venous pressure catheter to ensure adequate fluid management. Once the patient was stabilised, if the bleeding continued I would discuss with the consultant obstetrician and consider taking her to theatre for an emergency caesarean section. If this was the case I would perform this under direct supervision with the consultant scrubbed to improve the safety of the procedure. This would be carried out under general anaesthesia and I would use a cell saver to reduce the amount of blood products needing to be transfused. Following delivery I would ensure the uterus was contracted and the bleeding was minimal, if the bleeding continued I would use a step up approach using initially uterotonics including syntocinon, ergometrine, haemobate and misoprostol and if these were ineffective I would consider alternative measures such as B-Lynch suture, Rusch catheter or caesarean hysterectomy as a last resort to control the bleeding. If the unit had access to interventional radiology services I would discuss the case with them prior to going to theatre and ensure everyone was on stand-by in case the bleeding continued. Following delivery I would transfer the patient to a high dependency or intensive care unit depending on her well being and closely monitor her during the recovery period. I would debrief her regarding the chain of events to ensure she understood everything that had happened and also book her in for a postnatal review 6-8 weeks postpartum to answer any further questions she had. I would fill in a critical incident form so that the case could be reviewed at a risk management meeting.

I'd like to know how much is the bleeding( < 50 ml- minor APH, >50 ml- major APH), and whether it has settled now( as that'd determine how urgent the situation is). If the bleeding has settled, i'll ask whether this was the first episode of bleeding and any aggravating factors like intercourse, trauma to abdomen, is there any pain associated( risk of abruption).i'll enquire about fetal movements.i'll ask about previous obstetric history, esp about previous cesarean section( as risk of placenta accreta in previous cesarean with anterior low lying placenta)., previous bleeding episode, any scans done after the 21 week scan for placental location.i'll ask about any other major illness like diabetes, hypertension( as that'll help in planning management).

i'll check her PR,BP,RR,temp for evidence of any hemodynamic changes. i'll examine her abdomen to see symphysiofundal height( increased if concealed hemorrhage), any increase in uterine tone or tenderness(will point to concealed hemorrhage), any evidence of uterine contractions, auscultate fetal heart, and do a CTG. i'll do a gentle speculum examination to see if the bleeding has settled, whether its a local cervical cause or bleeding through cervical os.i'll check her blood group( if Rh negative, will need Anti D and  kleihauer test for estimation of feto maternal hemorrhage,and check her hemoglobin) i'll arrange for a scan to check for placental location and fetal well being.

b)- this is an obstetric emergency. i'll start resuscitation and call for help simultaneously. i'll start major hemorrhage protocol. i'll involve senior anaesthetist, consultant obstetrician, senior midwife, alert blood bank,hematologist and porters. Two large bore IV cannula with bloods taken for FBC, Crossmatch for at least 4-6 units of blood,U & E, LFT,clotting screen. start her on iv hartmann's to go fast, till blood is available.i'll inform the theatre for arranging cell salvage( if available, and team is skilled).if there are known red cell antibodies  and delay in crossmatch of blood anticipated, hematologist consultation and O Rh negative blood can be given. If patient is able to give consent, then a consent for emergency cesarean section is taken after explaining the risk of major bleeding, and may need hysterectomy to save life, and her views respected. the senior most obstetrician who's experienced to perform cesarean section with placenta praevia should be operating with consultant directly observing. during procedure, care taken to avoid cutting through placenta, may need classical cesarean section. early recourse to obstetric hysterectomy after trying conservative methods( like undersuturing placental bed) will reduce maternal morbidity and mortality.expert in neonatal resuscitation should be availavle as risk of fetal hypoxia. After operation, she'd be transferred to HDU/ITU, with strict MEOWS charting, input /output charting. Debriefing should be done after she recovers. incident reporting should be done. contraceptive advice to woman, and risk of low lying placenta, and adherent placenta be explained to her( if hysterectomy not needed). Mental health guidance as this was a traumatic experience,and help with breastfeeding given.

a)Her initial assessment includes detailed history about amount of bleeding to assess severity whether it is minor  or major antepartum  haemorrhage. Any associated abdominal  pain or painless fresh bleeding  is asked .Maternal perception of foetal movements are asked. Any history of maternal trauma , sexual intercourse are asked sensitively to  know the triggering factor for bleeding.Review her past reproductive history to assess mode of delivery especially caesarean section, surgical management of miscarriage and manual removal of placenta as  these are risk factors for placenta praevia. Lifestyle factors  like smoking ,drug misuse  are sensitively found out. Past history of  hospital admission for similar problem is asked,  recurrent antepartum haemorrhage  increases the risk of maternal and perinatal morbidity and mortality.
                                Quick  clinical examination is done to check her PR, BP to look for tachycardia and hypotension, abdominal examination to assess fundal height , as it is more than period of gestation in concealed abruption. To look for uterine tenderess, tone of uterine contraction,and woody feel of uterus as these findings are suggestive of abruptio placenta.Fetal heart is checked with Doppler and then CTG is done to assess fetal wellbeing once maternal condition is stable. Gentle speculam examination done to assess  amount of bleeding and to exclude local cause for haemorrhage.
                         Woman is admitted in hospital. If bleeding  persists FBC ,group and save serum, baseline clotting studies urea, and electrolytes, LFT are done to have baseline value and to assess HB  ,need for immediate blood transfusion and correction of  clotting abnormality. Gentle Trans vaginal scan is done for location of placenta  and to look for placenta accreta if it is a placenta praevia especially with anterior placenta without disturbing the cervix.
                            b)As she is having heavy bleeding  resuscitation is started  immediately .Communiation is done to alert multidisciplinary team simultaneously  including  consultant obstetrician , anaesthetist, haematologist, paediatrician, blood transfusion laboratory staffs and porters to bring  blood.Assess her airway , breathing  start 10-15 ml of oxygen/ min, two  IV access with 14 gauge cannula started , 20 ml blood collected for investications including FBC and clotting studies. 4 units of cross matched  blood  ordered . Woman is started on prewarmed crystalloid  Hartmann’s solution till blood arrives..If crossmatched blood is not ready, cross matched group specific blood or O’ negative blood may be started. Urine  Output monitored  hourly by inseting Foleys catheter.Vitals are monitored  continuously and CVP line is started.After getting informed  consent from the patient including the additional serious risks with placenta praevia  , placenta accreta, blood transfusion ,interventional radiological procedure and hysterectomy  woman is shifted for caesarean section. Consultant obstetrician and anaesthetist  must be present. Choice of anaesthesia depends on consultant. Peadiatrician must be present for neonatal resuscitation. During caesarean avoid cutting through the placenta because if it is accreta haemorrhage would be more, may  need hysterectomy to arrest bleeding. If it is accreta donot try to remove placenta  leave the placenta insitu and close the uterus  or hysterectomy done with placenta insitu. Prophylactic antibiotics given. Placenta separated but woman is continuously bleeding  from  placental bed  bilateral uterine artery embolisation is done if mechanical and pharmacological method fails.  Post operatively  woman is shifted to ICU/HDU  and continous monitoring done  and  vitals plotted on  MEOWS chart for early detection of haemorrhage. Thromboprophylaxis started and woman is advised to use TED stockings for 6 weeks to prevent VTE.
          Debriefing done by senior consultant once woman recovers and receptive. Contact numbers for psychological support provided as it is traumatic event to reduce stress disorder. Information provided to  GP and community midwife for local follow up. Follow up appointment after 6 weeks to discuss  about recurrence of placenta praevia  in future pregnancy if hysterectomy is not done. Incident report given for risk assessment  .

] This patient has ante partum haemorrhage where there is a increased risk of maternal and perinatal mortality and morbidity .take a history of vaginal bleeding . Duration of bleeding, amount of bleeding and associated symptoms such as pain abdomen  . if associated pain abdomen along with vaginal bleeding  then patient must be suffering from  abruptive placenta . ask her if  she  is feeling fetal movements . if patient has vaginal bleeding without continious pain abdomen and feeling fetal movements then it must be due to placenta previa  or any cervical ,vaginal or vulval pathology .  Ask her if any previous episodes  of bleeding before . Review her antenatal notes for any risk factor and USG finding of  placental location , if low lying placenta and  any multiple pregnancies . Obstretic history such as number of previous pregnancies , mode of delivery , any Previous termination of pregnancies . menstrual history such as last menstrual period , regularity and flow . medical history such as any history of chronic diseases such as diabetes and hypertention . surgical history such as any previous ceaserean section and surgical evacuation of uterus and execessive curettage  which is risk factor for placenta previa . contraception history such as previous use of contraception and associated complication . history of multiple sexual partner and any recent change in partner and use of condoms for sexual transmitted disease . history of smoking , alcohol, and using any recreational drugs .Examination such as pulse, temperature , BP, BMI . per abdomen for abdominal tenderness, any  contractions , Fetal heart auscultation . per speculam examination to check for any cervical polyp  any erosion and  to see if any cervical dilatation  and nature of bleeding . avoid digital examination since it may provoke bleeding in placenta previa . and avoid PR examination .Investigations FBC, Group and save , kleiheur test if rhesus negative  ,LFT ,RFT and coagulation profile . urine analysis . USG for fetal heart, placental location ,and multiple gestation .It is difficult to detect  retroplacental clot by usg . do CTG for fetal well being .

B]This is an obstretic emergency . call for help from consultant  obstretician, anaesthetist , haematologist, and inform the scbu .Resuscitate the patient by maintaining airway, breathing and circulation . obtain venous access  with two wide bore needle of 14 guage . collect blood for FBC ,group and save 4 units of blood ,coagulation profile , kleiheur test for rehsus negative  . rehydrate with  urgent fluid replacement with colloid or crystalloid with 12-15 ml per kg . check temperature, pulse and BP every 15 mins until stable . maintain oxygen saturation by giving fascial oxygen .  give o negative blood until group specific blood is available . if in need of blood products in case of massive haemorrhage consult  with haematologist . every thing must be done simultaneously . monitor fluid replacement by CVP . maintain input and out put chart . and monitor pulse and BP . obtain informed consent depending on the womens condition ,if stable . councel about risk of intrapartum and post partum bleeding and may need hysterectomy and other procedures such as uterine artery ambolisation and internal artery ligation in case of intractable bleeding . if the patient is haemodynamically unstable procede with out consent after informing the relatives of the patient that she needs grade 1 ceaserean section under GA . neonatologist must be present at the time of delivery . active management of third stage by giving slow bolous of syntometrine . close the wound with drain . assess for post operative thromboprophylaxis . anti-d in case of rhesus negative  patient and perform kleiheur test 2 hrs later for extra dose of anti d . encourage early mobilisation, avoid dehydration .encourage breast feeding . detail documentation about the incident including the time called for help , findings and the procedure done . debrieff about the incident  to the women and relatives . give postnatal appointment after 6 weeks .advice on contraception before dischrage .

I will first assess the ouvert blood loss,check the womans pulse rate and blood pressure. On ascertaining her condition is stable I will proceed to ask her how much was the bleeding, and if she had previous bleeding episodes.I will ask for associated pain and if present was it continuous or intermittent like labour pains.Whether she is perceiving fetal movements should be asked to judge the fetal condition.  Any history of trauma is also to be asked as it may cause abruption.I will ask about her past obstetric history as if she had a previous caesarean section as a uterine scar is a risk factor for a placenta previa .Also I will explain the possibility of the placenta being morbidly adherent to the scar which can be diagnosed on Ultrasound using colour Doppler. As her 21 week anamoly  scan showed a low lying placenta I will now subject her to a Transvaginal ultrasound to confirm placenta previa .A third trimester scan may reclassify a previa in 12% of cases.A gentle speculum examination has to be done to identify any ongoing bleed,see the state of cervix and do an opportunistic infection screen.Digital examination is certainly avoided once placenta previa is confirmed. If there is no active bleeding she can be managed on an outpatient basis.If there is a major degree placenta previa  I will advise admission at 34 to 36 weeks as there are strong chances of rebleed due to formation of the lower uterine segment. I will tell that delivery will be by a caesarean if placental edge is within 3cm from the os.Risk of haemorrhage ,potential need for blood transfusion,objections to transfusion if any to be noted.   If rhesus negative antiD to be given followed by a kleihauer Betke test to know if more doses required. Haematologist to be notified in case of atypical antibodies.Information leaflets and hospital contact details are to be provided.

             Tachycardia and hypotension implies a major blood loss.Stabilising the mother is the primary goal. Resuscitation has to be commenced checking her airway and breathing,  help to be called for. A venous access has to be secured and blood to be taken for grouping and crossmatching. Initially colloids may be started till the blood is available.Fresh whole blood if available is preferred as it replaces clotting factors also. A haemoglobin done now may not reflect the true picture as it takes time to fall. A coagulation screen has to be done as major blood loss triggers a consumption coagulopathy.As she is 35 weeks with a bleed severe enough to cause a hemodynamic compromise and FHR is normal ,she should be taken up for an emergency grade 1 caesarean section.Steroid inj Betamethasone 12mg to be given for fetal lung maturity. Consultant obstetrician and consultant Anaesthetist must be available as she is at high risk of haemorrhage .General anaesthesia is preferred as there is hypotension and delivery must be  as fast as possible. Informed consent to be taken explaining risk of haemorrhage,need for blood  and blood products,uterotonics,uterine artery embolisation,internal iliac ligation to manage PPH and as a last life saving resort Hysterectomy. Availability of blood to be ensured before starting the surgery.Any denial for transfusion to be noted. Antibiotic given as per unit protocol.Clear documentation of time of arrival,decision making and decision to delivery interval to be made to avoid litigations.A specialist trained in advanced neonatal life support should be present for baby resusucitation and bed in the ICU to be ready for the mother.Detailed documentation of intra operative findings to be done namely placental localisation,any blood stained liquor,retroplacental clot,condition of neonate and cord gases as this is vital for her future obstetric management.Post op debriefing to the woman once she is stable and to her family to be done about the need for caesarean,the findings and the condition of the newborn.Anti D to be given if Rh negative and further dose based on Kleihauer Betke test .Post operative Thromboprophylaxis given as per unit protocol.

a) In the  assessment  I will ask her about the  onset  and  duration of bleeding,  whether small or large in amount which will indicate its severity . In her  obstetrical history  I will ask her  if she  has had any past history of APH as recurrence is found in subsequent pregnancies( 5%after 1 and 20-25 %after  2 APH). I will also enquire about any previous cesarean as this may increase the chance of placenta praevia. I will also ask about any history of abdominal pain or contraction along with beeding pv as this may suggest abruption  and painless bleeding point towards placenta praevia . Bleeding after intercourse may suggests  pl.praevia and local causes like polyp. I will take history of smoking and drug misuse as smoking and cocaine are high risks for abruption. I would like to know the history of rupture of membranes or any vaginal discharge  as it may explore the cause of  APH as vasopraevia and infection  respectively. I will review her notes of current pregnancy to know any high risk factors of APH like preeclampsia, polyhydramnios, iugr,ivf pregnancy and multiparity. I will ask about fetal movements as this will ensure fetal well being.

In examination I will do general examination  and vitals monitoring(pulse, B.P., temp,respiratory rate and SPO2) to assess her well being. Abdomen to be palpated, tense and woody abdomen suggest abruption and relaxed abdomen suggests placenta praevia or other local causes.Fundal height and presentation and fetal heart to be checked to assess fetal wellbeing. Any  contractions to be noted. Per speculum to be done to assess amount and colour of bleeding. Any dilatation of cervix , any ruptured membranes  or any vagnal discharge to be noted. Digital examination to be avoided until  placenta praevia is ruled out by scan. Urgent bed side scan to be done to know the placental site preferably transvaginal  after explaining its safety. Abruption is a clinical diagnoses and sensitivity of USG in detecting abruption is only 25 %.

B) This is an obstetric emergency  so I will initiate  a major haemorrhagic  protocol that requires  input from MDT for optimizing the management . Communication ,resuscitation, monitoring and assessment  should be done simultaneously. I will involve consultant obstetrician , anaesthetist, haematologist , paediatrician , SCBU staff,OR staff, blood bank  and porters . I will check airway , breathing and circulation  and will  place her in left lateral position . I will start her oxygen by mask at 10-15 litrs/min. I will place two large bore cannula 14 gauge and take blood samples  for  FBC( to know her Hb status  and requirement  of blood, platelet count  to assess  plan of surgery ) U&E ( to assess RFT  )and coagulation profile ( to know  any coagulopathy) and cross match 4 -6 units  in case  of massive haemorrhage. I will start will crystalloids  and then colloids total  upto 2-3 litres till the cross match is available . 4 units of FFP and 10 units of Croyoprecipitate can be given in view of massive haemorrhage while  awaiting results of coag profile and platelet count. In emergency O negative blood can be given till group specific is ready. Haematologist is involved if atypical antibodies  are present or need of any blood products  is required. Liaision  with anaesthetic  team  if CVP monitoring is required  to  manage fluid balance. Continuous catheterization to be done to monitor output , one- to- one care to be given  and vitals are monitored regularly  every 15 minutes till the woman is stable . Continuous electronic fetal monitoring  is recommended and plan for urgent delivery is made  in conjunction with the woman and her family.The need of urgent cesarean to be discussed  explaining risks of severe bleeding ,need of massive blood transfusion, risks of injuries to viscera, risk of losing  womb  and psychological impact. Any concerns should be answered sensitively giving all information and her wish should be respected. Surgery should be conducted by senior obstetrician  under supervision  by consultant obstetrician .If facilities are available in the unit for cell saver  and interventional  radiology then I will make arrangement for that immediately  . Cell saver will reduce the need of  blood  products  and intervention radiology is very effective as uterine embolization  but  it is difficult to time  with the emergency and also not available  in all units .

General anaesthesia  is preferable as it facilitates in resuscitation and expedite the delivery. Site of the   incision on the uterus should be away from placenta to reduce blood loss, may require classical incision. Pharmacological ( oxytocin/syntometrine/carboprost/misoprostol) and Surgical measures( suturing placental bed, rusch balloon , B-lynch suture) taken to prevent PPH .Consider UAE and  Bilateral uterine/internal ilac artery ligation if bleeding persisting  and ultimately last resort is cesarean hysterectomy in view of intractable bleeding. The procedure should be covered by prophylactic antibiotic . Following delivery  she should be transferred to HDU/ITU and should be monitored under MEOWS charting  . Thromboprophylaxis  should be given  to avoid VTE complications  and kleihauer test to be done in Rh-ve unsensitized women to assess FMH and to gauge anti d. Neonatal assessment  by senior neonatologist to be done to assess  fetal  anemia . Incidental reporting to be done to assess risk management. Debriefing to be done by senior member of MDT team regarding the events and its future outcom . In the absence of hysterectomy  ,issues regarding recurrence, and adherent placenta in subsequent pregnancies should be discussed, contraception  need to be discussed . Mental health guidance and psychological support to be given  to avoid post traumatic stress disorder.

A) Antepartum haemorrhage is associated with  significant maternal morbidity and mortality. Attention is paid to assess her haemodynamic stability. Presence of hypotension, tachycardia in the presence of  heavy overt bleeding suggest maternal shock in which case immediate resuscitative measures are employed following ABC principles to stabilise the woman. 

If the woman is haemodynamically stable history is taken about associated symptoms like pain abdomen. History of abdominal trauma and continuous pain point towards abruptio placenta. Intermittent pain suggests threatened miscarriage.

History of previous caesarean section , history of curettage or myomectomy with pain less bleeding suggest placenta pre via. 

History of illicit drug use should be asked as use of cocaine predisposes to placental abruption.

Examination includes assessment for pallor. Pulse, blood pressure and temparature are recorded. Abdominal examination is done to assess uterine height which is more than the gestational age in case of polyhydramnios or multiple pregnancy which predispose to abruption. Assessment is done to identify uterine tenderness. Tense and woody feel of the uterus on palpation indicates placental abruption.

Speculum examination is done to assess the cervix and to identify local factors for bleeding such as presence of cervical polyps.

Maternal investigation are dependant on the amount of bleeding.

In case of minor haemorrhage, FBC , group and save are done. Ultrasound is required for the location of placenta and for the assessment of fetal heart.

In case of major haemorrhage, FBC and crossmatching done for 4 units of blood. Clotting screen is required. U& E , LFT are done. Kleihauer test is done if the woman is Rh negative to quantify fetomaternal haemorrhage. Ultrasound is done to diagnose placenta praevia but does not exclude abruption.

b) Heavy bleeding, with hypotension and tachycardia suggest hypovolemic shock . 

Resuscitation and immediate delivery of the baby are required to reduce maternal morbidity , mortality and perinatal mortality. 

Multidisciplinary care for the management of antepartum care is associated with better outcome.

 Help is summoned from senior obstetrician, anaesthetist and midwifery staff. Immediate resuscitative measures are employed. The woman is Airway checked and breathing assessed. 100% oxygen is given by facial mask at a rate of 10- 15 lts/min. IV access is obtained with two wide bore cannulas. Blood is obtained for FBC, group and crossmatch, U&E and cross- match 4 units of blood. Fluid resuscitation is done with warmed crystalloid and colloid. Haematology is lab is informed about the urgent requirement if blood.  O Rh negative blood transfusion is arranged while waiting for the crossmatched blood.

Communication among professional colleagues  is important as better communication avoids delays in management and to deliver appropriate care to reduce maternal and perinatal mortality.  SCBU is informed about the potential need for delivery. 

Arrangements are done for the caesarean section and theatre staff are informed. While arrangements are made for the transfer to the theatre, monitoring is done which includes, continuous monitoring of pulse, blood pressure, SO2, respiratory rate and ECG and entered on  Obstetric early warning chart for early identification of maternal condition.  Fetal well being is monitered by CTG.

Urinary catheter is inserted which is essential before caesarean section to reduce the bladder injury and for monitoring urinary out put.

Communication with the woman and her family is essential to reduce the anxiety and for preparing them psychologically for the situation and possible complications.  If the woman is stable , she should be explained about the possible need for emergency caesarean section and intra operative complications  like haemorrhage and need for hysterectomy. 

Interventions are required to minimise morbidity which include involving Consultant anaesthetist and consultant obstetrician should be involved during the caesarean section for better out come. 

 Arranging for intraoperative cell salvage and intervention radiology are required for the management of intra operative haemorrhage, if she declines blood transfusion 

Surgical interventions like bimanual compression, B-Lynch suturing and balloon tamponade may enable the conservation of the uterus. In case of persistent haemorrhage  early recourse to hysterectomy is required as delay in decision making is associated with significant morbidity and mortality.

The woman should be transferred to high dependency unit for close observation of vital signs on early obstetric warning chart as she is at risk of continuous haemorrhage in the post operative period. 

Appropriate thromboprophylaxis is given as she is at risk of VTE.

Debriefing with an explanation of what happened, and any implications is done when is she is physically and psychologically stable.

Clinical incident forms should be completed. 

a).Initial assessment depends on her hemodynamic stability. Airway breathing circulation are assessed , hypotension, tachycardia indicate clinical shock and resuscitation started.

If she is hemodynamically stable ask about amount ,duration of bleeding .It is important to determine the cause of antepartum hemorrhage mainly abruption and placenta previa. Ask about abdominal pain , leaking per vaginum to rule out early labour or abruption placenta. She is asked about previous bleeding episodes in this pregnancy. Ask whether she is  able to feel fetal movements. History of abdominal trauma is asked. Previous obstetric history noted , previous caesarean , curettage, uterine surgery which would make placenta previa, accreta more likely.  

Examination done for  pulse ,blood pressure  and pallor . Abdominal examination done for fundal height , uterine tenderness ,woody feel in case of abruption, uterine contractions. Fetal heart is noted.  Speculum examination done to assess any local causes like cervical ectropion,  note any ongoing heavy bleeding.  Per vaginal exam not done as it may provoke torrential bleed in suspected previa.      IV line secured blood taken for full blood count , blood group type. Group and save done .         Kliehauer test done if rhesus D negative to estimate fetomaternal hemorrahge. In case of ongoing bleeding liver function test(LFT), urea electrolytes ,coagulation profile to be done.  Ultrasound arranged once stabilised to confirm placenta previa .Transvaginal scan has better sensitivity in diagnosing placenta previa. In case of previous caesarean , anterior previa overlying scar consider Doppler, MRI to diagnose placenta accreta.

b). Initial management involves major obstetric hemorrhage protocol. Communication is important. call for help from senior midwife, senior obstetrician anaesthetist .Airway breathing circulation assessed. Nasal oxygen given by mask, secure airway, intubation by skilled professional if need be.  Inform consultant obstetrican and consultant anaesthetist on call to attend.  Start two iv  lines 14 G (orange), commence fluid resuscitation as she in shock.        Inform blood bank for urgent need for 4 units packed cells. Till blood arrives give Hartmann solution crystalloid  upto 2litres followed by colloids 1-2 litres. Arrange 4 units fresh frozen plasma if 4 units packed cell transfused

  Take blood for Full blood count , LFT, urea electrolytes, coagulation profile, crossmatching. Ask for uncrossed or onegative blood if delay . Infuse warm fluids , keep woman warm. Once maternal condtion stable , asses fetal well being by CTG if possible .

 If she has capacity inform about need for urgent Category 1 cesarean section as life saving measure for her and baby. Explain about possible risks like post partum hemorrhage, need for hysterectomy, ICU care.  Keep relatives informed about plan. If previous caesarean section with anterior placenta previa treat as suspected placenta accrete with care bundle in place.  Senior obstetrician and anaesthetist to be present at time of delivery. Arrange for intervention radiology if facility available for  uterine artery embolisation, Cell salvage if available.

SCBU neonatologist to be informed and should be present at time of delivery. Intraoperatively make uterine  incision away from placental site. If placenta does not separate leave in situ or proceed with hysterectomy as per plan . Consultant obstetrician to be involved in decision.  Interventions to prevent bleeding like early use of uterotonics, uterine compression sutures, bakri balloon will be needed. Uterine artery, iliac artery ligation applied if facility not available for intervention radiology. Early resort to hysterectomy if other measures fail to stop bleeding to save the life of mother may be needed.

If woman lacks capacity in shock category 1 cesarean done  as life saving measure.

Post operatively she is observed in HDU, critical care using MEOWS (modified early obstetric warning score) for early detection of ongoing hemorrhage. Anti D given a sper protocol .Thromboprophylaxis by elastic stocking , avoid dehydration , mobility started. Heparin considered only after risk of hemorrage settled by senior obstetrician. Debreifing done for the woman and family as can lead to post traumatic stress disorder. 

Any delay or near miss would need incident form to be filled.

I'll take detailed history as regard amount & duration of bleeding, presence of clots.Also I;ll ask about abdominal pain(contractions),awarness of fetal movements& previous attacks of APH in this pregnancy.I'll ask about previuos CS delivery (possible placenta previa &accreta).

I'll examine her vitals ( temp,blood pressure&pulse) assess general condition to evaluate if heamodynamically stable or not. I'll palpate abdomen for contractions as the patient may be in labour, ckeck fundal height (possible small for gestational age,oligohydramnios in recurrent APH).I'll not perform P/V just check amount of bleeding.I'll check fetal heart beat by sonicaid, CTGto assess fetal wellbeing, repeat ultrasound to confirm fetal viability(if not heared)  & plcental site.

I'll request admission, IV line (14gauge), group&save if minor bleeding or cross matching &full resuscitation if major one.Patient should be kept at hospital at least till bleeding stops.AntiD should be given to nonsenthetised RH -ve patient irrespective to antinatal prophylaxis.I'll request kelihauer test to adjust dose.If recurrent APH repeat AntiD/ 6weeks.A single course of corticosteroids is requsted as preterm delivery is expected. Tocolytics should not be used except in certain cases of placenta previa with contraction after discussion with consultant. 

B) This is a severe attack of APH with maternal compromise so I'll start immediate resuscitation while preparing for CS once patient stable.I'll admit  her,call for help by multidisciplinary team (consultant obstetrician, anesthetist, heamatologist, senior midwife neonatologists, theatre& lab staff, porters todeliver blood &samples.) Rasuscitation should follow ABCD. Mentain patent Airway, administer facial O2 to support Breathing.I;ll insert 2 canulae 14 gauge, take blood sample for FBC, urea,electrolyts,liver function tests,cross matching blood urgently at least 4 units of packed RBCs.I'll keep patient warm &in left lateral position & start IV crystalloids 2L harrtman,s solution& 1Lcolloids( plasma protein fraction) till blood avaibla.If still blood not available O-ve blood can be considered. Despite it is recommended that administration of Fresh frozen plasma & cryoppt  should be guided by coagulation profile, in such case of massive Hg they can be given imperically till results avaible. Aim is to keep Heamoglobin> 8gm/dl, fibrinogen>1gm/dl, platelets> 75x 10 9l,PTt&APTT> 1.5x control. Obtain consent if patient condition allows, verbal consent can be considered, otherwise perform CS without consent as it is life saving condition.

 Once stabilized categeory 1 CS is performed (Delivery). I'll request cell salvage if available, prepare cross matched blood ,ask consultant to directly supervise the operation. General anesthesia is preffered to facilitate resuscitation,&expedit delivery.Neonatologist should attend to resuscitat  baby. I'll inform him about diagnosis , umbilical cord should be cut away from umbilicus to allow cetheterisation & blood transfusion should the need  arise.Active manegment of 3^rdstage  by syntometrine as postpartum Hg is expected.

Postoperatively patient should be kept in high dependency unit with continuous monitoring of vitals ,input output fluid chart to avoid overload& observation of bleeding. Investigation should be done daily or more often according to clinical situation.consider thromboprophylaxis after control of bleeding.

Debriefing &psychological support  are very important. Keep the patient  & her family informed at every step. I'll fill incidental report & keep it in patient's notes. I have to allocate one of team member to record events. 

A healthy 23 year old woman presents at 30 weeks gestation with fresh vaginal bleeding. Anomaly scan at 21 weeks showed an anterior low-lying placenta. (a) Discuss your initial assessment [7 marks]. 

 If the patient is in no apparent compromise and able to give history, I will assess the amout of bleeding by checking for presence of clots and whether the patient is experiencing dizziness, faintness as these may reflect symptoms of shock  and will thus necessitate initiation of resuscitative measures. Presence of abdominal pain especially if continuous might denote placental abruption, and if intermittent preterm labour. Fetal movement is enquired about as it gives an idea about fetal well being. I will ask whether this bleeding was provoked by trauma ( with possibility of domestic violence) or by intercourse which may be due to a cervical cause (polyp, ectropion). I would check if she is uptodate with her pap smear  and whether she had previous abnormal smear tests, as cervical neoplasia may be associated with irregular bleeding and postcoital bleeding.Her past obstetric history should be enquired about, whether she had previous placental abruption as this might recurr in a subsequent pregnancy (5%), history of previous cesarean, uterine curettage or uterine scar as this will predispose to placenta accreta. Smoking and illicit drug misuse (cocaine, amphitamine) can predispose to placental abruption.Her blood group should be checked to detect if she is rhesus negative as she will need antiD immunoglobulin injection.

I will check the general condition of the patient, and check the vital signs and oxygen saturation, looking for hypotension < 100mmHg and tachycardia >100bpm are associated with clinical shock and would necessitate immediate resuscitation. Abdominal exam is done looking for uterine tone and tenderness as tense and tender uterus is associated with placental abruption, uterine contractions can be felt. Fundal height larger for dates might indicate polyhydramnios which might predispose to premature labour. Abdominal tenderness and rebound tenderness would point to peritoneal irritation due to intrabdominal bleeding as in uterine rupture. High presenting part and abnormal lie can also point to a low lying placenta. speculum exam can be done after ascertaining the placental location by ultrasound to rule out placenta previa. the cervix should be inspected looking for local lesions like polyps, ectropion and abnormal lesions. Speculum exam may also give an idea about cervical dilatation. Pelvic exam cannot be done in case of placenta previa for fear of bleeding. Fetal heart rate should be auscultated by doppler and a CTG done to ensure fetal well being and detect presence of uterine contraction. the amount of bleeding can be visually assessed and is usually underestimated.

the placental location should be identified by a transvaginal utlrasound as this is a safe procedure and can assess the lower edge of placenta in relation to the cervix. It also can look for signs of placenta accreta. It may also detect large placental abruption but abscence of collection cannot rule out placental abruption. MRI can be ordered in equivocal cases of placenta accreta to supplement diagnosis of ultrasound.

patient should have FBC, to check for anemia. Group and save, and clotting factors are needed if massive hemorrhage or if low platelet count is present denoting consumption. Kleihauer test is used to assess need for further doses of antiD immunoglobin in rhesus negative patient.

(b) Placenta previa is confirmed and she experiences heavy bleeding at 35 weeks gestation. BP = 80/45, pulse = 120 / min and fetal heart rate is normal. Justify your management [13 marks].

This patient is hemodynamically unstable as shown by her vital signs. Immediate initiation of local protocol for management massive obstetric hemorrhage, help should be summoned, and a multidisciplinary team should be involved in the resuscitation (senior midwife, obstetrician, anesthetist, blood bank, Lab personnel, porter). Patient should be put in left lateral position, Oxygen should be administered by facial mask.  Two large bore iv cannulas should be sited, blood should be sent for FBC, Clotting factors, cross matching of four units of packed cells. additional cross matching can be ordered according to needs. 4 units FFP, 10 units cryoprecipitate and platelets should also be prepared and transfused if suspecting coagulopathy. Kleihauer test should taken if mother is rhesus negative to guide antiD immunoglobin and to quantify Fetomaternal hemorrhage. Fluid resuscitation should be started by three litres of crystalloids e.g Hartman's solution ofr 0.9 normal saline awaiting for the cross match. In the event of massive hemorrhage, O negative blood can be administered if cross matched blood is not ready. Operating theater and senior neonatologist should be alerted for possible need of emergency cesarean delivery. A foley catheter should be inserted to monitor urine output. Fetal assessement should be initiated by continuous fetal monitoring, and an ultrasound done to check for placental position to plan the uterine incision.Ultrasound scan will fail to detect placental abruption in 75%of cases so should not waste time to check for retroplacental collection. Consent should be taken as regard need for emergency cesarean delivery , the possibility of placent accreta, leaving the placenta in situ, the need for blood transfusion and possible hysterectomy. If the patient refuses blood transfusion, alternative should be discussed e.g activated factor 7 or cell salvage if available. the discussion should be documented in the notes. If the patient has red cells antibodies the advice of hematologist should be sought early. If patient is rhesus negative antiD immunoglobulin should be adminstered regardless of previous anti D .Senior obstetricain and senior anethesist should attend the cesarean.Extra help form another senior colleague with superior gynaecological surgical skills should be called early. The anesthesia in this case would preferably be under general anesthesia in order to control maternal resuscitation and expedite delivery. Neonatologist should be alerted early for possibility of placental abruption, in order to prepare O negative blood cross matched with the mother's blood in case of fetal anemia. All the staff should be alert to the association of antepartum hemorrhage with postpartum hemorrhage. 

Care should be taken to avoid incision through the placenta to minimize bleeding and if this was inevitable it should be carried out by an experienced consultant. in the event of adherent placenta that is not delivered by usual measures, the placenta can be left in situ if no bleeding, and uterus closed, there is high risk of bleeding and infection at a later stage. Uterotonics should be administered as part of active management of third stage to decrease postpartum hemorrhage. If bleeding persists other measures like B lynch sutures or internal iliac ligation can be done. If this fails hysterectomy will be needed. Patient should be care in level 2 care unit with monitoring of vital signs, oxygen saturation and fluid balance using MEOWS chart for early recognition of any deterioration in her condition. TED stockings should applied and heparin use should be weighed against risk of bleeding, and should be given to those patients at high risk for thrombosis. Debriefing of the patient of what was done and why and implications for future pregnancies. An incident report should be filled.

Ans : If she is clinically stable, I shall ask her if this is first or recurrent episode, duration and amount of blood loss and about fetal movements. I will go through her notes.  Any associated pain? Intermittent lower abdomen pain suggests  labour with show.  Constant  abdominal pain suggests  abruption. Pre eclampcia, abdominal trauma, smoking or drug abuse increase risk of  abruption. Ask about sexual intercourse, as it can provoke bleeding from placenta praevia , or from  local causes eg  ectopy or cervical growth . Her parity, previous history of cesarean section, surgical termination of pregnancy,and myomectomy all increase the risk of placenta previa accreta. On examination , I ll check her blood pressure , pulse to assess effect of blood loss . Abdominal examination , for symphisio fundal height. I will check for palpable contractions(labour). Abdominal tenderness and rigidity points towards abruption, and soft nontender abdomen with high presenting part suggests previa .  Auscultate for fetal heart sounds. I will check her notes for blood grouping and Rh factor and save it for cross match. If she is Rh negative , nonsensitized mother, arrange for Kleihauer  test  to calculate dose of anti D Ig if indicated. Full blood count will be done to assess for anemia . Check platelet count, if low only then I will go for coagulation tests. I will arrange for ultrasound to confirm if placenta is still low lying, (might not exclude abruption). If previa confirmed , I will arrange for 3 D Doppler ultrasound to rule out accreta, as anterior placenta previa, if associated with previous  scar is a risk factor. CTG will be done for fetal  assessment.

b) She has massive antepartum hemorrhage, and it is an obstetric emergency. Resuscitation , monitoring, investigation and treatment have to be undertaken simultaneously. Call for help has to be initiated.  It requires multidisciplinary management. Consultant obstetrician anaesthetist,haematologist, senior midwife, neonatologist, Special care baby unit(SCBU),   blood transfusion laboratory and porter have to be alerted and involved.  Assess airway and breathing(A& B). Oxygen 10 -15 liters/minute via face mask started in left lateral tilt and she is kept warm.  Double intravenous (IV) line maintained with 14 gauge cannula.(C circulation) Blood(20 ml) sent for urgent tests. Full blood count done, to check for hemoglobin, hematocrit and platelets. Prothrombin time, thrombin time, partial thromboplastin time, and fibrinogen assay as there is risk of coagulopathy . Urea and electrolytes ( risk of acute renal failure) and liver function tests.  If Rh negative mother, Kleihauer test done .Send cross match and arrange for 4 units of group specific cross matched blood. Meanwhile, give upto 2 liters (l) of crystalloids and upto 1.5l of colloids( warmed) If situation urgent  uncross matched group specific or O negative blood can be given. If massive hemorrhage 4 units fresh frozen plasma and 10 units cryoprecipitate can be given .  Catheterize , intake output record, maintain Modified  early obstetric warning(MEOWS)chart. Meanwhile arrange  continuous electronic fetal heart rate monitoring.  As soon as mother is stabilized arrange urgent cesarean section ( category 1) by senior obstetrician and if accreta, by consultant obstetrician( elements of care bundle fulfilled). Review notes. There should already be written plan and informed consent agreed between patient and consultant, risks & treatment options. It includes decisions regarding uterine and skin incisions, and use of interventional radiology and intra operative cell salvage( especially if she refuses donor blood) . Whether she wants conservative treatment if accreta or straight hysterectomy.  This plan will be followed.  During cesarean avoid cutting through placenta. Active management of third stage. Beware of Postpartum hemorrhage. In case of atony, IV oxytocics, intramuscular and if required intramyometrial  carboprost can be given.  If no response brace (B lynch) sutures , uterine artery ligation and uterine packing considered if appropriate. Early resort to hysterectomy if intractable bleeding. Vigilent post operative monitoring.   Involve physician if renal faiure & heamatologist  if coagulopathy. Give anti D Ig if indicated. Fill out incident form. Keep patient and partner informed sensitively. Arrange postnatal followup, and debriefing if adverse outcome. Give written information leaflet, and support group contacts.      

Adequate hydration, early mobilization, deterrant stockings for thromboprophylaxis. If higher risk for thrombosis involve hematologist.

a)      Antepartum hemorrhage is associated with maternal and fetal morbidity and mortality.Woman should assessed for the amount of blood loss and  maternal and fetal compromise which would require urgent surgical intervention.Multidiciplinary team including  obstetrician ,midwife,anesthetist,neonatologist and laboratory and theatre facilities should be involved in her care.

If the woman is not compromised ,history is taken regarding associated abdominal pain-continuous or intermittent, and  leaking water h/o trauma –accidental or domestic violence. h/o fetal movements.Smear history is obtained.

h/o smoking and drug abuse is taken as it is associated with increased risk of placenta previa.

Examination for general condition and BMI.BP and pulse recorded .

Abdominal examination is done for fundal height,abdominal tenderness /uterine contractions.Presentation and fetal heart is checked.

Vaginal examination is avoided. Amount of blood lost is assessed by inspection.

P/Speculum exam done to see blood loss ,status of cervical os and any cervical pathgology.

              Investigations include FBC , group and save, Kleihauer test    ,USS for placental localization         and fatal being.Transvaginal scan is done for diagnosis of placenta previa.CTG is done to assess fetal heart rate and assist decision on timing and mode of delivery.

b)      Woman is in clinical shock.This is an obstetric emergency.Local Protocol for massive hemorrhage should be followed. Help should be called immediately from multidicilinary team including consultant obstetrician ,anesthetist,neonatologist ,hematologist,midwifery labor ward coordinator.Laboratory and portering staff should be alerted.If facilities are available interventional radiologist should be alerted.One member of the team is designated to record events ,fluids , drugs and vital signs.Woman and her partner should be kept informed of the situation.

   .Airway and breathing is assessed.Facial O2 10-15 L  is given.IV line is secured using 2 wide bore cannulae.(14 guage).Bloods are taken for FBC,blood group ,coagulation profileLFTs ,and         urea electrolytes.Cross match 4units of blood.Crystalloids are infused rapidly upto 3,5 litres until crossmatched blood is available.If there is delay in crosmatched blood,type specific or O neg blood may be transfused.She should be continuously monitored for BP.pulse and respiratory rate and O2 saturation.Foley catheter is inserted for monitoring urine output.

Preparations should be made for urgent category 1 CS.Verbal consent is obtained.She should be informed of high risk of hemorrhage ,blood transfusion and hysterectomy.General anesthesia is required.Consultant obstetrician should be present during CS.Baby is  delivered quicly.Active management of third stage should be done as she is at high risk of PPH. Uterotonics are given for uterine atony.If bleeding is not controlled she would require ballon  tamponade or B-Lynch suture .In case of continued bleeding internal iliac or uerine artery ligation  is done .Uterine artery embolisation can be done if facilities are available.In case of uncontrolled bleeding decision for hysterectomy should not be delayed.

Postop she should be transferred to HDU.closely monitored by MEOWS chart.Blood lost should be replaced .She should be debriefed by the senior member of the team.All events ,procedures and drugs are documented and Incident report is made.Thromboprophyxis should be given accordsing to RCOG guidelines.Antibioics will be given intraoperatively and postoperatively.Encourage woman for breastfeedsing and advise her if she wants contraception .She is at risk of recrrent placenta previa and also placenta accreta.Hence she should have early booking and follow up at consultant led clinic

dear dr paul

in the question part a  is ( initial assesment) and answer plan shows (initial management). so do we have to  include investigations  also in the initial assement ? please explain