Severe anemia is associated with increased maternal and perinatal morbidity and mortality. Anemia is considered severe when hemoglobin falls below 7 gm/dl. According to WHO anemia contributes to 40% of maternal death in third world countries. In India, the prevalence of severe anemia in pregnancy is around 5 to 10%. Severe anemia can cause cardiac failure, infections and thromboembolism in the mother. There is an increased risk of preeclampsia, abruptio placentae, preterm labor and postpartum hemorrhage in women with severe anemia. In addition, the reported adverse effects on fetus are prematurity, fetal growth restriction and intrauterine death. All pregnant women with severe anemia should be admitted. Blood transfusion preferably with packed cells is recommended in symptomatic severely anemic patients irrespective of period of gestation with an aim to increase red cell mass and consequently to increase oxygen carrying capacity. Labor and immediate postpartum period are the most critical periods. In labor, intensive monitoring of vital signs should be done and prophylactic antibiotics and adequate pain relief should be given. Active management of third stage of labor is advocated to prevent PPH which if occurs, should be treated energetically with all the usual measures like concentrated oxytocin infusion and packed cell transfusion. Specific treatment for anemia is continued in post delivery period for minimum of three months and pregnancy should be avoided for a minimum of next two years.