Emergency Cesarean Section
In a 33-week pregnant woman with severe bleeding, hypotension (90/60 mmHg), and Category II fetal heart rate decelerations during active labor, immediate cesarean section is the only appropriate management regardless of fetal station.
Critical Decision-Making Framework
Why Cesarean Section is Mandatory
Maternal hemodynamic instability with severe bleeding represents obstetric hemorrhage requiring immediate delivery, as young women can maintain seemingly adequate blood pressure until sudden catastrophic decompensation occurs 1, 2.
The combination of hypotension (90/60 mmHg) and severe bleeding indicates that maternal physiologic reserves have been exceeded, signaling hypovolemic shock that requires urgent intervention 1.
Category II decelerations in the context of maternal hemorrhage and hypotension suggest uteroplacental insufficiency, requiring expedited delivery to prevent progressive fetal acidemia 3, 4.
Operative vaginal delivery (forceps or vacuum) is absolutely contraindicated in maternal hemodynamic instability, as these procedures require maternal hemodynamic stability and adequate time for setup that this patient does not have 5, 2.
Why Operative Vaginal Delivery is Inappropriate
Forceps and vacuum extraction require stable maternal hemodynamics and controlled conditions—attempting operative vaginal delivery while the mother is actively bleeding and hypotensive delays definitive management and risks both maternal and fetal death 2.
The +2 station, while favorable for operative delivery in stable conditions, becomes irrelevant when maternal life is threatened by hemorrhage, as cesarean section allows simultaneous access to the bleeding source and fetal delivery 3, 6.
There is less than 10 minutes to permanent fetal brain damage once fetal anoxia is presumed, and operative vaginal delivery setup time exceeds this window in an unstable patient 2.
Immediate Management Algorithm
Pre-Delivery Resuscitation (Concurrent with Cesarean Preparation)
Establish large-bore IV access immediately and begin aggressive fluid resuscitation with crystalloid while preparing for massive transfusion protocol 6.
Activate massive transfusion protocol with 4:4:1 ratio (RBC:FFP:platelets) and administer tranexamic acid early 6.
Administer supplemental oxygen and position patient in left lateral tilt to optimize uteroplacental perfusion during transport to operating room 1.
Intraoperative Priorities
Cesarean section provides simultaneous access to deliver the fetus and identify/treat the bleeding source (placental abruption, uterine atony, uterine rupture) 6.
Prepare for potential hysterectomy, uterine artery ligation, or interventional radiology as these may be required for uncontrolled hemorrhage 7, 6.
Administer uterotonics immediately after delivery (oxytocin 20-40 IU in 1000 mL IV infusion or carbetocin 100 mcg IV bolus) to prevent further atony-related bleeding 7.
Critical Pitfalls to Avoid
Do not delay for fetal scalp sampling or prolonged fetal monitoring—the maternal hemorrhage and hypotension mandate immediate delivery 2.
Do not attempt intrauterine resuscitation maneuvers beyond initial positioning and oxygen—the primary problem is maternal hemorrhage requiring surgical intervention 4.
Do not underestimate blood loss based on visual estimation—use clinical markers (hypotension, tachycardia, altered mental status) to guide urgency 7, 2.
Do not wait for laboratory values or crossmatched blood—proceed to cesarean section with O-negative blood if necessary 6.