What is the best course of action for a 37-week gestation patient experiencing contractions, with a cephalic (head-down) baby, 4cm cervical dilation, and the baby at 1+ station, who now presents with bleeding and a tender abdomen, but has a normal Cardiotocography (CTG)?

Emergency Cesarean Delivery is Immediately Indicated

This patient has placental abruption—a life-threatening obstetric emergency requiring immediate cesarean delivery, not oxytocin, observation, or attempted vaginal delivery. The combination of acute vaginal bleeding with abdominal tenderness during active labor is pathognomonic for placental abruption, even with a reassuring CTG 1.

Why This is Placental Abruption

• Vaginal bleeding that developed acutely during active labor is a key diagnostic feature of placental abruption 1
• A tender abdomen indicates concealed hemorrhage and uterine irritability, which are significant findings in placental abruption 1
• The patient is in active labor at 37 weeks with 4cm dilation, which increases the risk of abruption progression 1
• A normal CTG does NOT rule out placental abruption—significant placental separation has already occurred, and fetal compromise becomes evident only when the situation is already advanced 1

Why Each Option is Wrong

Option A (Oxytocin) - CATASTROPHIC

• Oxytocin augmentation would be catastrophic in suspected abruption, as it increases uterine contractility and can worsen placental separation, leading to massive hemorrhage 1
• Oxytocin is only indicated for slow progress in uncomplicated active labor, not in the presence of bleeding and abdominal tenderness 1

Option B (Surgical Vaginal Delivery) - DANGEROUS

• Attempting vaginal delivery is contraindicated, even if labor progresses, as it delays definitive management and risks catastrophic hemorrhage 1
• The time required for vaginal delivery (even operative) allows continued placental separation and maternal/fetal deterioration

Option C (Observation) - NEGLIGENT

• Waiting for CTG abnormalities to develop is a critical error—by the time fetal heart rate decelerations appear, significant placental separation has already occurred and fetal compromise is advanced 1
• Observation allows progression of concealed hemorrhage behind the placenta without proportionate external bleeding 1

Immediate Management Protocol

Activate emergency cesarean protocol with goal of delivery within 30 minutes 1:

• Establish large-bore IV access and initiate massive transfusion protocol 1
• Send urgent laboratory studies: complete blood count, type and crossmatch, coagulation panel, and thromboelastography 1
• Prepare for potential massive hemorrhage with packed red blood cells, fresh frozen plasma, and platelets available in 1:1:1 ratio 1
• Maintain maternal temperature above 36°C and avoid acidosis, as clotting factors function poorly below this threshold 1
• Administer prophylactic antibiotics and re-dose if blood loss exceeds 1,500 mL 1
• Ensure anesthesia team is prepared for potential hemodynamic instability and need for general anesthesia if regional is contraindicated by coagulopathy 1

Critical Pitfall to Avoid

Underestimating blood loss is a critical error—significant concealed hemorrhage can occur behind the placenta without proportionate external bleeding 1. The tender abdomen in this case signals substantial concealed hemorrhage that is not reflected in the visible vaginal bleeding.

The correct answer is D (Anesthesia)—as the immediate step to prepare for emergency cesarean delivery.