Bleeding Monitoring

Part of Midwifery and Childbirth

Assessing blood loss before, during, and after childbirth to identify hemorrhage early.

Why This Matters

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, responsible for approximately 27% of maternal deaths globally. Most of these deaths are preventable — not through surgical intervention, but through early recognition and rapid response. A birth attendant who identifies excessive bleeding early has minutes to act before the situation becomes life-threatening. A birth attendant who misses the signs may not recognize the emergency until the mother is in irreversible shock.

Blood loss assessment is genuinely difficult. People consistently underestimate blood loss visually — studies show that even experienced medical professionals underestimate blood loss by 30-50%. Blood mixes with amniotic fluid, spreads on cloth, and pools in ways that obscure the true amount. Developing objective assessment skills is therefore critical.

Normal Blood Loss

During Labor

Small amounts of blood-tinged mucus (“bloody show”) are normal throughout labor as the cervix dilates. This is not hemorrhage — it is the mucus plug being expelled.

Ruptured membranes release amniotic fluid — typically clear or slightly cloudy. Normal amniotic fluid is straw-colored to clear. Red or brown amniotic fluid suggests bleeding from the placental separation. Green amniotic fluid suggests fetal distress (meconium passage).

During Delivery

A small amount of bright red bleeding typically occurs as the baby delivers, as small vessels in the perineum and cervix stretch and tear. This is normal.

After Delivery (Third Stage — Placenta)

After the baby is born, the uterus continues contracting to deliver the placenta. As the placenta separates, a gush of blood (typically 100-200 mL) is released — this is the retroplacental blood that was behind the placenta. This is normal.

Postpartum (First 24 Hours)

After placenta delivery, bleeding (lochia) continues. Normal postpartum bleeding:

• Day 1: Moderate to heavy — like a heavy menstrual period
• Days 2-4: Decreasing, dark red to pink
• Day 5+: Light, pink to yellowish

Normal blood loss at birth: Up to 500 mL for vaginal delivery is within the range that a healthy woman with normal hemoglobin can compensate for.

Hemorrhage threshold: Blood loss exceeding 500 mL is defined as postpartum hemorrhage. Loss exceeding 1,000 mL is severe hemorrhage.

Assessing Blood Loss

Visual Estimation Calibration

Train yourself to recognize volumes:

• A standard cup (240 mL) of blood soaks approximately a 30 cm x 30 cm pad of medium-thickness cloth completely
• 500 mL fills approximately a 500 mL jar
• Blood on a surface spreads and looks like more than it is; blood soaked into cloth looks like less

The sock test: Hold a clean folded cloth pad in your hand. After delivery, if blood reaches your palm in under 5 minutes, blood loss rate is approximately 500 mL/hour — hemorrhage.

Weighing Method (Most Accurate)

If a scale is available, weigh cloth pads before and after use. 1 gram of blood equals approximately 1 mL. Record and sum. This method, used in hospitals, increases accuracy of blood loss assessment by 30-60% compared to visual estimation.

Checking the Uterus

After placenta delivery, place a hand gently on the lower abdomen. The uterus should be:

• Palpable as a firm, round mass at or below the level of the navel
• Contracting well (hardening) with stimulation — if you massage gently, it should firm up

A boggy, soft uterus that does not contract with stimulation is failing to close off the blood vessels at the placental site. This is the most common cause of postpartum hemorrhage and requires immediate uterine massage and other interventions.

Vital Sign Monitoring

Changes in vital signs confirm hemorrhage when blood loss assessment is uncertain.

Sign	Normal	Early Concern	Emergency
Pulse (resting)	60-100	100-120	Above 120
Blood pressure	Normal for her	Slightly low	Dropping rapidly
Skin color	Pink	Pale	White/gray
Mental state	Alert	Anxious	Confused, drowsy
Breathing	Normal	Slightly fast	Rapid, shallow

The pulse is the most reliable early sign. A rising pulse rate — especially above 100 — indicates the body is trying to compensate for blood loss. This occurs before the blood pressure drops. When blood pressure drops, the situation is already serious.

Feeling the pulse: Index and middle finger placed on the inner wrist below the thumb, or on the side of the neck. Count beats in 30 seconds and multiply by 2.

Timeline of Monitoring

During delivery: Watch for abnormal bleeding (placenta previa presentation, abruption). See warning signs below.

Immediately after baby born: Observe gush of blood as placenta separates. Time the third stage.

After placenta delivered:

• Check placenta for completeness (retained placental fragments are a major cause of PPH)
• Assess uterine tone — massage if boggy
• Estimate total blood loss
• Continue monitoring every 15 minutes for first hour

First hour postpartum: Most postpartum hemorrhages occur in this window. Check uterine tone, pulse, and conscious level every 15 minutes.

2-24 hours postpartum: Check every 30-60 minutes. Secondary hemorrhage (occurring hours after delivery) can occur from retained placental tissue or infection.

Warning Signs Requiring Immediate Response

Before delivery:

• Sudden, painless, bright red bleeding — may indicate placenta previa (placenta covering cervix)
• Painful, board-hard abdomen with dark bleeding — may indicate placental abruption
• Either of these before delivery: do not perform vaginal examination. Lay woman on left side, manage for shock, transport if possible.

After delivery:

• Bleeding that soaks a large pad in less than 15 minutes
• Uterus that is soft and does not firm with massage
• Pulse rising above 100 and continuing to climb
• Woman becoming pale, cold, clammy, confused
• Continued bleeding more than an hour after placenta delivery

Immediate response to PPH: See the hemorrhage article.

The Postpartum Hour

The first hour after delivery is the most dangerous hour of childbirth for the mother. Sit with her. Check her uterus every 15 minutes. Watch her face and pulse. Do not leave her alone or consider the birth complete until this hour has passed without hemorrhage. Most PPH deaths occur because attendants relaxed their vigilance after the baby was born.