Skip to Main Content


  • Severe hemorrhage happens in about 6.7/1,000 deliveries:
    • Seventeen percent of maternal deaths are due to hemorrhage in the United States
    • Maternal hemorrhage is the leading cause for maternal death in developing countries


See following table.

Table Graphic Jump Location
Favorite Table | Download (.pdf) | Print
Changes in Vital Signs Associated with Maternal Hemorrhage
Changes in vital signsEstimated blood loss (% of total blood volume)
NoneUp to 15–20%
  • Tachycardia (<100 bpm)
  • Mild hypotension
  • Peripheral vasoconstriction
  • Tachycardia (100–120 bpm)
  • Hypotension (SBP 80–100 mm Hg)
  • Restlessness
  • Oliguria
  • Tachycardia (>120 bpm)
  • Hypotension (SBP <60 mm Hg)
  • Altered consciousness
  • Anuria

  • Trivial bleeding:
    • Occurs in about 6% of pregnancies
    • Usually secondary to cervicitis. Important to exclude more serious scenarios
    • No bleeding is trivial in the pregnant patient until serious causes have been excluded
  • Placental abruption:
    • Occurs in 10% of pregnancies
    • May occur at any gestational age
    • Known risk factors:
      • Hypertension
      • Smoking
      • Advanced maternal age
      • Cocaine
      • Trauma
      • PROM
      • History of previous abruption
    • May be complicated by:
      • Amniotic fluid embolism
      • Uterine rupture
      • Coagulopathy
    • IUGR, fetal malformations are common
    • Presents with:
      • Vaginal bleeding (often concealed)
      • Uterine tenderness
      • Increased uterine activity
    • Ultrasound exam often diagnostic but may miss small abruptions
    • Tocolytic therapy in preterm patients is controversial
    • FHR monitoring is essential
    • Mode of delivery is determined by:
      • Condition of mother
      • Condition of fetus
    • Labor and vaginal delivery:
      • If coagulation studies normal, epidural analgesia is not contraindicated
      • Place two large IVs
      • Monitor hemodynamic status closely
    • Cesarean section:
      • Often emergent
      • General anesthesia in most cases
      • Aggressive volume resuscitation is a must; large-bore venous access may necessitate central venous cannulation
      • If necessary, place an arterial line to guide therapy
      • Uterine atony, rapidly developing coagulopathy may worsen hemorrhage
      • Consider postdelivery ICU admission of unstable patients
  • Placenta previa:
    • Prior uterine trauma is often associated
    • Painless vaginal bleed is often first sign
    • Up to 10% may have associated abruption
    • Diagnosed by ultrasonography
    • MRI may be helpful if uterine wall invasion is suspected
    • Avoid vaginal examination
    • Expectant management with admission to hospital
    • Optimal tocolytic is still debated:
      • MgSO4 worsens maternal hypotension
    • IUGR is common
    • Always abdominal delivery
    • All patients should be evaluated on arrival
    • Place at least one large-bore IV
    • Send labs, type, and crossmatch (2 U PRBC)
    • Start volume resuscitation if indicated
    • Double setup if vaginal examination is necessary
    • Cesarean section:
      • Increased risk of bleeding even during elective case
      • Place second IV before start
      • Order a minimum of 4 U PRBC in actively bleeding patients
      • Consider general anesthesia for patients presenting with significant hypovolemia


  • In case of uncertainty as the source of hemorrhage in a patient with known placenta previa it may become necessary to perform a vaginal examination
  • The patient is prepped and draped as for a Cesarean section with a team ready to perform an emergency abdominal delivery should the hemorrhage become threatening
  • An obstetrician then performs the vaginal examination
  • An anesthesiologist is always present, ready to induce GA in case of an emergency:...

Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.