Emergency Cesarean Section is Immediately Indicated
This patient has placental abruption and requires emergency cesarean delivery within 30 minutes, regardless of the reassuring CTG. The combination of acute vaginal bleeding with abdominal tenderness during active labor is pathognomonic for placental abruption, and the normal fetal heart tracing does not rule out this life-threatening diagnosis 1.
Why This is Placental Abruption
The clinical presentation is diagnostic:
- Acute bleeding during active labor (37 weeks, 4cm dilated, regular contractions) combined with a tender abdomen indicates placental separation with concealed hemorrhage 1
- The reassuring CTG is misleading - by the time fetal heart rate abnormalities appear, significant placental separation has already occurred and fetal compromise is advanced 1
- Abdominal tenderness reflects uterine irritability from blood infiltrating the myometrium and concealed hemorrhage behind the placenta 1
Immediate Management Protocol
Activate emergency cesarean protocol immediately:
- Aim for delivery within 30 minutes of diagnosis 1
- Establish two large-bore IV lines (14-16 gauge) and activate massive transfusion protocol 1, 2
- Send urgent labs: complete blood count, type and crossmatch for 4+ units, coagulation panel including fibrinogen, and thromboelastography 1
- Prepare blood products in 1:1:1 ratio (packed red blood cells, fresh frozen plasma, platelets) 1
- Maintain maternal temperature >36°C as clotting factors function poorly below this threshold 1
- Administer prophylactic antibiotics and re-dose if blood loss exceeds 1,500 mL 1
Why Other Options Are Catastrophic
Option A (Oxytocin) would be catastrophic:
- Oxytocin increases uterine contractility and worsens placental separation, leading to massive hemorrhage 1
- It is only indicated for slow progress in uncomplicated labor, never with bleeding and abdominal tenderness 1
Option B (Surgical vaginal delivery) is contraindicated:
- Attempting vaginal delivery delays definitive management and risks catastrophic hemorrhage 1
- Even if labor progresses rapidly, vaginal delivery is inappropriate as it cannot control the ongoing placental separation 1
Option C (Observation) is dangerous:
- Waiting for CTG abnormalities to develop means significant placental separation has already progressed to fetal compromise 1
- Concealed hemorrhage can be massive without proportionate external bleeding 1
Option D (Anesthesia alone) is incomplete:
- While anesthesia preparation is essential, it must be part of the emergency cesarean protocol, not a standalone action 1
- The anesthesia team must be prepared for hemodynamic instability and potential need for general anesthesia if regional is contraindicated by coagulopathy 1
Critical Pitfall to Avoid
Do not be falsely reassured by the normal CTG. The American College of Obstetricians and Gynecologists explicitly warns that a reassuring fetal heart rate pattern does not exclude placental abruption when clinical signs (bleeding + tender abdomen) are present 1. Significant concealed hemorrhage occurs behind the placenta, and maternal-fetal compromise can be profound before CTG changes appear 1.