What is the next best step in management for a 39-week pregnant woman with severe abdominal pain, heavy vaginal bleeding, hypotension, and a dilated cervix?

Emergency Cesarean Section

This patient requires immediate emergency cesarean section. The combination of sudden severe abdominal pain, heavy vaginal bleeding, and hypotension (BP 90/60 mmHg) at 39 weeks strongly indicates placental abruption with hemodynamic compromise—a life-threatening emergency requiring urgent delivery regardless of cervical dilation or normal CTG findings 1.

Clinical Reasoning

The clinical presentation is diagnostic of severe placental abruption with maternal shock:

• Sudden severe abdominal pain with heavy vaginal bleeding in late pregnancy is the classic triad for placental abruption 1
• Hypotension (90/60 mmHg) indicates significant blood loss and hemodynamic instability requiring immediate intervention 1
• A normal CTG at this moment is falsely reassuring—fetal status deteriorates rapidly in placental abruption as oxygenated blood is shunted away from the uterus 2
• The 4 cm cervical dilation is irrelevant; waiting for vaginal delivery would be catastrophic given the maternal instability 1

Why other options are incorrect:

• Amniotomy (Option A) would waste critical time and worsen bleeding without addressing the underlying emergency 1
• Observation (Option B) is contraindicated with hemodynamic instability and active hemorrhage 1
• Oxytocin (Option D) is used for labor augmentation or postpartum hemorrhage, not for managing placental abruption with shock 1

Immediate Management Algorithm

Activate emergency protocols simultaneously:

• Call for immediate cesarean section and notify anesthesiology, neonatology, and intensive care 2, 1
• Activate massive transfusion protocol immediately 1, 3
• Establish large-bore IV access (two lines) and begin aggressive fluid resuscitation 1
• Order blood products stat: packed red blood cells, fresh frozen plasma, and platelets in 1:1:1 ratio 1, 3

Proceed directly to cesarean section without delay:

• Do not wait for laboratory results—treat based on clinical presentation 1
• Decision-to-delivery interval should be within 25 minutes for optimal maternal and neonatal outcomes 4
• Delivery by immediate cesarean section improves long-term neonatal neurologic outcome in sustained fetal compromise 4

Critical Intraoperative Considerations

Anticipate severe coagulopathy:

• Disseminated intravascular coagulation (DIC) occurs in over 80% of severe abruption cases 1, 3
• Continue transfusing blood products in fixed 1:1:1 ratio throughout surgery 1, 3
• Administer tranexamic acid 1 g IV over 10 minutes if hyperfibrinolysis is suspected 3

Maintain physiologic homeostasis:

• Keep patient warm (temperature >36°C) as clotting factors function poorly with hypothermia 1, 3
• Avoid acidosis which impairs coagulation 1
• Administer oxygen to maintain adequate maternal and fetal oxygenation 3

Prepare for potential complications:

• Have uterotonic agents ready (oxytocin, methylergonovine, carboprost, misoprostol) for postpartum hemorrhage 1, 3
• Be prepared for potential hysterectomy if bleeding is uncontrollable after delivery 1
• Use slow IV oxytocin (<2 U/min) to prevent postpartum hemorrhage while avoiding systemic hypotension 1

Common Pitfalls to Avoid

Do not use crystalloid alone for resuscitation:

• Crystalloid-only resuscitation causes dilutional coagulopathy and volume overload 1
• Use blood products for volume replacement in hemorrhagic shock 1

Avoid methylergonovine in this hypotensive patient:

• Methylergonovine causes vasoconstriction and can worsen hypotension 1, 3
• Reserve for refractory uterine atony after hemodynamic stabilization 3

Do not delay for "optimization":

• Hemodynamic instability with ongoing hemorrhage demands immediate delivery 1
• Every minute of delay increases maternal and fetal mortality risk 4

Postoperative Management

Intensive monitoring is mandatory:

• Continue ICU-level monitoring for at least 24 hours postoperatively due to hemodynamic changes and fluid shifts 1, 3
• Monitor for ongoing coagulopathy with serial coagulation studies 1
• Watch for postpartum hemorrhage and maintain low threshold for re-exploration if bleeding continues 1, 3
• Monitor for complications including renal failure, liver failure, and Sheehan syndrome 3