Bleeding in Late Pregnancy
Placenta Previa, Placental Abruption, and Trauma
Comprehensive Nursing Education Resource
Table of Contents
- 1. Introduction to Late Pregnancy Hemorrhage
- 2. Placenta Previa
- 3. Placental Abruption
- 4. Trauma in Pregnancy
- 5. Differential Diagnosis of Late Pregnancy Bleeding
- 6. Assessment and Diagnostic Procedures
- 7. Management and Nursing Interventions
- 8. Mnemonics and Memory Aids
- 9. Emergency Protocols
- 10. References and Further Reading
1. Introduction to Late Pregnancy Hemorrhage
Bleeding during late pregnancy (after 20 weeks of gestation) is a serious complication that affects approximately 3-5% of all pregnancies. It is considered an obstetric emergency that requires immediate attention as it threatens both maternal and fetal well-being. The three major causes of late pregnancy hemorrhage are placenta previa, placental abruption, and trauma, each with distinct pathophysiology, clinical presentation, and management approaches.
Key Concepts:
- Late pregnancy hemorrhage occurs in 3-5% of pregnancies
- It is a leading cause of maternal and perinatal morbidity and mortality
- Prompt recognition and management of hemorrhage is critical for favorable outcomes
- Accurate differential diagnosis determines the appropriate intervention
- Nursing assessments and interventions are vital components of comprehensive care
Understanding the pathophysiology, risk factors, clinical presentation, and management of these conditions is essential for nursing students to provide evidence-based care in obstetric settings. This educational resource will provide comprehensive information about each condition with clear distinctions between their presentations and management approaches.
2. Placenta Previa
Placenta previa is a condition where the placenta implants in the lower uterine segment, partially or completely covering the internal cervical os. It is a significant cause of hemorrhage in the third trimester, affecting approximately 0.5% of all pregnancies.
Fig 1: Placenta previa – The placenta attaches in the lower part of the uterus, covering part or all of the cervical opening
Classification of Placenta Previa
| Type | Description | Hemorrhage Risk |
|---|---|---|
| Complete Placenta Previa | Placenta completely covers the internal cervical os | Highest risk of severe hemorrhage |
| Partial Placenta Previa | Placenta partially covers the internal cervical os | High risk of hemorrhage |
| Marginal Placenta Previa | Placenta reaches the edge of the internal cervical os | Moderate risk of hemorrhage |
| Low-lying Placenta | Placenta implants in lower uterine segment but does not reach the os (within 2cm) | Lower risk but still monitored closely |
Etiology and Risk Factors
The exact etiology of placenta previa remains unclear, but several risk factors have been identified:
- Previous cesarean delivery (risk increases with number of previous C-sections)
- Previous uterine surgeries or procedures (myomectomy, D&C)
- Multiparity (more than one previous pregnancy)
- Advanced maternal age (≥35 years)
- Multiple gestation (twins, triplets)
- Previous placenta previa
- Smoking during pregnancy
- Cocaine use
- Large placenta (as in diabetes or erythroblastosis fetalis)
- Assisted reproductive technology
Pathophysiology
In placenta previa, the abnormal placental location exposes maternal blood vessels to mechanical forces during uterine growth and cervical changes. As the lower uterine segment stretches and the cervix begins to efface and dilate, particularly in the third trimester, the placental attachments are disrupted, leading to hemorrhage. This bleeding has several key characteristics:
Characteristic Features of Placenta Previa Hemorrhage:
- Painless, bright red vaginal bleeding
- Bleeding often occurs spontaneously without apparent trigger
- May be precipitated by sexual intercourse or vaginal examination
- Bleeding is typically intermittent with increasing severity over time
- First episode is rarely fatal but serves as a warning sign
Clinical Manifestations
The cardinal symptom of placenta previa is painless, bright red vaginal bleeding typically occurring in the late second or third trimester. The clinical presentation includes:
- Bleeding: Painless, bright red, may be minimal initially but can become profuse
- Uterine activity: Typically no contractions or tenderness
- Fetal status: Usually normal unless significant hemorrhage occurs
- Maternal vital signs: May remain stable initially but can deteriorate rapidly with severe hemorrhage
- Abdominal examination: Soft, non-tender uterus
- Leopold’s maneuvers: May reveal abnormal fetal lie or presentation (transverse lie or breech) due to abnormal placental location
Critical Nursing Alert:
Never perform digital vaginal examinations on a patient with suspected placenta previa. Digital examination can cause severe, potentially fatal hemorrhage by disrupting the placental attachment. Always confirm placental location by ultrasound before any vaginal examination.
3. Placental Abruption
Placental abruption (abruptio placentae) is the premature separation of a normally implanted placenta from the uterine wall after 20 weeks of gestation and before delivery of the baby. It occurs in approximately 1% of all pregnancies and is a significant cause of maternal hemorrhage and perinatal mortality.
Fig 2: Placental abruption – Premature separation of the placenta from the uterine wall with retroplacental hemorrhage
Classification of Placental Abruption
| Grade | Clinical Findings | Extent of Separation |
|---|---|---|
| Grade 0 (Asymptomatic) | Discovered incidentally after delivery with a retroplacental clot | Minimal separation |
| Grade 1 (Mild) | Minimal to no vaginal bleeding, slight uterine tenderness, normal maternal vital signs, no signs of fetal distress | <25% separation |
| Grade 2 (Moderate) | Moderate vaginal bleeding, significant uterine tenderness with tetanic contractions, maternal tachycardia, fetal distress present, early signs of coagulopathy | 25-50% separation |
| Grade 3 (Severe) | Heavy vaginal bleeding (or concealed), tetanic/board-like uterus, maternal shock, coagulopathy, fetal death | >50% separation |
Types of Placental Abruption
| Type | Description | Clinical Presentation |
|---|---|---|
| Concealed Abruption | Blood is trapped between placenta and uterus, with no external bleeding | Abdominal pain, uterine tenderness, maternal shock disproportionate to visible blood loss |
| Revealed (Apparent) Abruption | Blood escapes through the cervix, resulting in visible vaginal bleeding | Visible vaginal bleeding, abdominal pain, uterine tenderness |
| Mixed (Complete/Partial) Abruption | Combination of both concealed and apparent bleeding | External bleeding that is less than expected given the maternal condition |
Etiology and Risk Factors
The exact cause of placental abruption is often unknown, but several risk factors have been identified:
Maternal Factors:
- Hypertensive disorders (chronic hypertension, preeclampsia)
- Previous history of placental abruption (10-15% recurrence rate)
- Advanced maternal age (>35 years)
- Multiparity
- Thrombophilic disorders
- Maternal smoking
- Cocaine or methamphetamine use
- External trauma (falls, motor vehicle accidents, domestic violence)
Pregnancy-Related Factors:
- Premature rupture of membranes
- Chorioamnionitis
- Multiple gestation
- Polyhydramnios
- Short umbilical cord
- Rapid uterine decompression (after delivery of first twin or rupture of membranes with polyhydramnios)
- Uterine anomalies
- Previous cesarean delivery
Pathophysiology
Placental abruption occurs when the maternal vessels tear away from the placenta, causing bleeding between the uterine wall and the placenta. This process involves:
- Initial Vessel Rupture: Bleeding begins in the decidua basalis (maternal portion of the placenta)
- Blood Accumulation: Blood collects and forms a hematoma between the uterine wall and placenta
- Progressive Separation: The expanding hematoma causes further separation of the placenta from the uterine wall
- Compromised Blood Flow: Decreasing surface area for oxygen and nutrient exchange between mother and fetus
- Uterine Response: The bleeding irritates the myometrium, causing increased uterine tone and contractions
Placental abruption can lead to several serious complications:
- Maternal hemorrhage: Can be external, internal, or both
- Disseminated intravascular coagulation (DIC): Develops in approximately 10-20% of severe cases
- Hypovolemic shock: Due to significant blood loss
- Ischemic necrosis of distal organs: Kidneys (acute renal failure), liver, pituitary (Sheehan syndrome)
- Fetal compromise: Hypoxia, acidosis, growth restriction, preterm birth, or death
Clinical Manifestations
The classic presentation of placental abruption includes:
Key Clinical Signs of Placental Abruption:
- Vaginal bleeding: Dark red bleeding (may be absent in concealed abruption)
- Abdominal pain: Sudden onset, severe, persistent
- Uterine tenderness: Localized or diffuse
- Uterine hypertonicity: Wood-like or board-like uterus on palpation
- Frequent contractions: Often with poor relaxation between contractions
- Fetal distress: Abnormal fetal heart rate patterns, decreased fetal movement
- Maternal shock: Disproportionate to visible blood loss in concealed hemorrhage
Critical Nursing Alert:
The severity of external bleeding does not always correlate with the extent of placental separation. A patient with concealed abruption may have minimal or no vaginal bleeding yet have significant internal hemorrhage leading to shock. Always assess maternal vital signs and fetal status regardless of the amount of visible bleeding.
Nursing Assessment for Placental Abruption:
- Monitor maternal vital signs frequently (increased pulse, decreased BP indicate hypovolemia)
- Assess uterine tone, tenderness, and contractility
- Measure and document amount, color, and character of vaginal bleeding
- Monitor fetal heart rate continuously
- Assess for signs of coagulopathy (petechiae, ecchymosis, bleeding from puncture sites)
- Monitor urine output (decreased output suggests hypovolemia or renal injury)
4. Trauma in Pregnancy
Trauma complicates approximately 6-7% of all pregnancies and is the leading non-obstetric cause of maternal mortality. Trauma-induced hemorrhage in late pregnancy can result from direct injury to the placenta, uterine vasculature, or the uterus itself.
Types and Causes of Trauma in Pregnancy
| Type of Trauma | Common Causes | Associated Risks for Hemorrhage |
|---|---|---|
| Blunt Trauma | Motor vehicle accidents (50% of cases), falls, direct abdominal blows, domestic violence | Placental abruption, uterine rupture, fetomaternal hemorrhage |
| Penetrating Trauma | Gunshot wounds, stabbings | Direct vessel/organ injury, uterine perforation, fetal injury |
| Falls | Loss of balance due to shifted center of gravity, syncope | Placental abruption, preterm labor |
| Pelvic Fractures | High-impact collisions, falls from height | Massive hemorrhage from pelvic vessels, bladder/urethral injury |
Physiologic Changes Affecting Trauma Response
Several normal physiologic changes of pregnancy affect the body’s response to trauma and can mask or exacerbate hemorrhagic conditions:
Cardiovascular Changes:
- Increased blood volume (45-50%)
- Increased cardiac output (30-50%)
- Decreased systemic vascular resistance
- Physiologic anemia of pregnancy
- Supine hypotension syndrome
- Heart rate increased by 15-20 bpm
Anatomical Changes:
- Enlarged uterus displacing abdominal organs
- Decreased gastric emptying
- Increased risk of aspiration
- Stretched abdominal wall with decreased sensitivity
- Elevated diaphragm
- Dilated ureters with increased risk of injury
Impact on Hemorrhage Recognition:
Due to increased blood volume in pregnancy, a pregnant woman may lose up to 30-35% of her blood volume (1500-2000 mL) before showing clinical signs of shock. This “compensatory reserve” can mask significant hemorrhage until sudden decompensation occurs.
Trauma-Related Causes of Late Pregnancy Hemorrhage
1. Placental Abruption
The most common complication of trauma in pregnancy, occurring in up to 40% of severe trauma cases. Blunt force causes the relatively inelastic placenta to shear away from the elastic uterine wall. Even minor trauma can cause abruption, with symptoms sometimes appearing up to 48 hours after the initial injury.
2. Uterine Rupture
Though rare (occurring in <1% of trauma cases), uterine rupture has a fetal mortality rate approaching 100% if not immediately treated. It typically occurs with direct, high-impact force to the abdomen, especially in women with prior uterine scars.
Fig 3: Traumatic uterine rupture – Tear in the uterine wall causing hemorrhage and potential fetal compromise
3. Fetomaternal Hemorrhage
Trauma can cause fetal blood to enter the maternal circulation through placental disruption. While this occurs to some extent in 30% of normal pregnancies, significant fetomaternal hemorrhage (>30 mL) occurs in about 8-15% of trauma cases and can lead to fetal anemia, distress, or death.
4. Direct Vascular Injury
In late pregnancy, pelvic and uterine vessels are enlarged and more vulnerable to injury. Pelvic fractures can tear these vessels, leading to massive retroperitoneal hemorrhage. Maternal mortality from pelvic fracture in pregnancy is as high as 9%.
Critical Nursing Assessments After Trauma:
- Assess for vaginal bleeding, amniotic fluid leakage
- Monitor vital signs frequently (noting that hypotension is a late sign)
- Evaluate uterine activity, tone, and tenderness
- Monitor fetal heart rate continuously
- Observe for signs of developing shock
- Assess for abdominal pain, contractions, or changes in fetal movement
Important Considerations:
All Rh-negative pregnant women who experience trauma should receive Rh immune globulin (RhoGAM) within 72 hours, regardless of the apparent severity of the trauma, to prevent maternal sensitization from potential fetomaternal hemorrhage.
5. Differential Diagnosis of Late Pregnancy Bleeding
Accurate differential diagnosis of bleeding in late pregnancy is crucial for appropriate management. The table below highlights the key differences between major causes of late pregnancy hemorrhage:
| Clinical Feature | Placenta Previa | Placental Abruption | Trauma-Related Bleeding | Other Causes |
|---|---|---|---|---|
| Onset of bleeding | Sudden, spontaneous | Sudden, may follow trauma or hypertensive episode | Following traumatic event | Variable |
| Character of bleeding | Bright red, painless | Dark red, painful (may be concealed) | Variable, depends on cause | Variable |
| Abdominal pain | Absent | Present, severe | Often present, location depends on injury | Variable |
| Uterine tone | Normal, relaxed | Tetanic, board-like | Variable, may have localized tenderness | Usually normal |
| Fetal heart rate | Usually normal | Often abnormal, distress common | Variable, depends on extent of injury | Usually normal |
| Contractions | Absent initially | Often present, high-frequency | May develop following trauma | May be present in labor |
| Ultrasonographic findings | Placenta covering cervical os | Often normal; may show retroplacental clot | Variable; may show free fluid or abruption | Depends on cause |
| Coagulation status | Usually normal | May develop DIC | Variable; DIC possible with massive hemorrhage | Usually normal |
Other Causes of Late Pregnancy Bleeding
Other conditions that may cause bleeding in late pregnancy include:
- Bloody Show: Mucus-tinged bloody discharge that occurs with cervical dilation and effacement at term
- Vasa Previa: Fetal vessels crossing the internal os, unprotected by placental tissue or umbilical cord
- Cervical/Vaginal Lesions: Polyps, cervicitis, cervical ectropion, or cervical cancer
- Uterine Rupture: Can occur spontaneously, especially with previous cesarean scar
- Marginal Sinus Rupture: Bleeding from the edge of the placenta
6. Assessment and Diagnostic Procedures
Initial Assessment
The initial assessment of a patient with late pregnancy bleeding should include:
Primary Assessment (ABCDE Approach):
- Airway: Ensure patent airway and oxygen saturation
- Breathing: Assess respiratory rate, depth, and effort
- Circulation: Check maternal vital signs (BP, pulse, capillary refill)
- Disability: Assess level of consciousness
- Exposure: Assess amount of visible bleeding
Maternal Assessment:
- Complete vital signs (including orthostatic measurements)
- Visual estimation of blood loss (quantity, color, presence of clots)
- Abdominal examination (tenderness, rebound, guarding)
- Uterine assessment (tone, tenderness, contractions)
- External genital examination
- Speculum examination (only after placenta previa ruled out)
Fetal Assessment:
- Fetal heart rate (auscultation or electronic monitoring)
- Fetal movement assessment
- Uterine activity monitoring
- Cardiotocography (CTG) if available
- Assessment of gestational age
- Previous fetal assessment results review
Critical Warning:
Never perform digital vaginal examination in a patient with late pregnancy bleeding until placenta previa has been ruled out by ultrasound.
Diagnostic Procedures
Laboratory Tests:
- Complete blood count (CBC) with platelets
- Blood type and screen/cross-match
- Coagulation profile (PT, aPTT, fibrinogen)
- Comprehensive metabolic panel
- Kleihauer-Betke test (in Rh-negative mothers with trauma)
- Urinalysis (to rule out urinary tract causes)
Imaging Studies:
- Transabdominal ultrasound (placental location, fetal status)
- Transvaginal ultrasound (if anterior placenta previa ruled out)
- Doppler studies (fetal blood flow assessment)
- CT scan (in trauma cases, with appropriate shielding)
- MRI (for detailed placental assessment in complex cases)
Monitoring Parameters
| Parameter | Frequency | Critical Values |
|---|---|---|
| Maternal Vital Signs | Every 15 minutes in active hemorrhage, then as indicated | HR >120, SBP <90 mmHg, RR >30, O₂ sat <94% |
| Fetal Heart Rate | Continuous electronic monitoring | Bradycardia <110 bpm, tachycardia >160 bpm, late decelerations, minimal variability |
| Uterine Activity | Continuous tocodynamometry | Hypertonus, tachysystole, tetanic contractions |
| Vaginal Bleeding | Hourly pad count and weight | Saturating 1 pad in <15 minutes |
| Urine Output | Hourly via indwelling catheter | <30 mL/hr indicates hypovolemia |
| Mental Status | Every vital sign check | Confusion, agitation, lethargy |
7. Management and Nursing Interventions
General Approach to Management
The management of late pregnancy hemorrhage follows these essential principles:
- Maternal stabilization takes priority over fetal considerations
- Rapid assessment of maternal and fetal status
- Volume resuscitation to maintain hemodynamic stability
- Continuous monitoring of maternal and fetal parameters
- Definitive management based on severity, cause, and gestational age
Management by Specific Condition
| Condition | Initial Management | Definitive Management | Nursing Interventions |
|---|---|---|---|
| Placenta Previa |
|
|
|
| Placental Abruption |
|
|
|
| Trauma-Related Hemorrhage |
|
|
|
Nursing Care Plan for Late Pregnancy Hemorrhage
1. Nursing Diagnosis: Deficient Fluid Volume related to active blood loss
Expected Outcomes: Patient will maintain adequate fluid volume as evidenced by stable vital signs, adequate urine output, and appropriate level of consciousness.
Interventions:
- Establish at least one large-bore IV (16-18 gauge)
- Administer isotonic crystalloid fluids as ordered
- Monitor vital signs every 15 minutes during active hemorrhage
- Maintain strict intake and output measurements
- Position patient in left lateral position to maximize cardiac output
- Assess for signs of hypovolemic shock (tachycardia, hypotension, decreased urine output, altered mental status)
- Prepare for and assist with blood product administration as needed
2. Nursing Diagnosis: Risk for Impaired Fetal Gas Exchange related to placental separation/disruption
Expected Outcomes: Fetus will maintain adequate oxygenation as evidenced by reassuring fetal heart pattern and absence of late decelerations.
Interventions:
- Maintain continuous electronic fetal monitoring
- Administer oxygen via face mask at 8-10 L/min if fetal distress is present
- Maintain left lateral positioning to enhance uteroplacental perfusion
- Monitor and document fetal heart rate patterns and variability
- Report abnormal patterns immediately to provider
- Prepare for emergency delivery if persistent fetal distress occurs
3. Nursing Diagnosis: Anxiety related to uncertain maternal and fetal outcomes
Expected Outcomes: Patient will verbalize decreased anxiety and utilize effective coping strategies.
Interventions:
- Provide clear, concise explanations about condition and procedures
- Maintain calm, reassuring demeanor even in emergency situations
- Include support person in care when appropriate
- Encourage verbalization of fears and concerns
- Provide frequent updates on maternal and fetal status
- Utilize therapeutic communication techniques
- Offer spiritual support based on patient preferences
4. Nursing Diagnosis: Risk for Ineffective Peripheral Tissue Perfusion related to hypovolemia
Expected Outcomes: Patient will maintain adequate tissue perfusion as evidenced by normal capillary refill, warm extremities, and adequate urine output.
Interventions:
- Assess peripheral pulses, capillary refill, and skin temperature every hour
- Monitor for signs of decreased tissue perfusion (cool extremities, delayed capillary refill)
- Maintain normothermia with warm blankets
- Elevate legs if not contraindicated
- Administer fluids and blood products as ordered
- Monitor laboratory values (hemoglobin, hematocrit) for trends
8. Mnemonics and Memory Aids
Mnemonics can help nursing students remember key concepts related to bleeding in late pregnancy.
P.R.E.V.I.A
For remembering placenta previa characteristics:
- Painless bright red bleeding
- Relaxed, soft uterus
- Episodes of bleeding (recurrent)
- Vital signs often stable initially
- Intact membranes (typically)
- Avoid vaginal examination!
A.B.R.U.P.T
For recognizing placental abruption signs:
- Abdominal pain (severe)
- Board-like uterus (tetanic)
- Rigid abdomen
- Uterine tenderness
- Pain disproportionate to visible bleeding
- Tachysystole (frequent contractions)
H.E.M.O.R.R.H.A.G.E
For prioritizing care in late pregnancy hemorrhage:
- Help (call for assistance)
- Evaluate vital signs
- Monitor fetal heart rate
- Oxygen administration
- Rapid IV access (two large-bore)
- Record blood loss (weigh pads)
- Hold vaginal exams until previa ruled out
- Assess uterine tone
- Get blood samples (type and cross)
- Elevate legs/left lateral position
T.R.A.U.M.A
For assessing pregnancy trauma patients:
- Tilt (left lateral position to prevent aortocaval compression)
- Resuscitation (follows standard ABCDE approach)
- Abruption (monitor for signs even with minor trauma)
- Uterine assessment (tone, tenderness, contractions)
- Monitor fetus (continuous electronic monitoring)
- Anti-D immunoglobulin for Rh-negative mothers
C.A.U.S.E.S of Late Pregnancy Hemorrhage
For remembering differential diagnosis:
- Cervical causes (polyps, ectropion, cancer)
- Abruption of placenta
- Uterine rupture
- Show (bloody show of labor)
- Edge separation (marginal sinus rupture)
- Situated low (placenta previa)
9. Emergency Protocols
Massive Obstetric Hemorrhage Protocol
Fig 4: Algorithm for management of massive obstetric hemorrhage
Key Emergency Actions
Placenta Previa Emergency
- Position in left lateral position
- Two large-bore IV lines (16-18g)
- Draw blood for CBC, coagulation panel, type and cross
- Give oxygen by face mask at 10-15 L/min
- Prepare for emergency cesarean delivery
- Ultrasonography to confirm diagnosis
- Avoid vaginal examination
Placental Abruption Emergency
- Two large-bore IV lines
- Rapid crystalloid infusion
- Blood product preparation (RBCs, FFP, platelets)
- Continuous fetal monitoring
- Monitor for signs of DIC
- Prepare for potential emergency delivery
- Hourly urine output measurement
Trauma Emergency
- Primary trauma assessment (ABCDE)
- Left lateral tilt displacement of uterus
- Avoid supine position after 20 weeks
- RhoGAM for Rh-negative mothers
- Kleihauer-Betke test for fetomaternal hemorrhage
- Extended monitoring (24+ hours)
- Early obstetric consultation
Blood Transfusion Protocol
| Blood Loss Volume | Transfusion Strategy | Nursing Responsibilities |
|---|---|---|
| Class I (≤15% blood volume) | Crystalloid fluids only | Monitor vital signs, ensure adequate IV access |
| Class II (15-30% blood volume) | Crystalloids + consider blood products | Draw type and cross, warm fluids, continuous monitoring |
| Class III (30-40% blood volume) | Crystalloids + immediate RBC transfusion | Activate massive transfusion protocol, warming devices, frequent labs |
| Class IV (>40% blood volume) | Massive transfusion protocol (RBC:FFP:Platelets in 1:1:1 ratio) | Assist with rapid infusion devices, monitor for transfusion reactions, frequent assessments |
Critical Nursing Alerts:
- Never delay resuscitation to obtain fetal heart tones
- Digital vaginal examination is absolutely contraindicated in suspected placenta previa
- Anticipate coagulopathy in severe abruption cases; have blood products ready
- Maintain vigilance for delayed abruption (up to 48 hours after trauma)
- Maternal shock = 80% fetal mortality; aggressive maternal resuscitation is priority
10. References and Further Reading
- Schmidt, P., Skelly, C., & Raines, D. (2022). Placental Abruption. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482335/
- Mayo Clinic. (2023). Placenta previa – Symptoms & causes. https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768
- Toy, F., Mahan, M., & Kiel, J. (2022). Pregnancy Trauma. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430926/
- American College of Obstetricians and Gynecologists. (2019). Placenta previa. ACOG Practice Bulletin No. 204. Obstetrics & Gynecology, 133(1), e1-e17.
- Society for Maternal-Fetal Medicine, Gyamfi-Bannerman, C. (2018). Society for Maternal-Fetal Medicine (SMFM) Consult Series #44: Management of bleeding in the late preterm period. American Journal of Obstetrics & Gynecology, 218(1), B2-B8.
- Oyelese, Y., & Ananth, C. V. (2006). Placental abruption. Obstetrics & Gynecology, 108(4), 1005-1016.
- Downes, K. L., Grantz, K. L., & Shenassa, E. D. (2017). Maternal, Labor, Delivery, and Perinatal Outcomes Associated with Placental Abruption: A Systematic Review. American Journal of Perinatology, 34(10), 935-957.
- Royal College of Obstetricians and Gynecologists. (2018). Antepartum hemorrhage (Green-top Guideline No. 63).
- Tillett, J., & Hanson, L. (1999). Midwifery triage and management of trauma and second/third trimester bleeding. Journal of Nurse-Midwifery, 44(5), 439-448.
- Merck Manual Professional Version. (2023). Vaginal Bleeding During Late Pregnancy. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/symptoms-during-pregnancy/vaginal-bleeding-during-late-pregnancy