Bleeding in pregnancy
Any bleeding in later pregnancy is dangerous. Before 22 weeks, think of miscarriage and ectopic pregnancy. After 22 weeks, think of the placenta and the uterus: placenta praevia, abruption, rupture. The two rules at first-level care are simple: never do a digital vaginal examination, and get her to a hospital that can operate and transfuse.
- Setting: Health centre with a birthing room, 90 minutes from a hospital with caesarean section and blood transfusion
- For midwives, nurses, clinical officers and doctors at first-level facilities
- Reviewed October 2026
The presentation
Joy, 30, is 32 weeks pregnant with her third baby. She woke an hour ago in a pool of bright red blood. There is no pain. The baby is moving. Her first baby was born by caesarean section, the second vaginally. She attended 3 antenatal contacts; no scan has been done.
| Vital sign | Value |
|---|---|
| Pulse | 104 per minute |
| Blood pressure | 112/72 mmHg |
| Breathing rate | 20 per minute |
| Temperature | 36.8 °C |
| Fetal heart | 140 per minute |
| Conscious level (AVPU) | Alert |
Tests at hand: Haemoglobin (Hb) · Urine dipstick · Blood glucose (finger-prick) · Malaria rapid diagnostic test (RDT)
- Placenta praevia Must not missStill possible
- Placental abruption (abruptio placentae) Must not missStill possible
- Ruptured uterus Must not missStill possible
- Onset of labour (show)Still possible
- Bleeding from the cervix or vagina (cervicitis, polyp, trauma, cancer)Still possible
- Pre-eclampsia (a cause of abruption)Still possible
Work through it
Read each question and decide your own answer first. Then open the model answer and see how the differential changes.
- Step 1 of 7 · Look
What do you do in the first minutes? Name the one examination you must not do.
Model answer
- Shout for help.
- Rapid evaluation: pulse, BP, breathing, conscious level, skin colour and temperature; how much blood; whether there is pain.
- Shock is a pulse of 110 or more with a systolic BP below 90. Joy's pulse is 104 and her BP is normal: not in shock yet, but she can deteriorate quickly. Keep shock in mind at every check.
- Insert an IV line (large bore). Take blood for haemoglobin and for grouping and cross-match before starting fluids.
- Listen to the fetal heart: below 100 or above 180 beats per minute suggests fetal distress. Joy's baby is at 140.
No vaginal examinationDo not do a digital vaginal examination when there is bleeding after 22 weeks. If the placenta is low, an examination can provoke torrential bleeding. A vaginal examination is done only in a theatre ready for an immediate caesarean.Differential now- Placenta praevia Must not missStill possible
- Placental abruption (abruptio placentae) Must not missStill possible
- Ruptured uterus Must not missStill possible
- Bleeding from the cervix or vagina (cervicitis, polyp, trauma, cancer)Still possible
- Pre-eclampsia (a cause of abruption)Still possible
- Onset of labour (show)Less likely (moved down)
- Step 2 of 7 · Ask
What do you ask that helps separate the causes?
Model answer
- Pain: painless bleeding suggests placenta praevia; constant or intermittent abdominal pain suggests abruption; severe pain (which may ease after the event) suggests rupture.
- How much blood, and whether it is still flowing.
- Fetal movements.
- Contractions, a mucous show or leaking fluid (labour).
- Previous caesarean section: a risk for both praevia and rupture.
- Headache, blurred vision or swelling (pre-eclampsia, linked to abruption).
- A fall, a blow to the abdomen or violence; bleeding after intercourse.
- Previous bleeding in this pregnancy; any scan showing where the placenta is.
No pain at all, no contractions, no leaking. The bleeding is slowing. The baby is moving normally. One previous caesarean. No headache or visual problems. No fall or injury; no intercourse. A small painless bleed 2 weeks ago that she did not report.
Differential now- Placenta praevia Must not missLeading (moved up)
- Bleeding from the cervix or vagina (cervicitis, polyp, trauma, cancer)Still possible
- Pre-eclampsia (a cause of abruption)Still possible
- Placental abruption (abruptio placentae) Must not missLess likely (moved down)
- Ruptured uterus Must not missLess likely (moved down)
- Onset of labour (show)Set aside for now (moved down)
- Step 3 of 7 · Look
What do you look for on abdominal examination, and what does each finding suggest?
Model answer
- Uterus: soft and relaxed (praevia) or tense, hard and tender (abruption).
- Contour: an abnormal uterine shape, tenderness and fetal parts easy to feel under the skin (rupture).
- Lie and presentation: a high presenting part or an abnormal lie, with an empty-feeling lower pole (praevia: the placenta is in the way).
- Fundal height for dates; contractions.
- Look at the pad: how much fresh blood; clots.
The uterus is soft and not tender, size about right for 32 weeks. The baby is lying obliquely; no presenting part in the pelvis. No contractions. The pad shows a moderate amount of bright red blood; the flow has slowed.
Differential now- Placenta praevia Must not missLeading
- Bleeding from the cervix or vagina (cervicitis, polyp, trauma, cancer)Still possible
- Pre-eclampsia (a cause of abruption)Still possible
- Placental abruption (abruptio placentae) Must not missSet aside for now (moved down)
- Ruptured uterus Must not missSet aside for now (moved down)
- Onset of labour (show)Set aside for now
- Step 4 of 7 · Test
Which tests help, and which do not change what you do?
Model answer
- Haemoglobin, from the IV cannula sample: a baseline for the hospital. It may fall later as she bleeds.
- Urine dipstick for protein, with the BP: pre-eclampsia is a cause of abruption and would change management.
- Glucose and a malaria RDT do not change the plan here, unless she becomes drowsy or has a fever.
Results: Hb 10.2 g/dL. Urine protein negative. BP 110/70 on repeat.
Ultrasound to locate the placenta is a hospital test. Do not wait for it: the decision to transfer is made on the clinical picture.
Differential now- Placenta praevia Must not missLeading
- Bleeding from the cervix or vagina (cervicitis, polyp, trauma, cancer)Less likely (moved down)
- Placental abruption (abruptio placentae) Must not missSet aside for now
- Ruptured uterus Must not missSet aside for now
- Onset of labour (show)Set aside for now
- Pre-eclampsia (a cause of abruption)Set aside for now (moved down)
- Step 5 of 7 · Do
What is the working diagnosis, and what does she need?
Model answer
Placenta praevia is most likely: painless bright red bleeding after 22 weeks, a previous warning bleed, a relaxed non-tender uterus, an oblique lie with nothing in the pelvis, a previous caesarean, and a well baby.
Abruption is less likely (no pain, soft uterus, normal fetal heart), and rupture is unlikely (no pain, normal contour), but both remain possible until she is assessed in hospital. Cervical causes cannot be excluded without a speculum, and finding one does not exclude praevia.
She needs a hospital that can transfuse and perform a caesarean at any moment: refer urgently, now, even though the bleeding is slowing. Bleeding from a praevia often recurs, and can be heavy.
- Step 6 of 7 · Do
How do you make the transfer safe?
Model answer
- Send word ahead: placenta praevia suspected, previous caesarean, 32 weeks, blood group and cross-match needed.
- IV line running. Give fluids rapidly (normal saline or Ringer's lactate) if bleeding becomes heavy or she shows signs of shock: 1 litre in 15 to 20 minutes, reassessing after each litre.
- A skilled birth attendant goes with her, with delivery equipment, and a relative who could donate blood.
- Transport her lying on her left side. Check pulse, BP, bleeding and fetal heart every 15 minutes on the way.
- Handover note: time bleeding started, estimated loss, vital signs over time, Hb, fluids given, previous caesarean.
- If birth becomes imminent before transfer (bulging perineum, head visible), deliver her in the birthing room and prepare for postpartum haemorrhage.
The bleeding is probably coming from the afterbirth lying low in the womb. You and the baby are stable now, but it can start again suddenly. You need to be in the hospital, where they can give blood and do an operation if needed. We are going with you now.
- Step 7 of 7 · Ask
What happens at the hospital, and what does she need to know for later?
Model answer
- If the bleeding is light or has stopped and the baby is alive but preterm, the hospital may manage her expectantly, keeping her in until the birth with blood available.
- If the bleeding is heavy and continuous, a caesarean is done whatever the gestation.
- Anaemia is corrected (WHO: ferrous sulfate or fumarate 60 mg by mouth daily for six months during expectant management).
- Any future pregnancy should be booked early, with a scan to locate the placenta and a plan to give birth in a hospital.
Must-not-miss conditions
| Condition | Clues | What to do at first-level care |
|---|---|---|
| Placenta praevia | Painless bleeding after 22 weeks, often bright red, sometimes after intercourse; relaxed uterus; high presenting part or abnormal lie; normal fetal condition; previous warning bleed or caesarean. | No vaginal examination; IV line, blood for Hb and cross-match; fluids if heavy or shocked; immediate transfer to a hospital with theatre and blood. |
| Placental abruption | Bleeding (which may be concealed) with constant or intermittent abdominal pain; tense, tender uterus; reduced or absent fetal movements; shock out of proportion to visible blood; pre-eclampsia. | IV fluids, treat shock, check clotting at the bedside if possible; immediate transfer; prepare for postpartum haemorrhage. |
| Ruptured uterus | Severe abdominal pain (may ease after rupture), shock, abdominal distension, abnormal uterine contour, easily felt fetal parts, absent fetal heart; previous caesarean, obstructed labour. | IV fluids, treat shock, immediate transfer for laparotomy. |
| Shock from blood loss | Pulse 110 or more, systolic BP below 90, pallor, sweating, fast breathing, confusion, little urine. | Two large-bore lines, blood first, 1 litre in 15 to 20 minutes, at least 2 litres in the first hour; transfer. |
Decision at first-level care
Joy has antepartum haemorrhage at 32 weeks, most likely placenta praevia: painless bright red bleeding, a previous warning bleed, a soft non-tender uterus, an oblique lie and a previous caesarean, with mother and baby currently stable. No vaginal examination is done. An IV line is placed, blood taken, and she is transferred now, accompanied, to a hospital with caesarean section and blood transfusion.
Source: WHO Managing complications in pregnancy and childbirth (2017); WHO Pregnancy, childbirth, postpartum and newborn care (2015).
- Blood-stained mucus (show) with regular contractions at term, normal vital signs and fetal heart: manage as normal labour.
- Birth imminent before transfer is possible: deliver in the birthing room, prepared for postpartum haemorrhage.
- Bleeding after 22 weeks is never observed at first-level care: every case goes to hospital.
- After 22 weeks, only a show with labour at term is managed in the birthing room, with close monitoring.
- Any bleeding after 22 weeks other than a show: urgently, now, without a vaginal examination.
- Bleeding with abdominal pain, a tense uterus or fetal distress: now.
- Bleeding with signs of shock: resuscitate and transfer now.
- Bleeding with raised BP or proteinuria: now, following the pre-eclampsia protocol.
Key learning points
- Any vaginal bleeding after 22 weeks other than a show is an antepartum haemorrhage and is dangerous.
- Never do a digital vaginal examination for bleeding in later pregnancy at first-level care.
- Painless bleeding with a soft uterus suggests placenta praevia; pain with a tense uterus suggests abruption; severe pain with shock and an abnormal uterine shape suggests rupture.
- Take blood for Hb and cross-match before fluids; shock is a pulse of 110 or more with systolic BP below 90.
- Refer even when the bleeding has slowed: praevia often bleeds again, and heavily.
Sources
- World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd edition. 2017. Vaginal bleeding in later pregnancy and labour: Table S-8 (show versus antepartum haemorrhage), rapid evaluation, no vaginal examination, fetal heart below 100 or above 180, IV line with blood taken first, Table S-9 (abruption, ruptured uterus, placenta praevia), abruption with concealed bleeding and preparation for postpartum haemorrhage, placenta praevia (no vaginal examination unless ready for immediate caesarean; caesarean if heavy; expectant management if light and preterm; iron 60 mg daily for six months). Shock: pulse 110 or more, systolic below 90, 1 litre in 15 to 20 minutes, at least 2 litres in the first hour.
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. Rapid assessment and management B4: late pregnancy, any bleeding is dangerous; do not do vaginal examination; IV line; fluids rapidly if heavy bleeding or shock; refer urgently; proceed with birth if imminent. Shock: position on her left side; referral with a relative who can donate blood.
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016. One ultrasound scan before 24 weeks recommended (helps locate the placenta and date the pregnancy).