Bleeding- Pregnancy, Labor, Delivery and Postpartum
by Audrey Rees
Many women experience some bleeding during the first trimester of pregnancy. It can range from mild to heavy spotting and does not necessarily mean miscarriage. Bleeding can occur after sexual activity or merely from a vaginal exam. Other causes include implantation of the fertilized egg in the uterine wall, bleeding caused by fluctuating hormone levels, polyps of the cervix, and a condition known as a “friable cervix” in which the tissue of the cervix is easily split. This last one can usually be improved with a high quality diet. The amount of bleeding can help determine the type of care necessary.
Another lesser known cause of bleeding and cramping during pregnancy is a UTI. This can be confirmed by a UA and should be nipped in the bud immediately as it can result in miscarriage. For a UTI drink lots of water, practice a triple void pee, pee before and after sex, drink unsweetened cranberry juice, consume no sugar, use Echinacea, Vit. C, Uva ursi, and Wild Yam.
Perhaps the most dangerous cause of cramping , sometimes accompanied by bleeding is an ectopic pregnancy. Symptoms alerting you to this include an unusually early, late, missed or spotty period; abdominal pain can be dull or intensely sharp; and irregular bleeding. Other signs may include pain in only one side that may radiate into the arm, shoulder, chest, and upper back; brownish bleeding that is intermittent; and eventually signs of shock. Ectopic pregnancy is a life threatening emergency requiring immediate medical care.
Heavy or steady bleeding during the first four months of pregnancy usually signals a threatened miscarriage. If spotting, bleeding, or cramping with a low back ache this can also be a signal. These symptoms may begin abruptly or slowly and will usually persist for hours or even days. Recommendations for threatened miscarriage include: treat yourself with love and compassion-love your body. Come to a place of peace emotionally, and spiritually concerning the well being of your body and the baby inside you. Get off your feet and rest. Practice visualizations of well being. Avoid lifting heavy objects and abstain from sex. Take a warm (not hot) bath. Think positively and use relaxation techniques. Drink and eat warm foods. Take vitamin E. Eat foods high in vitamin C. Be certain that you are getting adequate protein, carbs, vitamins, minerals and fluids. Partridge berry is a good herb to use as well as Cramp bark, Ginger and black haw. False unicorn root can be a good hormone balancer. Chasteberry helps to increase progesterone levels. Lobelia can reduce uterine contractions. It is a good idea to check in with your health care provider at the first sign of any of these symptoms. It is very important to not be alone if you are miscarrying. Be with someone who can help you if need be. If you feel weak, spaced out, strange, or have been cramping heavily or bleeding for more than two hours then going to the hospital is probably warranted. Any signs of shock should mean emergency transport to the hospital.
Bleeding in late pregnancy may be related to a placental problem, such as placenta previa or placental abruption. Both of these situations require immediate medical attention. A blood loss that causes you to soak a medium size pad within thirty minutes is termed hemorrhage. All bleeding that occurs during pregnancy should be traced to the cause.
Bleeding during the second trimester is serious and the source of blood must be determined. In most cases, bleeding is from the placenta however, small amounts can be from an inflamed cervix. Placental abruption, if minor, can sometimes be resealed with the help of oral vitamin E and vitamin C. It is important to monitor carefully for shock symptoms and signs of increasing intrauterine pressure and pain, as well as increased bleeding, which would signal continued internal bleeding. If suspected in the slightest, mother should be referred to a physician.
The most common cause for third trimester bleeding is normal cervical change. Be sure to rule out infection of the cervix as the source of bleeding. There are a number of uncommon or rare causes of bleeding in the third trimester; however about half the non-cervical bleeding you see will be due to either placental abruption or placenta previa. The other half of the cases, the cause is often less clear and often no cause is ever determined. The most serious threats to pregnancy are life threatening hemorrhage and preterm birth.
Placental abruption is when a portion of the placenta’s surface separates for the uterine wall after the 20th week but before the actual birth. Abruption is directly related to poor nutrition and frequently accompanies hypertension. Placental separation always causes bleeding but distinguishing it from other causes of bleeding can sometimes be tricky. Abruption may present as follows: External or apparent abruption- blood may be dark and clotted or bright. Since there is little or no build up of blood, this type of abruption is not usually painful or mildly so. The degree of anemia and shock is roughly equivalent to the amount of bleeding observed.
Mixed or combined abruption- some of the blood is coming from the yoni while some of it is remaining behind the placenta or trapped high in the uterus. There may or may not be pain and therefor it is hard to determine the severity of the condition.
Classic, internal or concealed abruption- this shows as sudden, increasing uterine pain from blood building rapidly behind a partially or completely detached placenta. This may start contractions but doesn’t always. The uterus will remain hard between contractions due to the trapped blood. The woman will soon show signs of shock and hopefully you will have already transported her to emergency care as this is a life threatening situation for both mother and baby.
Slow leak concealed abruption- a small abruption can take place which does not threaten the life of either mother or baby. Neither care provider or mother will be aware of this until the blood clot is found during the placental exam after the birth. In other cases it can cause a reduction in nutrient transport and lead to intrauterine growth retardation of the fetus. A variation on this type is the concealed abruption which causes a rupture of the membranes near the site of bleeding. Blood then enters the uterine cavity, and mixes with amniotic fluid. When the membranes rupture a port wine stained fluid is released, indicating that bleeding is occurring somewhere. This is reason to transport immediately. If any abruption is suspected midwife should palpate the uterus and listen to the fetal heart rate. Then evaluate the mothers vitals for signs of shock. If mother and fetus appear stable and you suspect a small abruption has occurred, review moms diet and make changes, ask about substance abuse, recommend vit. E and C and bioflavonoids daily for 2 weeks. If mother notes more pain or bleeding she is to call at once or get someone to drive her to the hospital. If you are unclear an ultrasound should be done. If major abruption has occurred and you are unclear of amount of blood loss or bleeding is continuing, transport. A slow bleed may not be life threatening but should still be transported.
Placenta previa occurs when the placenta is implanted partially or completely over the internal os of the cervix. The likelihood is 1 out of every 200 births. It is most common to become symptomatic after the seventh month of pregnancy but can happen in the late first or second trimesters as well. Symptoms include: Painless “warning hemorrhage” after 7 months- usually the mother has a sudden, painless, bright red discharge of blood from her yoni. Frequently women say they woke up in a pool of blood or had a sudden discharge of blood into the toilet. Often such a hemorrhage will stop spontaneously until another one occurs. These are called warning bleeds because they can alert you to a problem before life threatening hemorrhage begins. Rarely no such warning hemorrhage will occur and the first sign could be life threatening. In a previa uterine tone is always normal, blood is bright red, presenting part of baby is high, fetal heart is usually heard, and woman feels little or no pain. If previa is suspected you should never do an internal exam. If bleeding occurs and then stops, the safest option is to send the woman in for an ultra sound. Preterm birth is the major problem with previa. When previa is found women may return home and await 37 weeks and a surgical birth, with recommendations to avoid heavy lifting, rest frequently and call at once if bleeding resumes.
Uncommon causes of bleeding during late pregnancy include yoni or cervical lesions, vasa previa, or uterine rupture. Whenever bleeding occurs maternal well being should be monitored with assessment of vitals as soon as possible and hemoglobin check 36 hours after bleeding has ceased. Anemia should be treated. Fetal movement and heart rate should be assessed as well. Rh negative women should have blood drawn to see if fetal blood has entered her system. Prolonged bleeding can lead to a reduction in clotting factors and make a clotting crisis more likely. A clotting panel can be done to determine if normal clotting status is being maintained. When a bleeding episode occurs, preterm birth is most likely happen within 7-10 days after the episode.
At the onset of labor it is not unusual to see some intermittent bleeding. This occurs as the cervix begins to dilate, particularly in first time mothers. This bloody show is a sign that cervical changes are taking place. More bloody show that begins again in late labor as full dilation approaches is a good sign of progress. It occurs because small capillaries break as the cervix thins and opens. The amount of normal bleeding can vary widely and may at times be so much that you must rule out serious cause before relaxing.
The bloody show is normally scant but at times can be a thick, mucilaginous, gelatinous, stretchy, stringy or ropy and medium to darkish red. Occasionally it can be dark brown and may have small clots mixed in. Bright red streaks in otherwise mucusy show may indicate that cervical scar tissue is being stretched; more blood could indicate the cervix is tearing.
Bleeding during labor can manifest with three basic presentations: concealed (usually painful), in which not of the blood loss is visible; revealed(most often painless), in which only some of the blood loss is visible; and partially revealed.
Painful bleeding may be related to a partially or fully concealed abruption, uterine rupture, laceration of maternal tissues, or a hematoma. Painless bleeding may be due to normal bloody show, cervical trauma or tearing, placental abruption or placenta previa. If the water has broken, painless bleeding could originate from a concealed abruption with bleeding into the sac as well as a ruptured vasa previa, torn cord or other sources of fetal bleeding.
In any of these cases it is best to transfer. As you wait for an ambulance or prepare for the transfer follow these guidelines:
Listen to the FHT to determine if there are signs of compromise. Talk to the baby.
Find the fundus and mark the height with a marker. This will allow you to monitor whether the fundus is rising to do concealed bleeding.
Check the mothers blood pressure and pluse frequently. Stay with her. Note her color, respirations, and level of awareness. Ask her to report and question her often about changes within her.
Start an IV
If the baby is showing signs of compromise, give the mother oxygen by a nonrebreathing mask.
Evaluate for increasing intrauterine pain or pressure.
If the baby is coming be prepared to resuscitate the baby and treat hemorrhage in the mother.
The time between placental detachment and the clamping down of the empty uterus is the
most potentially dangerous time for a healthy mother. A well nourished mother is fully prepared to withstand the normal blood loss that occurs during birth. As a rule, she can loose up to 25% of her original not pregnant blood volume and be just fine. However other factors can reduce her tolerance for blood loss.
Just like in labor, bleeding can be revealed, partially revealed or concealed during the postpartum period. The main bleeding problems that happen during the third and fourth phases of labor can be divided into: those that occur while the placenta is still undelivered and those that occur once the placenta is out.
Once the baby is born, the woman is in no danger while waiting for the placenta as long as she is not bleeding. The trick is to make sure there is no concealed bleeding either. It is customary to wait at least one hour before worrying about the placenta, unless other factors cause you to act sooner. Some blood loss may indicate that the placenta has separated and about to be born. As you wait for the placenta to be born it is important to assess how much blood was lost during labor(if any), how much is currently being lost, and how much more the mother is likely to loose during and after the placental delivery. Many texts state that normal blood loss is about 500 ml or around 2 cups. However many well-nourished women can loose much more and be fine.
A retained placenta with no bleeding whatsoever in the presence of good uterine contractions may be due to placenta accreta. In this case transport is the best option.
If the placenta is not coming nursing the baby, nipple stimulation, acupressure, uterine tonic herbs(angelica or cottonroot bark), mother going pee, fundal pressure, controlled cord traction, Pitocin or Cytotec could be used.
Once the placenta is out the uterus should be massaged in order to help it clamp down. If mother is bleeding more than normal shepards purse can be given for clotting, magic can be essential, a pinch of placenta under the tongue, compression techniques should be tried and PIT, Cytotec or Methergine(only if certain all the placenta is out) could be used.
Usually small fragments of placenta that may have broken off do not cause postpartum bleeding but they could. If you suspect retained parenchyma, transport. Give uterine contractant herbs or drugs to control bleeding during transport.
Of the mother reports that she feels weak, faint, queasy or uncomfortable, reports pressure in the abdomen, becomes unstable in an upright position, or if she seems shocky it would be likely that bleeding may be continuing. If you suspect blood clots are filling the uterus, inspect the placenta. If nothing appears missing you can try to get the clots out by pressing firmly downward on the uterine fundus while gently guarding the uterus. If this doesn’t’ work a manual sweep of the inside of the uterus may be in order. Otherwise, transport if not resolved. Once the uterus is empty, most women have a remarkable and rapid recovery of their sense of well-being.
Slight but steady bleeding that persists in the immediate postpartum hours may be due to a variety of factors. If you cannot stop a trickle bleed, transport.
A woman who has experienced a significant amount of blood loss may have depleted clotting factors. IF you suspect this is interfering with a womans ability to stop bleeding give Yunanbiao or shepherds purse and transport immediately.
A hematoma could be a cause of internal bleeding and could be very serious and life threatening, if suspected transport.
Lacerations can also produce bleeding and could come from the yoni, cervix or uterus. Yoni repairs can be made by some midwifes but if not should be transported to a hospital. Small cervix tears are usually symptom free while larger tears of the cervix are more likely to bleed profusely. The blood will be bright red and quite liquid. Large cervical tears should be clamped at the apex with a ring forceps and the woman should be transported for repair. If you suspect or detect uterine damage, transport immediately.
Normal blood loss during the next two to three hours postpartum consists of dark, sporadic flow that should not exceed that of a heavy period and is often much lighter. The blood should be medium to dark red transitioning to pink. It should feel thick and substantial, similar to mucus. Constant or bright red or more fluid bleeding could be a missed perineal or cervical tear, or could be from the placental site as well. Bright orange-red blood would signify a torn artery. A constant watery reddish to dark pink trickle suggests bleeding from behind clots lodged in the cervix. It could also be caused by depletion of clotting factors.
Small clots may be expelled with fundal check. After the first hour, it is normal to have clots that would fit in a rounded tablespoon and may be as large as a lemon; often they are smaller. Numerous table spoon size clots with each check are cause for concern-one or two are normal. Herbs such as white oak bark can be given to help normalize bleeding. When a woman changes position it is normal to have a rush of pooled blood but should not continue as a steady flow. It would be considered excessive to soak more than one maternity-sized pad every 15 minutes during the first hour after birth.
Normal lochia flow is to progressively diminish. There should be no foul smelling discharge. Bleeding should not increase or be continuous. Passage of more than one large clot is abnormal. If any of this happens or changes the midwife should be called immediately.