Bleeding & Staining in Pregnancy - Nishmat Yoatzot Halacha

Introduction

Vaginal bleeding and spotting sometimes occur during pregnancy. Such bleeding should always be discussed promptly with a medical provider, but is not necessarily cause for alarm. There are many benign causes of bleeding, especially in early pregnancy.

In some cases, bleeding during pregnancy may be a sign of preterm labor or miscarriage. For a discussion of miscarriage and pregnancy loss, see here. For a discussion of preterm labor, see here.

Niddah in Pregnancy

Uterine or placental bleeding during pregnancy can cause a woman to become niddah. When this happens, the standard process of becoming tehorah applies. Sometimes, a woman may also need to observe vesatot.

Since staining is common during pregnancy, a woman is advised to take precautions to avoid becoming niddah from possible staining, as she would at other times. When asking a halachic question about a stain, she should mention that she is pregnant, which might affect the halachic ruling that she receives.

For a discussion of bleeding, niddah, and childbirth, see here.

Heavy Bleeding in Pregnancy

In some scenarios, a woman may experience heavier bleeding in pregnancy.

Bleeding that is like a period or is accompanied by stomach cramps should be evaluated by a woman’s medical provider within one or two days.
Bleeding that is heavier than a period (soaking through more than a pad an hour or passing blood clots) or is accompanied by dizziness, weakness, or fever, warrants immediate medical attention. In this case a woman should first try to reach her healthcare provider for guidance about whether she can be seen in an office or should go straight to an emergency care setting. If she cannot get in touch with her healthcare provider, then she should go to an obstetric/gynecological urgent care clinic (in Israel, a moked nashim) or a hospital with a labor and delivery unit. If that is unavailable, she should go to an emergency room.

Heavy bleeding during pregnancy will usually make a woman niddah.

First Trimester Spotting

Approximately 15-25% of women bleed or spot during the first twelve weeks of pregnancy. Discussion of first trimester spotting can often wait until regular office hours, rather than requiring immediate attention in an emergency setting.

There are a few common causes of light bleeding or spotting in the first trimester:

Implantation bleeding can occur when the fertilized egg implants in the uterus. This typically happens 10-14 days after fertilization, often a few days before a woman is expecting her period, and may last 1-2 days. About a quarter of pregnant women experience implantation bleeding.
Hormonal changes involved in early pregnancy may sometimes cause spotting.
Infections, such as a urinary tract infection or a vaginal yeast infection, may cause light bleeding as well, and are treated with medication.

Bleeding from these causes is often light, so that a woman can rely on the leniencies of stains to avoid becoming niddah. Bleeding that can be attributed to a non-uterine source, as from an infection, would not make a woman niddah regardless.

Cervical Bleeding

Cervical changes in pregnancy can lead to the cervix becoming more friable (likely to bleed, sometimes also called cervical sensitivity), so that even mild irritation can trigger vaginal staining or spotting. This spotting can occur following sexual intercourse, following medical exams such as a Pap smear, pelvic exam, or transvaginal ultrasound, or following a bedikah.

We recommend that a woman ask her doctor at the time of any medical exam or procedure whether it is likely to cause bleeding, and what the likely source of that bleeding would be. If the doctor believes bleeding following the procedure would likely be due to a wound or to cervical irritation, the woman may consider such bleeding dam makkah, bleeding from a wound, which would not make her niddah.

Cervical bleeding is generally light enough that a woman can take precautions against staining (wearing colored underwear or a disposable pantiliner and being careful with toilet paper). In this way, it is often possible to avoid halachic uncertainty.

If a woman’s cervix is prone to bleeding and she needs to count seven clean days, then her bedikot may need to be modified so that they do not cause bleeding. In this situation, a woman is advised to reduce the number of bedikot to just the hefsek taharah and one bedikah each on days one and seven of the clean days, and preferably one on an intermediate day. In addition, she should do the bedikot less deeply, only up to her first knuckle, so as to avoid irritating her cervix. Learn more about increasing comfort when performing bedikot here.

If a woman finds blood on a bedikah that she suspects may be from her cervix, she should ask a halachic question.

Subchorionic Hematoma

A subchorionic hematoma occurs when blood accumulates between the wall of the uterus and the chorionic membrane, which is the outermost layer of the amniotic sac. While some women experience no symptoms, many women experience vaginal bleeding.

Medical Background

Subchorionic hematoma is one of the most common causes of vaginal bleeding in early pregnancy. It is most likely to be diagnosed at 10-20 weeks of pregnancy, usually by ultrasound imaging (sometimes transvaginal ultrasound), and it may be monitored with multiple ultrasounds over time.

Subchorionic hematomas often resolve on their own over the course of a number of weeks. However, various factors such as medical history and gestational age may lead a medical provider to suggest particular treatment plans such as rest and monitoring.

Bleeding from a subchorionic hematoma is halachically considered bleeding that can cause niddah. Therefore, a flow of blood would make a woman niddah, while lighter bleeding would be evaluated according to the laws of stains.

Placenta Previa

Placenta previa is a condition where the placenta partially or completely covers the cervix during pregnancy.

Medical Background

Placenta previa occurs in about 0.5% of pregnancies and can happen as early as the beginning of the second trimester. It is diagnosed by ultrasound.

If placenta previa is discovered during the second trimester, then it may resolve prior to childbirth, as the uterus grows. But when it continues into late pregnancy, it may not resolve. In such cases, a C-section is considered the safest way to deliver a baby, as there is significant risk of severe bleeding if the baby is born vaginally when the placenta covers the opening of the cervix.

Placenta previa can cause vaginal bleeding from the placenta, which is halachically considered bleeding that can cause niddah. Therefore, a flow of blood would make a woman niddah, while lighter bleeding would be evaluated according to the laws of stains.

In many cases, a woman with placenta previa will be medically forbidden from having anything enter her vagina, including having sexual intercourse and some types of medical exams. She may be instructed to rest from physical activities or exercise.

A woman who needs to count seven clean days should discuss with her physician whether it is safe for her to do internal bedikot. If she is permitted to do bedikot, she should perform the minimum number (hefsek taharah, one bedikah each on days one and seven of the clean days, and preferably one on an intermediate day). These bedikot should be shallow, only up to the first knuckle. If she is medically prohibited from any sort of internal check, she should reach out to a halachic advisor for individualized counsel.

Even if sexual intercourse is medically forbidden, it may be permissible for the couple to modify relations, in consultation with their treatment team and a halachic authority. The precise recommendation for the couple would depend on their specific situation.

Placental Abruption

Placental abruption refers to a rare condition where the placenta partially or completely detaches from the uterus during pregnancy. Placental abruption occurs rarely, most often later in pregnancy and due to a specific trigger, such as severe high blood pressure or physical trauma. Often, bleeding from a placental abruption is accompanied by uterine contractions, abdominal pain, back pain, and decreased fetal movement.

A placental abruption can pose a significant risk to the mother and fetus, so any heavier bleeding in the second half of pregnancy warrants immediate medical evaluation. This should typically be done in a hospital setting, in a labor and delivery unit or in an emergency room, although a woman’s healthcare provider can guide her to the best environment for care. In some cases, close monitoring of the fetal heart rate, ultrasounds, and blood tests will be sufficient, while more acute cases may necessitate an emergency delivery. A partial or chronic abruption may lead to longer term, lighter bleeding, which can be monitored closely over time.

After the women’s condition has been shown to be stable, then her halachic status can be evaluated. Bleeding from placental abruption is halachically considered bleeding that can cause niddah. Therefore, a flow of blood would make a woman niddah, while lighter bleeding would be evaluated according to the laws of stains.

Cerclage

Cervical insufficiency, (sometimes called “incompetent cervix”), occurs when a woman’s cervix softens, effaces, or dilates too early in the pregnancy. This puts the fetus at risk for preterm birth or pregnancy loss. It occurs in about 1% of pregnancies.

Sometimes cervical insufficiency is sometimes managed with medications and sometimes with a cerclage, a procedure that involves stitching the cervix closed.

Bleeding following the cerclage procedure originates from the cervix. It would be considered dam makkah (blood from a wound), and thus would not make a woman niddah.

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