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Question 138
Delivery suite → Haemorrhage
Classification
Question
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A woman at 34+6 weeks presents with her first episode of moderate painless vaginal bleeding. She is haemodynamically stable and the CTG is reassuring. Her anomaly scan report is unavailable and placental location cannot be confirmed from the records. Speculum examination shows blood in the vagina but no obvious cervical lesion. The cervix appears closed. Which is the most appropriate next step in assessing the genital tract?
Question Stem
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Options
A
Perform a digital vaginal examination to assess cervical dilatation before requesting ultrasound
B
Perform digital examination because the reassuring CTG makes placenta praevia unlikely
C
Avoid any further assessment of the vagina because speculum examination may provoke catastrophic bleeding
D
Exclude placenta praevia before performing a digital vaginal examination
E
Perform digital examination only after administering antenatal corticosteroids
Explanation
When placenta praevia is possible, digital vaginal examination should not be performed until placental location has been established and praevia excluded. Digital examination may provoke severe haemorrhage if the placenta overlies or approaches the cervical os. A speculum examination is different: it may help identify cervical or vaginal causes of APH and can provide useful information without digitally manipulating the cervix. Neither maternal stability nor a reassuring CTG excludes placenta praevia.
Option Validity
A) Digital assessment of cervical dilatation should not precede exclusion of placenta praevia when placental location is unknown.
B) A reassuring cardiotocograph does not exclude placenta praevia.
C) Speculum examination may appropriately identify a cervical or vaginal source of bleeding; particular caution applies to digital vaginal examination before placenta praevia has been excluded.
E) Administration of antenatal corticosteroids does not determine the safety of digital vaginal examination.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.