Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care — Médecins Sans Frontières 2026

MSFClinical guideline (chapter)Current edition

From Essential obstetric and newborn care › Chapter 3: Bleeding during the second half of pregnancy · Médecins Sans Frontières, Current online edition, 2026

Diagnostic table distinguishing placenta praevia, abruptio placentae and uterine rupture for obstetric clinicians.

In one sentenceDifferentiate life-threatening second-half pregnancy bleeding by pattern: placenta praevia (painless, bright red, soft uterus, proportional shock); abruptio placentae (painful, woody uterus, disproportionate shock); uterine rupture (retracted uterus, disproportionate shock).

Issuer: Médecins Sans Frontières
Edition: Current online edition, 2026
Audience: Obstetricians, midwives, emergency clinicians in resource-limited settings
Evidence: Expert consensus based on MSF field experience
Reviewed: 23 Oct 2026 · GMJ

Read the original on MSF Whole guideline (PDF)

Summary by GMJ Guidelines Desk•Reviewed by Prof. Giorgi Pkhakadze, MD, MPH, PhD•Record updated 23 Oct 2026•Next check Apr 2027

What this guideline says

GMJ summary

This section of the MSF Essential Obstetric and Newborn Care guideline provides a comprehensive differential diagnosis table for the three major causes of life-threatening bleeding in the second half of pregnancy: placenta praevia, abruptio placentae and uterine rupture. The diagnostic approach is structured around history, clinical signs (bleeding characteristics, haemorrhagic shock presentation, uterine findings), vaginal examination findings and foetal heart tones.

The guideline emphasises distinctive clinical patterns: placenta praevia presents with painless bright red bleeding, a soft uterus and visible blood loss proportional to shock; abruptio placentae with severe constant pain, a ‘woody uterus’ and shock out of proportion to visible bleeding; and uterine rupture with variable bleeding, shock disproportionate to visible blood loss and sometimes a palpable foetus under the abdominal skin. Key historical risk factors include previous caesarean section for placenta praevia and uterine rupture, pre-eclampsia and trauma for abruptio placentae, and grand multiparity (≥5 births) and overuse of uterotonics for rupture.

The central message is systematic differentiation of these three emergencies through pattern recognition of bleeding characteristics, uterine findings and the relationship between visible blood loss and haemorrhagic shock, enabling rapid appropriate management in resource-limited obstetric settings.

Key points

For clinicians — doses and thresholds as stated in the guideline

Placenta praevia presents with painless bright red bleeding, often after vaginal examination or intercourse, with a soft uterus and shock proportional to visible blood loss
Abruptio placentae presents with severe constant uterine and lower back pain, a painful 'woody uterus' on palpation and shock out of proportion to visible bleeding due to concealed retroplacental or intra-abdominal haemorrhage
Uterine rupture presents with variable bleeding, shock disproportionate to visible blood loss and sometimes a retracted uterus with the foetus palpable under the abdominal skin
Grand multiparity (≥5 births) is a specific risk factor for uterine rupture, along with prolonged labour, dystocia, previous caesarean section and overuse of uterotonics
Vaginal examination should be performed only once and very cautiously in suspected placenta praevia if ultrasound is unavailable; it is not helpful for diagnosing abruptio placentae
Foetal heart tones remain normal in placenta praevia unless maternal shock develops, but are absent or weak in both abruptio placentae and uterine rupture
In abruptio placentae, foetal position is difficult to determine due to the hard uterus and haematoma
Previous caesarean section is a risk factor for both placenta praevia and uterine rupture; pre-eclampsia and trauma are associated with abruptio placentae

Table 3.1 – Aetiological diagnosis of bleeding during second half of pregnancy

Table extracted from the guideline

Feature	Placenta praevia	Abruptio placentae	Uterine rupture
Bleeding characteristics	Bright red blood; painless, spontaneous or after vaginal exam/intercourse	Light blackish blood or sudden bright red; with severe constant uterine and lower back pain	Variable
Shock vs visible bleeding	Proportional to visible blood loss	Out of proportion (concealed intra-abdominal/retroplacental bleeding)	Out of proportion (concealed intra-abdominal bleeding)
Uterus	Soft; intermittent contractions if present; foetus high and mobile	Painful continuous contraction ('woody uterus'); foetal position hard to determine	Sometimes retracted into ball; foetus may be palpable under skin
Vaginal examination	Soft, spongy placenta (perform only one cautious exam if no ultrasound)	Cervix often closed; exam not helpful	—
Foetal heart tones	Normal unless maternal shock	Absent or weak	Absent or weak
Key risk factors	Twin pregnancy, caesarean section, previous bleeding	Pre-eclampsia, primipara, trauma	Long labour, primipara, dystocia, grand multipara (≥5), caesarean section, overuse of uterotonic

Source: Médecins Sans Frontières, Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care. Reproduced in summary form.

From the guideline

Verbatim

“Perform only one, very cautious, vaginal exam if ultrasound is not available.”

— Médecins Sans Frontières, Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care, Table 3.1, Placenta praevia vaginal exam (2026)

Editor’s perspective

Why this matters for Georgia and the region

Prof. Giorgi Pkhakadze, MD, MPH, PhD

Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration

As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise this MSF diagnostic framework addresses a persistent gap in Georgian obstetric emergency care. Georgia's rising caesarean section rate—now exceeding 40% in urban centres—has expanded the population vulnerable to placenta praevia and uterine rupture, yet our 2019 maternal mortality review identified delayed recognition of concealed haemorrhage as a recurrent theme in preventable deaths. I would stress to Georgian obstetricians the critical teaching that shock disproportionate to visible bleeding demands immediate laparotomy preparation, not expectant observation. The practical caveat for implementation is that whilst this table provides excellent pattern recognition guidance, its effectiveness depends on clinicians performing serial assessments and having immediate surgical capability; in our regional facilities where transfer times to operative capacity exceed one hour, we must ensure ambulance protocols include large-bore intravenous access and aggressive resuscitation during transport, as these women deteriorate rapidly.

ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026

Applicability

Georgia and the South Caucasus

Second-half pregnancy haemorrhage remains a leading cause of maternal mortality in Georgia and throughout the South Caucasus, where caesarean section rates have risen substantially in recent decades, increasing the population at risk for placenta praevia and uterine rupture. Georgian maternity services would benefit from standardised application of this differential diagnostic framework, particularly in regional facilities where ultrasound may be limited and clinical pattern recognition becomes essential. National maternal mortality review programmes should verify that clinicians consistently recognise the critical distinction between visible blood loss and haemorrhagic shock severity, as failure to identify concealed haemorrhage in abruptio placentae and uterine rupture accounts for preventable deaths. The grand multiparity threshold (≥5 births) for rupture risk remains relevant in rural areas of Georgia, Armenia and Azerbaijan, whilst overuse of uterotonics requires attention in settings with protocolised augmentation practices.

Questions this guideline answers

Quick answers

Why is shock out of proportion to visible bleeding a critical sign?

In abruptio placentae and uterine rupture, massive bleeding can occur into the retroplacental space or abdominal cavity, so the woman may be in profound shock with relatively little external bleeding. This concealed haemorrhage requires immediate recognition and intervention.

When should vaginal examination be performed in second-half pregnancy bleeding?

In suspected placenta praevia, perform only one very cautious vaginal examination and only if ultrasound is unavailable, as examination can provoke severe haemorrhage. Vaginal examination is not helpful for diagnosing abruptio placentae where the cervix is often closed.

What is the 'woody uterus' and why does it matter?

A 'woody uterus' refers to the painful, continuously contracted, hard uterus characteristic of abruptio placentae. This constant contraction (rather than intermittent contractions) combined with severe pain distinguishes abruptio placentae from placenta praevia and guides urgent management.

What defines grand multiparity as a risk factor for uterine rupture?

Grand multiparity is defined as five or more previous births (≥5). Combined with prolonged labour, dystocia or overuse of uterotonics, this substantially increases uterine rupture risk, particularly in women with previous caesarean section.

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Same guideline

Uterine rupture — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Abruptio placentae — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Placenta praevia — Essential obstetric and newborn care — MSF Essential obstetric and newborn careChapter 3: Bleeding during the second half of pregnancy
Molar pregnancy (hydatidiform mole) — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy
Ectopic pregnancy — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy
Abortion — MSF Essential obstetric and newborn careChapter 2: Bleeding during the first half of pregnancy

Diagnosis of bleeding during the second half of pregnancy (summary) — MSF Essential obstetric and newborn care

What this guideline says

Key points

Table 3.1 – Aetiological diagnosis of bleeding during second half of pregnancy

From the guideline