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Resuscitate significant haemorrhage while identifying its cause; pregnancy, timing in relation to birth, and the condition of the uterus determine the definitive treatment. A vaginal loss need not originate in the uterus, and the visible volume may underestimate concealed bleeding. Assess consciousness, pulse, blood pressure and ongoing loss; serious bleeding calls for urgent obstetric or gynaecological help, intravenous access, blood sampling and access to blood transfusion. Investigations must not delay control of a life-threatening source.

Outside pregnancy, distinguish excessive menstrual bleeding from irregular, postcoital or postmenopausal bleeding. Causes include uterine fibroids, endometrial polyps, disturbed ovulation, coagulopathy and cancer. A speculum examination may reveal a cervical or vaginal source. History, examination, blood count, and appropriately selected ultrasonography, hysteroscopy or tissue sampling establish the cause. Current treatment for heavy menstrual bleeding may use tranexamic acid or hormonal treatment where suitable; removal of a polyp or treatment of a uterine fibroid addresses a structural cause. Suspected cancer needs a diagnostic and specialist pathway, rather than repeated empirical suppression of bleeding.^[ref]

In early pregnancy, consider threatened or established miscarriage and retained pregnancy tissue. Establish the location and viability of the pregnancy with ultrasonography and, where appropriate, serial human chorionic gonadotropin measurements. Stable cases permit a choice among expectant, medical or surgical management according to the diagnosis and circumstances; heavy ongoing bleeding or instability changes the urgency. An ectopic pregnancy may cause vaginal bleeding together with dangerous internal haemorrhage, even though the bleeding pregnancy is outside the uterus. Pain, collapse or instability therefore demands urgent assessment rather than an assumption that all bleeding represents a harmless menstrual or uterine event.^[ref]

Later pregnancy requires distinction between placenta praevia, placental abruption and other genital-tract sources. Placenta praevia may cause heavy painless bleeding; placental abruption may involve pain, a tense uterus and concealed loss. Stabilise the mother, assess the fetus and locate the placenta by ultrasonography. Avoid a digital examination that could disturb a covering placenta before placenta praevia has been excluded. The timing and route of birth depend on severity, placental position, gestation and maternal and fetal condition. A placenta covering the cervical opening usually requires Caesarean section; the diagnosis is not an instruction to apply a vaginal plug and wait through major continuing loss.^[ref][ref]

During and after birth, organise postpartum haemorrhage causes as poor uterine contraction, retained tissue, genital-tract trauma and defective clotting. A uterine rupture is a surgical emergency; a contracting uterus does not exclude a traumatic source. For uterine atony, uterine massage and a suitable uterotonic accompany resuscitation; emptying a distended urinary bladder may help contraction. Examine for tears and repair them; deal with retained placental tissue with skilled obstetric care, and do not forcibly detach an abnormally adherent placenta. Correct relevant coagulopathy and use blood products as indicated. Current early treatment includes tranexamic acid within the recommended interval. Continuing bleeding may require balloon tamponade or surgery; a uterine inversion requires urgent skilled replacement and resuscitation, not treatment as simple atony. Delayed bleeding after birth suggests retained tissue or infection and requires renewed assessment.^[ref]

An 1864 practitioner could recognise miscarriage, abnormal placental attachment or separation, retained placenta, atony and traumatic bleeding, and could attempt pressure, manual measures and delivery appropriate to the cause. Cold applications and vaginal plugging appeared in period practice, but were not interchangeable cures. Contemporary obstetric discussion already distinguished several mechanisms of bleeding.^[ref] In particular, a uterotonic cannot repair a tear, and obstructing the outflow does not establish that internal haemorrhage has ceased. The modern diagnostic and resuscitative measures above explain why treatment must follow the mechanism rather than the symptom alone.

Classify the bleeding by anatomical source and by its relation to pregnancy, childbirth and menstruation; treatment must address that source. The amount of visible genital haemorrhage does not measure all the loss: a ruptured ectopic pregnancy or concealed placental abruption can cause major internal blood loss. Initial assessment of severe bleeding concerns the circulation, anaemia and the need for resuscitation while the cause is established. Bleeding from the urethra or rectum must first be distinguished from genital bleeding.

Local sources outside the uterine cavity. The vulva and vagina may bleed from lacerations after childbirth or other trauma, an inflamed lesion, a foreign body, a vascular lesion or cancer. Examination localizes the loss; treatment is local compression and repair of a significant laceration, removal of the foreign body, cause-directed treatment of infection, or specialist management of the lesion. A cervical polyp, cervical ectropion, cervicitis or cervical cancer can cause bleeding from the cervix, often noticed between periods or after intercourse. A suitable polyp can be removed and examined; inflammation requires its cause to be established, while a suspicious lesion requires diagnostic assessment rather than indiscriminate cauterization. After menopause, thin, fragile vulvovaginal tissues can also bleed; this does not remove the need to investigate a suspicious lesion. These are different conditions, not one disease called “uterine haemorrhage”. ^[ref]

Bleeding from the endometrium. Heavy or irregular menstruation may accompany ovulatory dysfunction, uterine fibroids, endometrial polyps, adenomyosis, a coagulopathy, medication effects or endometrial cancer. Modern assessment includes the menstrual and drug history, a full blood count, and selected ultrasound, hysteroscopy or tissue sampling according to the suspected cause. Where appropriate, menstrual bleeding can be reduced with tranexamic acid or hormonal treatment; an intracavitary polyp or uterine fibroid may instead need targeted removal. Persistent postmenopausal bleeding must not simply be treated as an ordinary period. ^[ref]

Early pregnancy. A miscarriage may bleed while pregnancy tissue separates or remains in the uterus. In a stable, confirmed case, expectant, medical or surgical management may be appropriate; heavy continuing loss or infection changes the urgency. Ectopic pregnancy requires a separate plan: selected stable cases may be monitored or treated medically, but rupture with haemorrhagic collapse requires urgent operative control, not treatment of the vagina as though it were the principal source. A hydatidiform mole is another pregnancy-related source of abnormal bleeding; current management includes removal by suction evacuation and subsequent human chorionic gonadotropin surveillance for persistent disease. ^{[ref] [ref] [ref]}

Later pregnancy and labour. Placenta praevia commonly produces relatively painless bleeding, whereas placental abruption more often causes pain and uterine tenderness; these are useful patterns, not infallible rules. Management depends on the mother's circulation, the fetus, the placental lesion and the stage of pregnancy, with urgent delivery when required. A blind digital cervical examination is inappropriate before a possible placenta praevia has been excluded. Ruptured vasa praevia causes fetal rather than maternal bleeding and demands a different interpretation. A small blood-stained mucous “show” during cervical change is not equivalent to these pathological losses. ^{[ref] [ref]}

After delivery. The principal categories are failure of uterine contraction, retained placental tissue, trauma and disordered coagulation. For uterine atony, the aim is to restore contraction with uterine massage and an appropriate uterotonic. Retained tissue, a genital laceration or uterine inversion requires correction of that particular cause; a coagulopathy requires haemostatic support. With placenta accreta spectrum, attempted forcible separation can provoke severe haemorrhage. Current care combines resuscitation with cause-directed measures, and can require tranexamic acid, balloon tamponade, embolisation or surgery when initial measures fail. Later postpartum bleeding also raises retained tissue and endometritis. ^[ref]

The 1865 distinction. An answer of the period could distinguish menstrual loss, local lesions, pregnancy-related haemorrhage and post-delivery failure of contraction through the history and physical examination. Compression, local plugging, removal of an accessible lesion and obstetric intervention were among the available approaches; their use was debated. The 1864 discussion of placenta praevia documents such disagreement. Modern imaging, blood banking, the present drug regimens and current operative pathways must not be attributed to that practice. Nor should historical astringents or depletion be substituted for identifying the source. ^[ref]

The source's “last half” includes a wider interval than the definition of antepartum haemorrhage from 24 weeks used by the cited British guideline. No diagnosis follows from intermittency alone.

In placenta praevia, the placenta covers the internal opening of the cervix. Development of the lower uterine segment and opening of the cervix disturb attachment at the placental margin, exposing maternal vessels. Bleeding is often painless and recurrent and can become severe after apparently minor episodes. In placental abruption, a normally situated placenta separates prematurely. Bleeding into the placental bed reduces exchange with the fetus; pain, tenderness and increased tone of the uterus are suggestive, but their absence does not exclude it. Some blood can remain concealed, making visible vaginal loss a poor measure of total loss.

In vasa praevia, vulnerable fetal vessels run through the membranes near the internal cervical opening. Rupture, particularly when the membranes break, can cause rapid fetal blood loss while the mother remains comparatively stable. Other causes include a blood-stained cervical “show” in labour, cervical ectropion, a cervical polyp, local infection, trauma, and occasionally a tumour of the cervix or vagina. These must be distinguished from placental bleeding rather than presumed harmless from a small volume alone.^[ref]

For an 1867 answer, the classic contrast is between “unavoidable” haemorrhage from placenta praevia and “accidental” haemorrhage from premature separation of a normally implanted placenta. The adjectives are historical classifications, not claims that either outcome is inevitable or that every placental abruption follows an accident. Period management sought to conserve maternal strength when slight bleeding settled, then accomplish delivery when recurrent loss or labour made waiting dangerous. For partial placenta praevia, rupture of membranes was used in suitable labour to bring the presenting part down against the bleeding region. For more extensive placenta praevia, vaginal plugging, dilation and turning to deliver the child were debated and used. Contemporary discussion shows disagreement about how long it was safe to temporise: an 1864 report describes both advocates of early delivery and arguments about plugs, dilating bags and turning.^[ref]

Those measures belong to the history of managing haemorrhage before modern operative safety, imaging and transfusion services. They must not be carried over as a modern algorithm: a vaginal plug can conceal continuing loss; attempted separation of the placenta or turning through placenta praevia can aggravate bleeding and endanger the fetus.

In current practice, the initial response to significant bleeding is hospital assessment with maternal resuscitation, monitoring, intravenous access and blood tests, with blood products available according to severity. Determine placental position by ultrasonography, assess the fetus according to gestational age, and look for local causes with appropriate examination. Do not perform a digital vaginal examination while placenta praevia remains a possible explanation until it has been excluded by ultrasonography. A carefully performed speculum examination and a skilled transvaginal ultrasound are different procedures; the latter is a safe, useful way to locate the placental edge. A normal ultrasound does not exclude placental abruption.^[ref]

During the later preterm months, a stable mother and fetus after bleeding has stopped may be managed expectantly under specialist supervision. The plan includes surveillance, correction of anaemia, readiness to return urgently, and individual decisions about admission and timing of birth. Corticosteroids are considered when preterm delivery is likely; they do not treat the bleeding. Ongoing major haemorrhage, maternal instability or serious fetal compromise can require delivery regardless of immaturity. This is not a policy of waiting for full term at any cost.

At or near term, the cause determines the route. Persistent placenta praevia covering the internal cervical opening requires caesarean birth; repeated bleeding may require earlier delivery. Current 2026 guidance individualises timing for uncomplicated low-lying placenta or placenta praevia and advises considering planned birth no later than 37 weeks and 6 days. A low-lying placental edge that does not cover the opening requires individual assessment of whether vaginal birth is appropriate. These timings are present guidance, not an 1867 rule.^[ref]

With placental abruption, expedite delivery when indicated by maternal or fetal condition; caesarean birth is often required for a live compromised fetus when vaginal delivery is not imminent, while vaginal delivery may be appropriate in other circumstances. A local cervical lesion requires cause-specific management. Suspected rupture of vasa praevia is an emergency for urgent caesarean birth and neonatal resuscitation; an antenatally detected vasa praevia calls for planned birth before labour or membrane rupture.^[ref] The central distinction is therefore safe observation of a settled, stable preterm episode versus timely delivery for an ongoing hazard, not a single remedy for every late-pregnancy bleed.