Immediate Cesarean Section
This patient requires immediate cesarean section without delay. The combination of vaginal bleeding, uterine tenderness, and relative hypotension (BP 90/80) at 38 weeks gestation strongly suggests placental abruption, which is a life-threatening emergency for both mother and fetus despite the currently reassuring CTG 1, 2.
Clinical Reasoning
Why This is Placental Abruption
Vaginal bleeding with a tender uterus is the classic presentation of placental abruption, which occurs in approximately 1% of pregnancies and is the most common cause of serious vaginal bleeding in late pregnancy 1.
The blood pressure of 90/80 mmHg represents relative hypotension in a pregnant patient, as pregnancy normally causes increased blood volume and cardiac output with maintenance of normal systolic pressures 3. This suggests significant concealed hemorrhage.
A reassuring CTG does not exclude abruption or predict maternal stability—ultrasound misses up to 50% of placental abruptions, and fetal status can deteriorate rapidly 4. The maternal condition takes priority in determining management urgency.
Why Cesarean Section is Mandatory
Placental abruption requires rapid operative delivery to prevent neonatal morbidity and mortality, particularly when maternal hemodynamic compromise is present 1, 2.
The patient is already at term (38 weeks) with 4 cm dilation, making expectant management or augmentation of labor unacceptably dangerous given the high likelihood of maternal decompensation and fetal compromise 1.
Maternal hypotension with ongoing bleeding indicates significant blood loss that will only worsen with continued labor, risking maternal shock, DIC, and fetal death 2.
Why the Other Options are Contraindicated
Amniotomy Alone (Option A) is Dangerous
Artificial rupture of membranes in the setting of suspected abruption can precipitate catastrophic hemorrhage and does not address the underlying placental separation 3.
There is no objective proof that amniotomy treats protraction or arrest of labor, and it would be inappropriate for a patient with active bleeding and hemodynamic instability 3.
Amniotomy with Oxytocin (Option C) is Equally Dangerous
Oxytocin is absolutely contraindicated when there is evidence of cephalopelvic disproportion or fetal distress, and abruption represents an obstetric emergency where vaginal delivery attempts are inappropriate 5.
The FDA labeling for oxytocin explicitly states that infusion should be discontinued immediately in the event of uterine hyperactivity or fetal distress, and abruption with maternal hypotension represents a contraindication to labor augmentation 5.
Attempting vaginal delivery with oxytocin augmentation in a patient with suspected abruption and hypotension risks maternal exsanguination, DIC, and fetal death 1, 2.
Immediate Management Steps
Activate massive transfusion protocol and prepare for emergency cesarean section with rapid assessment of maternal status and fluid resuscitation 1, 2.
Administer crystalloid resuscitation immediately while preparing blood products, as significant vaginal bleeding requires replacement of blood products when necessary 1.
Do not delay for additional imaging or monitoring—the clinical presentation is sufficient for diagnosis, and ultrasound is insensitive for abruption 4, 1.
Notify anesthesia and neonatal teams immediately for emergency operative delivery 2.
Critical Pitfall to Avoid
The single most dangerous error would be attempting to continue labor or augment contractions in this clinical scenario. The reassuring CTG is falsely reassuring—fetal status can deteriorate within minutes with abruption, and maternal hypotension indicates she has already lost significant blood volume 4, 1, 2. Every minute of delay increases the risk of maternal death from hemorrhagic shock and fetal death from hypoxia.