From Essential obstetric and newborn care › Chapter 3: Bleeding during the second half of pregnancy · Médecins Sans Frontières, Current online edition, 2026
Clinical guidance on diagnosis and emergency management of placental abruption for obstetric care providers.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Midwives, obstetricians, general physicians providing obstetric care
- Evidence
- Expert consensus based on clinical experience in humanitarian settings
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF guideline section addresses abruptio placentae (placental abruption), the premature separation of a normally implanted placenta before foetal expulsion. The condition often occurs with trauma, hypertension or pre-eclampsia, and can trigger disseminated intravascular coagulation with severe secondary haemorrhage. Emergency uterine evacuation—vaginal or caesarean—is required regardless of pregnancy stage to save both mother and foetus.
Clinical diagnosis is based on sudden severe continuous abdominal pain, a hard “woody” uterus in spasm, light blackish bleeding (or heavy if clotting disorder present), and shock disproportionate to external bleeding. Foetal distress or absence of heart tones may occur depending on abruption size. Management includes immediate IV access with Ringer lactate, assessment for clotting disorders using a bedside clot test, blood transfusion as indicated, and rapid delivery ideally before clotting disorders develop.
The guideline emphasises transfer to comprehensive emergency obstetric and newborn care (CEmONC) facilities in remote areas, preparation for potential transfusion with fresh whole blood when clotting disorders are present, and avoidance of salbutamol for uterine spasm. Caesarean section becomes imperative if labour progresses too slowly, even with intrauterine foetal death.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Insert IV line (16–18G catheter) and administer Ringer lactate immediately upon diagnosis
- Perform bedside clotting assessment: 2 ml blood in dry glass tube (10 mm × 75 mm), hold at ~37°C; failure to clot after 7 minutes or soft clot breakdown suggests clotting disorder
- For moderate bleeding without clotting disorder: transfuse packed red blood cells or whole blood
- For massive bleeding and/or clotting disorder: transfuse fresh whole blood (drawn <4 hours, unrefrigerated) or packed red blood cells/whole blood combined with fresh frozen plasma
- All blood products must be screened for HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas
- Deliver quickly, ideally before onset of clotting disorders; caesarean section imperative if labour progresses too slowly, even with intrauterine foetal death
- Transfer to CEmONC facility in remote areas in anticipation of transfusion, caesarean section, hysterectomy, and post-partum haemorrhage management needs
- Do not prescribe salbutamol to relax uterine spasm
From the guideline
Verbatim
“Emergency uterine evacuation (vaginal or caesarean) is needed to save the lives of the mother and foetus, no matter what the stage of pregnancy.”
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 placental abruption as a leading cause of maternal mortality that our obstetric workforce must recognise and manage swiftly. The bedside clotting test using a simple glass tube is particularly valuable for Georgia's rural maternity facilities where laboratory coagulation studies are unavailable, and I would stress to Georgian obstetricians the imperative to deliver quickly—even with intrauterine foetal death—before disseminated intravascular coagulation develops. The critical implementation challenge for our Caucasus region is ensuring 24-hour access to screened fresh whole blood or fresh frozen plasma at referral centres, alongside functioning cold-chain-free transport for fresh whole blood, which requires coordination between our national blood service and regional perinatal centres. MSF's emphasis on accompanying the transferred woman with potential family blood donors is a pragmatic approach suited to our healthcare context where directed donation remains common.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Placental abruption is a universal obstetric emergency relevant across Georgia and the South Caucasus. Implementation requires functional referral networks linking primary obstetric facilities to CEmONC centres capable of emergency caesarean section, blood transfusion services with adequate screening, and reliable ambulance transport. Georgian national maternal health programmes should ensure bedside clotting assessment capacity at all delivery facilities, access to fresh whole blood or fresh frozen plasma at referral centres, and training of midwives and obstetricians in rapid recognition and stabilisation. Blood safety protocols already established for hepatitis and HIV screening align well with MSF recommendations. The emphasis on early transfer from remote areas is particularly relevant for mountainous regions of Georgia, Armenia and Azerbaijan where transport times may be prolonged.
Questions this guideline answers
Quick answers
How do I perform a bedside test for clotting disorders in placental abruption?
Take 2 ml of blood into a dry, clean glass tube (approximately 10 mm × 75 mm). Hold the tube in a closed fist to keep it warm at approximately 37°C. After 4 minutes, tip the tube slowly to see if a clot is forming, then tip it again every minute until the blood clots and the tube can be turned upside down. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests a clotting disorder.
What type of blood product should I give for placental abruption with clotting disorder?
For massive bleeding and/or clotting disorder, transfuse fresh whole blood (drawn less than 4 hours ago and unrefrigerated) or packed red blood cells or whole blood combined with fresh frozen plasma. For moderate bleeding without clotting disorder, packed red blood cells or whole blood is sufficient. All blood products must be screened for HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas.
Should I perform caesarean section if the foetus has already died?
Yes. Caesarean section becomes imperative if labour progresses too slowly, even in the event of intrauterine foetal death. Delivery should be done quickly, ideally before the onset of clotting disorders, to save the mother's life.
Can I give medication to relax the uterine spasm in placental abruption?
No. Do not prescribe salbutamol to relax the uterine spasm in abruptio placentae. Emergency delivery is the definitive management, not uterine relaxation.
Related on GMJ
Interconnected resources
Dictionary of Public Health
GMJ News coverage
Quality & accreditation
- ASF Laboratory — Standard 1 — Governance & Document Control
- ASF Laboratory — Standard 6 — Pre-Examination: Specimen Pathway
- ASF Laboratory — Standard 7 — Examination: Process & Safety
- ASF Laboratory — Standard 8 — Post-Examination: Reporting & Critical Values
- ASF Hospital — Standard 5 — Safety & Emergency Preparedness
- ASF Hospital — Standard 11 — Critical Care
- ASF Medical Transport — Standard 6 — Emergency Response During Transport
- ASF Hospital — Standard 4 — Care & Treatment
- ASF Hospital — Standard 6 — Aftercare & Follow-up
Same guideline
- 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
- Monitoring complicated pregnancies — MSF Essential obstetric and newborn careChapter 1: Diagnosing and monitoring pregnancy
- Antenatal consultations — MSF Essential obstetric and newborn careChapter 1: Diagnosing and monitoring pregnancy
Other guidelines on this topic
- Placenta praevia — Essential obstetric and newborn care — MSF Essential obstetric and newborn care
- Molar pregnancy (hydatidiform mole) — MSF Essential obstetric and newborn care
- Ectopic pregnancy — MSF Essential obstetric and newborn care
- Abortion — MSF Essential obstetric and newborn care
- Monitoring complicated pregnancies — MSF Essential obstetric and newborn care
- Issuer
- Médecins Sans Frontières
- Guideline
- Essential obstetric and newborn care
- Chapter
- Chapter 3: Bleeding during the second half of pregnancy
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Languages
- English, French
- Scope
- Emergency diagnosis and management of abruptio placentae (placental abruption) in resource-limited settings
- Audience
- Midwives, obstetricians, general physicians providing obstetric care
- Evidence
- Expert consensus based on clinical experience in humanitarian settings
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Abruptio placentae. In: Essential obstetric and newborn care [Internet]. Paris: MSF; 2026 Oct 14 [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/en/viewport/ONC/english/abruptio-placentae-23537163.htmlGMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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