Obstetrics

Placenta Praevia & Low-lying Placenta (APH pathway)

IN REVIEWv3🌍 International referencePENDING CLINICAL VERIFICATION⚡ Massive APH (praevia/abruption)

Painless bright-red APH after 20 wks with malpresentation/high presenting part. NEVER digital examination. Localise with ultrasound; plan birth: resolve by 32 wks if minor/low-lying; caesarean for true praevia ~36–37 wks.

Admission & discharge ↓

Reviewer note: Medication regimens and dependent emergency instructions checked 17 October 2026. These targeted checks do not certify every statement in the module. Admission/discharge guidance checked 18 October 2026. This adds a scoped clinical synthesis and does not certify every statement in the module.

Admission & discharge

Care setting: Bleeding requires hospital assessment; inpatient versus home surveillance is individualised

Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.

When admission or continued hospital care is needed

Any new bleeding, contractions or pain requires immediate maternity assessment. Admit ongoing/recurrent significant bleeding, maternal instability, fetal concerns or inability to reach emergency care safely.

When clinic, day care or home care may be suitable

An asymptomatic, stable low-lying placenta may be managed with a specialist outpatient plan; admission depends on bleeding history, gestation, access to emergency care and support.

Before going home

Bleeding has stopped, maternal observations and Hb assessment are satisfactory, and fetal assessment is reassuring.
A senior obstetrician has documented why home care is safe, transport/support arrangements and the planned birth setting/date.

Discharge medicines and treatment changes

Treat anaemia when indicated; do not discharge with an unspecified tocolytic or steroid continuation prescription. Reconcile any remaining scheduled treatment explicitly.

Tests, pending results and their reviewer

Document placental location and dates of repeat imaging; assess blood group/antibody status and indicated anti-D after bleeding.

Home care and counselling

Provide immediate-return instructions for any bleeding, pain, contractions or ruptured membranes and a route to a hospital with obstetric/transfusion capacity.

Follow-up: when and what to review

When	Action / responsible service
At the booked scan and obstetric review	Review placental position and update birth timing/place; review immediately if symptoms recur.
Before planned birth	Confirm blood availability, transport and senior operative/anaesthetic arrangements.

Return urgently

Any further bleeding, pain, contractions, faintness or reduced fetal movement: contact/attend the maternity unit immediately.

Open the complete discharge checklist →

Sources for this plan:

RCOG · Current public care informationchecked NICE · NG25checked

Treatment

① Immediate stabilization — first minutes

Admit ALL significant APH
Crossmatch 2 units minimum (major praevia: group&save at minimum + immediate availability)
Continuous maternal+fetal monitoring
Nothing per vaginam

③ First-line treatment & drug regimens

<34+0 weeks + stable mother + viable fetus: EXPECTANT inpatient management — steroids complete, monitor, deliver on deterioration or reaching 36–37 wks
≥34+0–37 wks with recurrent/significant bleeding: DELIVER by caesarean
Asymptomatic low-lying (<20 mm): rescan 32 & 36 wks; vaginal birth permitted if edge ≥20 mm at 36 wks (NICE); individualise 15–20 mm
True praevia asymptomatic: planned caesarean 36+0–37+0 (uncomplicated major); 37+0–38+6 for low-lying borderline cases per unit policy

Betamethasone — antenatal courseWHOsummary checked

Dose12 mg IM, then 12 mg IM 24 hours later

RouteIM

FrequencyTwo doses, 24 h apart

DurationOne 24 mg course. Consider only ONE repeat course under NICE criteria; not routine weekly courses

PreparationConfirm product strength: for 6 mg/mL, 12 mg = 2 mL; volumes differ by formulation. Use the obstetric IM preparation

Max dose24 mg/course; NICE permits no more than 2 courses in total under its repeat-course criteria

Imminent preterm birth within the guideline gestational window; do not delay urgent maternal/fetal delivery
NICE offers at 24+0–33+6 weeks, considers 34+0–35+6; individual discussion at 22+0–23+6. Repeat: <34 weeks, prior course >7 days ago and very high risk of birth in 48 h.

Monitoring

Glucose monitoring and an insulin-adjustment plan in diabetes; assess infection and timing of birth

Contraindications: Do not delay lifesaving delivery to complete steroids; do not use a blanket “infection contraindication” without senior assessment

④ Drug treatment detail (2 agents)

Dexamethasone — antenatal alternativeWHOsummary checked

Dose6 mg IM every 12 h for four doses

RouteIM

FrequencyEvery 12 hours, four doses

Duration24 mg total over 36 h; ONE course, subject to the same repeat-course restrictions

PreparationCheck the injectable product: if 4 mg/mL, 6 mg = 1.5 mL; other strengths require recalculation. Give IM for this antenatal regimen

Max doseFour 6 mg doses = 24 mg/course; do not combine with a full betamethasone course

Indication: Alternative fetal-lung-maturation course when appropriate

Monitoring

Maternal glucose, infection assessment and birth timing; diabetes team plan

Contraindications: Do not prolong an unsafe pregnancy to finish the course

Magnesium sulfate — fetal neuroprotectionNICE · NG25checked

Dose4 g over 15 min, then 1 g/hour

RouteIV infusion

FrequencyLoading once, then continuous infusion

DurationStop at birth or 24 hours, whichever occurs first

Preparation50%: 4 g = 8 mL diluted in compatible sodium chloride 0.9%; maintenance example 20 g made up to FINAL 100 mL, 5 mL/hour via pump

Max dose24 hours for neuroprotection; do not add to an eclampsia regimen already running

Indication: Imminent preterm birth: NICE offers at 24+0–29+6 weeks and considers at 30+0–33+6 weeks; discuss 23+0–23+6 individually

Monitoring

Record pulse, BP, respiratory rate and tendon reflexes at least every 4 h; more often if oliguria or renal impairment

Contraindications: Myasthenia gravis, heart block or magnesium toxicity · Renal impairment or oliguria requires reduced/withheld maintenance and more frequent assessment

Definitive treatment

CAESAREAN BIRTH for praevia covering os — senior obstetrician + anaesthetist, cell-salvage/rapid infuser where available, anticipate accreta (see pas-spectrum)
Anterior praevia with prior scar: consent for possible hysterectomy; urology on standby for percreta

Monitoring

Expectant inpatient schedule	Frequency
Vitals + PV loss chart	4–6 hourly
CTG	Daily (viable)
Hb	Twice weekly (keep >100 g/L with iron)
Rescan growth	Every 2–3 wks
Steroid status	Complete course if <34+6

Response assessment

No further bleeding episodes ×48 h + stable Hb → discuss discharge criteria (living near hospital, reliable transport, companion)

Treatment failure

Any fresh bleeding episode in expectant phase → reassess for delivery
Massive bleed → activate massive haemorrhage pathway + emergency caesarean regardless of gestation (maternal life takes precedence)

Procedure / surgery

Caesarean technique: transverse uterine incision away from placenta where possible; anticipate need for internal iliac balloons/embolisation pre-placed in complex cases
NEVER attempt vaginal birth with placenta covering os

Escalation

Suspected accreta + limited facilities → IN-UTERO TRANSFER to centre with interventional radiology + blood bank + urology (do not deliver locally)
Massive haemorrhage team activation

⑮ Complications & their management

Massive antepartum haemorrhage

Emergency caesarean + MTP; left-lateral tilt; vasopressor-supported anaesthesia

Accreta spectrum invasion

pas-spectrum pathway

PPH after birth

Lower segment poorly contracts → carbetocin/oxytocin infusion, balloon readiness, compression sutures standby

Rh sensitisation

Anti-D 500 IU (or Kleihauer-guided) within 72 h of every bleed if Rh-negative

Post-treatment care

Post-caesarean surveillance for PPH/DIC
Thromboprophylaxis per risk assessment
Histopathology of placenta (confirm accreta)
Next-pregnancy counselling: recurrence + imaging strategy

Diagnosis & assessment

Red flags:

Active bleeding + CTG abnormality → deliver now
Bleeding after prior caesarean → suspect ACCRETA spectrum simultaneously
Haemodynamic instability
Bleeding at home remote from hospital → admit

Definition: Placenta covering/abutting internal os: low-lying (edge <20 mm from os), minor praevia (marginal/partially covering), major praevia (fully covering). Bleeding from placental-bed separation at lower-segment stretching.

Risk factors

Previous caesarean/scarsGrandmultiparityAdvanced maternal ageSmokingMultiple pregnancyPrevious praeviaAssisted conception

Presentation

PAINLESS bright red vaginal bleeding (any amount may herald massive bleed)
Malpresentation/transverse/unstable lie
High free head
Often first bleed resolves then recurs larger

Initial assessment

NO DIGITAL VAGINAL EXAMINATION (ever, until placenta excluded)
Speculum ONLY if placenta excluded and diagnosis unclear (gentle, at os level)
Stabilise: two IV lines, crossmatch, CBC+coags, Kleihauer if Rh-negative
CTG continuous if viable gestation
Transabdominal THEN transvaginal ultrasound (safe) to localise placental edge distance
Steroids <34+6; consider MgSO4 neuroprotection <30–32 if birth imminent

Investigations

Test	Looking for
TVS placental localisation	Edge-to-os distance (<20 mm = low-lying; placenta COVERING os = praevia)
Signs of accreta (loss of clear zone, bladder-line interruption, lacunae)	Coexisting PAS — changes surgical planning entirely
CBC/coags/crossmatch	Anaemia baseline; readiness for surgery
Kleihauer (Rh-negative)	Anti-D dose calculation (500 IU standard; more per Kleihauer)

Principles & follow-up

Management principles

Sources (11)

WHO / FIGO / ICM — Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
2025-10 · checked 2026-10-17 · verified-summary
Open source ↗

Targeted recheck: WHO 2025 recognition/treatment trigger (≥500 mL or ≥300 mL with abnormal haemodynamics), concurrent first-response bundle and refractory-haemorrhage fibrinogen target ≥2 g/L if replacing a level <2 g/L. Primary recommendation chapter/table indexed at https://www.ncbi.nlm.nih.gov/bo…

RCOG — Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality (Green-top Guideline No. 74)
2022-02 · checked 2026-08-23 · pending-verification
Open source ↗

Cited via RCOG GTG73 update note; direct PDF audit pending — flag

NICE — Intrapartum care (NG235)
2023-09-29 · updated 2026-06-09 · checked 2026-08-23 · verified-live
Open source ↗

NICE overview + Update information page (dates above confirmed)

WHO — Antenatal corticosteroids for improving preterm birth outcomes — 2022
· checked 2026-10-17 · verified-summary
Open source ↗

Recommendation 1.9/type-and-regimen evidence: IM dexamethasone or betamethasone total 24 mg; four 6 mg dexamethasone doses 12 hours apart or two 12 mg betamethasone doses 24 hours apart. NICE NG25 supplies gestational and repeat-course criteria.

NICE — NG25 — preterm labour and birth
20 November 2015 · updated 10 June 2022 · checked 2026-10-18 · verified-live
Open source ↗

Scope: additional clinical-detail explanation for ptl-threatened, ptl-established. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module. Additional admi…

RCOG — Placenta praevia, placenta accreta and vasa praevia
· checked 2026-10-18 · verified-live
Open source ↗

Primary information read: individualised admission by bleeding/history/access, urgent attendance for bleeding/pain/contractions, specialist PAS/vasa praevia birth planning and postoperative/fertility counselling. No universal asymptomatic admission week is inferred.

NICE — Postnatal care — NG194
· checked 2026-10-18 · verified-live
Open source ↗

Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.

India MoHFW / NHM — District Hospital Standard Operating Procedures — LaQshya
· checked 2026-10-18 · verified-live
Open source ↗

Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.

WHO — WHO recommendations on quality postnatal care — official recommendation summary
· checked 2026-10-18 · verified-live
Open source ↗

Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.

RCOG — Laparoscopy — recovering well
· checked 2026-10-18 · verified-live
Open source ↗

Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…

NICE — Acutely ill adults in hospital — CG50
· checked 2026-10-18 · verified-live
Open source ↗

Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.