Bleeding is the cause of one in four maternal deaths worldwide. Death may occur in less than two hours after the onset of bleeding associated with childbirth. Anaemia is common in pregnancy and women with anaemia and bleeding are at high risk of death. Appropriate care in pregnancy and labour includes:

Abortions and ectopic pregnancies are associated with bleeding in early pregnancy. In late pregnancy and in labour, bleeding may result from placenta praevia, placental abruption and uterine rupture. Bleeding following childbirth is associated with failure of the uterus to contract (atonic uterus), injuries to the birth canal and retention of placental tissue.

BLEEDING IN EARLY PREGNANCY

Bleeding in early pregnancy is usually related to abortion or miscarriage.
Abortion may be of spontaneous onset or induced.

Spontaneous abortion
Spontaneous abortion is the loss of a pregnancy before fetal viability. The stages of spontaneous abortion may include:

Induced abortion

Induced abortion is a process by which pregnancy is terminated before fetal viability.

Unsafe abortion

Unsafe abortion is a procedure performed either by persons lacking necessary skills or in an environment lacking minimal medical standards or both.

Septic abortion

Septic abortion is an abortion complicated by infection. Sepsis may result from infection if organisms rise from the lower genital tract following either spontaneous or unsafe abortion. Sepsis is more likely to occur if there are retained products of conception and evacuation has been delayed. Sepsis is a frequent complication of unsafe abortion involving instrumentation.

Ectopic pregnancy

An ectopic pregnancy is one in which implantation occurs outside the uterine cavity. The fallopian tube is the site of ectopic implantation in over 90% of cases. As the pregnancy grows, the tube ruptures. Intraperitoneal bleeding can lead to shock. Abdominal pain from rupture of the tube generally precedes vaginal bleeding in ectopic pregnancy. In an abortion, abdominal pain usually
follows vaginal bleeding.

BLEEDING IN LATE PREGNANCY AND LABOUR

Bleeding in late pregnancy and bleeding in labour are usually due to placental abruption or placenta previa.

Placental abruption

Abruption is the detachment of a normally located placenta from the uterus before the fetus is delivered. Fetal distress and fetal death are common when the placenta detaches prematurely. Maternal complications include shock, coagulation failure and renal failure. Immediate delivery is the preferred option.

Placenta previa

Placenta previa is implantation of the placenta at or near the cervix. Recurrent, painless vaginal bleeding in small amounts may occur in late pregnancy. Expectant management is the preferred option unless bleeding is sufficiently severe to cause maternal or fetal distress.

Uterine rupture

Uterine rupture is an important but less common cause of bleeding in late pregnancy and labour. This may occur in obstructed labour and in labour
with a scarred uterus. Bleeding from a ruptured uterus may occur vaginally unless the fetal head blocks the pelvis. Bleeding may also occur intraabdominally. Rupture of the lower uterine segment into the broad ligament, however, will not release blood into the abdominal cavity.

POSTPARTUM HAEMORRHAGE

Postpartum haemorrhage (PPH) is vaginal bleeding in excess of 500 ml after childbirth. The importance of a given volume of blood loss varies with the woman’s haemoglobin level. A woman with a normal haemoglobin level will tolerate blood loss that would be fatal for an anaemic woman. Bleeding may occur at a slow rate over several hours and the condition may not be recognized until the woman suddenly enters shock. Risk assessment in the antenatal period does not effectively predict those women who will have PPH.

Practise active management of the third stage of labour on all women in labour since it reduces the incidence of PPH due to uterine atony.

Closely monitor all postpartum women to determine those that have PPH.

Atonic uterus

Bleeding occurs from the placental site after delivery. Blood vessels in the placental site are surrounded by uterine muscles, which normally contract after delivery and close off the vessels.

Failure of the uterus to contract (atonic uterus) results in excessive bleeding. This is the commonest cause of bleeding after childbirth.

Other causes of bleeding

Tears in the genital tract may also cause bleeding. Retention of placental tissue and blood clots in the uterine cavity prevent adequate uterine contractions after delivery and are therefore associated with PPH. Infection of retained placental fragments may cause bleeding later in pregnancy.