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
| Assessment | Intervention |
|---|---|
General appearance/first impressions | Position of comfort Ensure patient privacy and psychosocial support |
Airway
| Assessment | Intervention |
|---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
| Assessment | Intervention |
|---|---|
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
| Assessment | Intervention |
|---|---|
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 |
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
| Assessment | Intervention |
|---|---|
| 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
| Assessment | Intervention |
|---|---|
| Temperature | Measure temperature |
| Skin inspection, including posterior surfaces | Check and document any abnormalities |
Fluids
| Assessment | Intervention |
|---|---|
| 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
| Assessment | Intervention |
|---|---|
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.
Drag the table right to view more columns or turn your phone to landscape
| Drug | Dose | Route | Frequency |
|---|---|---|---|
Fentanyl H, R | 16–65 years: 65 years and over: | 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 |
Over 20 years: | Oral/IV/IM | Once only | |
Morphine H, R | 16–65 years:
65 years and over: | Pain score 7–10 | |
| IV | Repeat once if required after 5 minutes | ||
| IM | Repeat once if required after 60 minutes | ||
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
16–65 years:
65 years and over: | Oral | Pain score 4–6 Repeat once if required after 30 minutes to maximum dose | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
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
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology. 2015 Nov;20(8):1182-91. DOI: 10.1111/resp.12620
- Borhart J. Approach to the adult with vaginal bleeding in the emergency department. UpToDate: Wolters Kluwer; 2022 [cited 23 Feb 2023]. Available from: https://www.uptodate.com/contents/approach-to-the-adult-with-vaginal-bleeding-in-the-emergency-department
- Elnahhas I, Mitwally M. Evaluation of vaginal bleeding. United Kingdom: BMJ Publishing Group; 2023 [cited 20 Feb 2023]. Available from: https://bestpractice.bmj.com/topics/en-us/1166
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- NSW Emergency Care Institute. Per Vaginal (PV) Bleeding. NSW, Australia: Agency for Clinical Innovation; 2023 [cited 20 Feb 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/tools/per-vaginal-bleeding
- NSW Health. Maternity - Management of Early Pregnancy Complications. Australia: NSW Health, Australian Government, NSW; 2012 [cited 20 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=PD2012_022
- NSW Health. Maternity - Rh (D) Immunoglobulin (Anti D). NSW, Australia: NSW Health; 2015 [cited 20 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2015_011
- Therapeutic Guidelines. Antiemetic drugs in adults. Australia: Therapeutic Guidelines Limited; 2022 [cited 15 Feb 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/topicTeaser?guidelinePage=Gastrointestinal&etgAccess=true#
| 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