Adult ECAT protocol

Vaginal bleeding

A7.8 Published: December 2023. Printed on 20 Jun 2024.

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Any person, 16 years and over, presenting with vaginal bleeding.  This applies to non-pregnant females or pregnant females, less than 20 weeks gestation.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

If sexual assault is disclosed or suspected refer to local sexual assault protocols.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

  • Presenting complaint
  • Onset of bleeding
  • Quantification of vaginal blood loss, e.g. pad changes
  • Date of last menstrual period
  • Preceding events, consider
    • Recent sexual activity
    • Presence of a foreign body
    • Trauma
    • Sexual assault, domestic and family violence
  • Pain assessment – PQRST
  • Pre-hospital treatment
  • Past admissions
  • Medical and surgical history, including
    • First menses, endometriosis and pelvic inflammatory disease
    • Perimenopause or postmenopausal
    • Current pregnancy, past pregnancies, complications, terminations and miscarriages
    • Tubal surgery
  • Current medications, including fertility treatment and contraception
  • Known allergies

Signs and symptoms

  • Dizziness or lightheaded
  • Nausea or vomiting
  • Presence of foul-smelling discharge, clots or retained products of conception
  • Abdominal or lower back pain
  • Psychological distress
  • Pallor
  • Malaise or lethargy

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

  • Meets trauma criteria
  • Unconfirmed pregnancy
  • A pregnancy of 20 weeks and longer
  • Post-natal period of less than 6 weeks

Clinical

  • Altered level of consciousness
  • Syncope or collapse
  • Hypotension
  • Hypertension
  • Referred pain, i.e. shoulder tip or diaphragmatic pain
  • Severe abdominal pain or rigidity
  • Passing large clots
  • Fever
  • Hourly pad changes

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

AssessmentIntervention

General appearance/first impressions

Position of comfort

Ensure patient privacy and psychosocial support

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

Respiratory rate and effort

Consider auscultation of chest (breath sounds)

Oxygen saturation (SpO2)

Assist ventilation, as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93%

Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

AssessmentIntervention

Blood loss

Perfusion (capillary refill, skin warmth and colour)

Pulse rate

Blood pressure

Cardiac rhythm

Start vaginal blood loss and pad change chart. Advise the patient to notify staff before toileting

If under 42 days postpartum, use standard maternity observation chart (SMOC) to record cumulative blood loss

Assess circulation

Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

IVC and/or pathology

Insert IV cannula, if trained and clinically indicated

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

AssessmentIntervention
ACVPU

If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment as clinically indicated

Pain

Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

AssessmentIntervention
Temperature

Measure temperature

Skin inspection, including posterior surfaces

Check and document any abnormalities

Fluids

AssessmentIntervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited Commence fluid balance chart, as required
Nausea and/or vomiting If present, see nausea and/or vomiting section

Glucose

AssessmentIntervention

BGL

Measure BGL, if clinically indicated

If less than 4 mmol/L, consider hypoglycaemia protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Consider abdominal focused assessment.

Consider dehydration focused assessment.

Precautions and notes

  • Consider the following in non-pregnant vaginal bleeding:
    • abnormal menstrual period or first period
    • trauma or foreign body
    • infection
    • bleeding from another source, e.g. rectal
    • postmenopausal bleeding.
  • Pregnancy-related vaginal bleeding may indicate a miscarriage or ectopic pregnancy in early trimester, particularly with pain.
  • Consideration should be given to the collection of products of conception. These may be sent for histology and/or genetic testing in consultation with obstetrics and gynaecology.
  • Rh and antibodies need to be considered in pregnancy. Anti-D may be required if Rh negative.

Interventions and diagnostics

Specific treatment

  • Vaginal bleeding of any cause requires a sensitive approach.
  • Always ensure privacy and psychosocial support.

Analgesia

Select pain score:

Pain score 1–3 (mild)

Give paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Ibuprofen is contraindicated in pregnancy – refer to the appropriate medication guide prior to administration.

Pain score 4–6 (moderate)

Give:

oxycodone (immediate release):

  • 16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Ibuprofen is contraindicated in pregnancy – refer to the appropriate medication guide prior to administration.

Pain score 7–10 (severe)

Give one of:

Fentanyl intranasal
  • 16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
  • 65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils

Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device

Fentanyl IV
  • 16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
  • 65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg
Morphine IV
  • 16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg
Morphine IM
  • 16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Ibuprofen is contraindicated in pregnancy – refer to the appropriate medication guide prior to administration.

If pain does not improve with medication, escalate as per local CERS protocol.


Nausea and/or vomiting

If nausea and/or vomiting is present, give:

  • metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
  • or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
  • or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.


Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.


Pathology

  • FBC, UEC, group and hold
  • Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport is delayed
  • Woman of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis
  • Under 42 days postpartum: coags

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

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Drug Dose Route Frequency

16–65 years
50 microg
Maximum dose 100 microg

65 years and over:
25 microg
Maximum dose 50 microg

IV/intranasal

Pain score 7–10

Repeat once if required after 5 minutes to maximum dose

Ibuprofen H, R

400 mg

Oral

Pain score 1–10

Once only

Ibuprofen is contraindicated in pregnancy – refer to appropriate medication guide prior to administration

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

16–65 years
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Pain score 7–10

IV Repeat once if required after 5 minutes
IM Repeat once if required after 60 minutes

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

16–65 years:
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Oral

Pain score 4–6

Repeat once if required after 30 minutes to maximum dose

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

Sodium chloride 0.9%

250 mL

Maximum dose 1000 mL

IV/intraosseous

Bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/vaginal-bleeding

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