The usual pattern is some combination of vaginal bleeding, abdominal or low-back pain, uterine tenderness and an abnormal fetal heart rate. No single feature is universal, and the fetal tracing may deteriorate before the maternal examination becomes dramatic. Visible blood may be dark red, but colour does not establish the diagnosis. In up to approximately 20% of cases, haemorrhage remains concealed behind the placenta. Severe abdominal or back pain, a tender or increasingly tense uterus, tachycardia, hypotension, pallor, altered mental status or falling urine output may therefore signal major blood loss even when the perineal pad is nearly dry. Uterine findings that increase concern include frequent, low-amplitude contractions; failure of the uterus to relax between contractions; persistent tenderness; and a hypertonic, rigid or board-like abdomen. A rapidly increasing fundal height can indicate an enlarging concealed haematoma. Fetal compromise is common and may be the first observable sign. Watch for recurrent late decelerations, a prolonged deceleration or bradycardia, minimal or absent variability, and a sinusoidal pattern suggesting fetal anaemia. A persistent abnormal tracing represents impaired placental exchange until proven otherwise and...