What is the next step for a pregnant patient in labor with severe bleeding and a normal Cardiotocography (CTG)?

Emergency Cesarean Section for Severe Bleeding in Labor

A pregnant patient in labor presenting with severe bleeding requires immediate emergency cesarean section, regardless of a normal CTG, as this clinical picture suggests placental abruption with hemodynamic compromise—a life-threatening emergency where fetal status can deteriorate rapidly despite initially reassuring fetal monitoring. 1

Immediate Management Algorithm

Activate Emergency Protocols Simultaneously

• Call for immediate cesarean section with a decision-to-delivery interval target of within 25 minutes for optimal maternal and neonatal outcomes 1
• Notify anesthesiology, neonatology, and intensive care teams immediately 1
• Establish two large-bore (14-16 gauge) intravenous lines for aggressive resuscitation 2

Initiate Massive Transfusion Protocol

• Begin blood product transfusion using packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio for hemostatic resuscitation in obstetric hemorrhage with hemodynamic compromise 1
• Order blood products immediately without waiting for laboratory results—treat based on clinical presentation 1
• Avoid crystalloid-only resuscitation to prevent dilutional coagulopathy and volume overload 1

Critical Pre-Operative Measures

• Administer tranexamic acid 1 g IV immediately, as it reduces total blood loss in severe postpartum hemorrhage (>1000 mL after cesarean delivery) 3
• Position patient in left lateral decubitus to optimize venous return and cardiac output, avoiding aortocaval compression 1
• Maintain maternal oxygen saturation >95% to ensure adequate fetal oxygenation 2

Why Not the Other Options?

Amniotomy (Option B) and Amniotomy with Oxytocin (Option C) Are Contraindicated

• These interventions are designed for labor augmentation in stable patients, not for managing life-threatening hemorrhage 4
• Severe bleeding with suspected placental abruption demands urgent delivery regardless of cervical dilation or labor progress 1
• Attempting vaginal delivery in this scenario risks maternal exsanguination and fetal demise 1

Waiting 2 Hours (Option D) Is Dangerous

• Hemodynamic instability with heavy vaginal bleeding demands urgent intervention to save both maternal and fetal life—fetal status can deteriorate rapidly in placental abruption even with a currently normal CTG 1
• A normal CTG at the moment of placental abruption can be falsely reassuring, as fetal status deteriorates rapidly due to shunting of oxygenated blood away from the uterus 1
• Delaying delivery risks progression to disseminated intravascular coagulation (DIC), which complicates over 80% of severe abruption cases 1

Critical Intraoperative Considerations

Maintain Optimal Conditions for Hemostasis

• Keep patient temperature >36°C during surgery, as clotting factors function poorly with hypothermia 1
• Avoid acidosis, which impairs coagulation 1
• Monitor for coagulopathy including DIC, which commonly complicates severe abruption 1

Prepare for Potential Complications

• Have a low threshold for hysterectomy if bleeding is uncontrollable after delivery 1
• Anticipate the need for additional surgical interventions for hemorrhage control 1

Postoperative Management

• Continue intensive monitoring in ICU setting for at least 24 hours postoperatively due to potential hemodynamic changes and fluid shifts 1
• Monitor for ongoing coagulopathy and maintain low threshold for re-exploration if bleeding continues 1
• Initiate antithrombotic prophylaxis with heparin after normalization of coagulation, as severe bleeding during cesarean is a thrombotic risk factor 5

Common Pitfalls to Avoid

• Do not be falsely reassured by a normal CTG—this does not exclude placental abruption or predict stable fetal status in the context of severe maternal bleeding 1
• Do not delay for laboratory confirmation—ultrasound is not sensitive for diagnosing placental abruption, and management should not be delayed pending confirmation 2
• Do not use vasopressors for initial resuscitation—they should only be used for intractable hypotension unresponsive to fluid resuscitation due to adverse effects on uteroplacental perfusion 2