Emergency Cesarean Delivery is Indicated
This patient requires immediate cesarean delivery due to suspected placental abruption—a life-threatening obstetric emergency that mandates urgent delivery regardless of labor progress. 1
Clinical Presentation Indicates Placental Abruption
The combination of painful vaginal bleeding with a tender abdomen in active labor represents the classic triad of placental abruption. 1 This diagnosis supersedes all other labor management considerations, as both maternal and fetal mortality rise precipitously with delayed intervention.
Key diagnostic features present in this case:
- Painful bleeding (distinguishes from placenta previa, which is painless) 1
- Uterine tenderness (indicates concealed hemorrhage and uterine irritability) 1
- Active labor with contractions (abruption commonly triggers labor) 1
The reassuring CTG is misleading—fetal heart rate patterns can remain normal initially even with significant abruption, then deteriorate rapidly and catastrophically. 2
Why Other Options Are Contraindicated
Option A (Oxytocin) is dangerous and contraindicated. Administering oxytocin in suspected abruption risks:
- Uterine hyperstimulation worsening the abruption 3
- Uterine rupture in an already compromised uterus 3
- Delayed recognition of fetal compromise 4
- Maternal hemorrhagic shock from progressive placental separation 1
Option B (Operative vaginal delivery) is inappropriate. While the fetal head is at +1 station, operative vaginal delivery requires:
- Full cervical dilation (this patient is only 4 cm) 5, 6
- Fetal head at +2 station or lower for safe vacuum/forceps application 6
- Absence of maternal/fetal compromise 5
Attempting operative delivery at 4 cm dilation would cause catastrophic cervical lacerations and is technically impossible. 6
Option C (Observation) is negligent. Placental abruption is a progressive condition where:
- Maternal mortality increases with each hour of delay 1
- Concealed hemorrhage can lead to DIC and maternal death 1
- Fetal hypoxia worsens as placental separation extends 2
- The "reassuring" CTG can deteriorate within minutes 2
Correct Management Algorithm
- Activate emergency cesarean protocol immediately 1
- Establish large-bore IV access (two lines) and send stat labs including CBC, type and crossmatch for 4+ units, coagulation studies (PT/PTT/fibrinogen) 1
- Administer crystalloid resuscitation while preparing for surgery 1
- Regional anesthesia (spinal/epidural) is preferred if maternal hemodynamics are stable; general anesthesia if unstable or immediate delivery required within minutes 2
- Ensure neonatal resuscitation team is present before delivery, as the infant may be compromised despite reassuring CTG 2
- Proceed to delivery within 10-15 minutes of decision-to-incision time 1
Critical Pitfalls to Avoid
- Never wait for CTG deterioration before acting on clinical diagnosis of abruption—fetal compromise can occur suddenly and irreversibly 2
- Never attempt vaginal delivery (augmented or operative) when abruption is suspected, regardless of cervical dilation or station 1
- Never underestimate blood loss—visible bleeding represents only a fraction of total hemorrhage in abruption, as much blood is concealed behind the placenta 1
- Never delay for additional testing—ultrasound has poor sensitivity for abruption and should not delay delivery 1
Post-Delivery Considerations
After cesarean delivery for abruption:
- Administer 10 units IM oxytocin after placental delivery to prevent postpartum hemorrhage 7
- Never give methylergonovine due to vasoconstriction and hypertension risk 7
- Monitor hemodynamics for 24+ hours as these patients are at high risk for DIC, hemorrhagic shock, and renal failure 7
- Implement thromboprophylaxis with early ambulation and compression stockings given the elevated VTE risk post-cesarean 7
The answer is D (Anesthesia)—but only as the immediate step toward emergency cesarean delivery, not as a standalone intervention.