A 37‑week pregnant woman in active labor (4 cm cervical dilation, 1+ station, cephalic presentation) develops painful vaginal bleeding with a tender abdomen and a normal fetal heart rate tracing. What is the most appropriate immediate management?

Emergency Cesarean Delivery is Indicated

This patient presenting with vaginal bleeding, abdominal tenderness, and a tender abdomen during active labor has a placental abruption until proven otherwise, and requires immediate emergency cesarean delivery. 1

Clinical Recognition of Placental Abruption

• Vaginal bleeding combined with a tender abdomen during active labor constitutes the classic presentation of placental abruption and mandates urgent assessment and expedited delivery, even when fetal heart rate monitoring appears reassuring. 1

• A normal CTG does not exclude significant abruption—fetal compromise can develop rapidly despite reassuring tracings, as placental separation can progress unpredictably. 1

• The triad of vaginal bleeding, abdominal tenderness, and uterine irritability in late third trimester labor should trigger immediate preparation for cesarean delivery to prevent maternal hemorrhage, fetal hypoxia, and death. 1

Why Oxytocin is Absolutely Contraindicated (Option A is Wrong)

• Oxytocin augmentation is absolutely contraindicated when placental abruption is suspected because uterine contractions worsen placental separation, increase maternal hemorrhage, and accelerate fetal hypoxia. 1

• Any existing oxytocin infusion must be discontinued immediately when vaginal bleeding suggestive of abruption is identified, per guidelines for abnormal electronic fetal monitoring. 1

• Oxytocin should never be started when there is active vaginal bleeding with uterine tenderness, as this clinical picture suggests ongoing placental separation that will be exacerbated by induced contractions. 2

Why Operative Vaginal Delivery is Not Feasible (Option B is Wrong)

• Operative vaginal delivery (forceps or vacuum) requires the fetal head to be at least at +2 station; at +1 station, such delivery is technically impossible and hazardous. 1

• The additional time needed for further cervical dilation (from 4 cm to complete) and fetal descent would permit further placental separation and worsening maternal-fetal compromise, making cesarean delivery the definitive intervention. 1

• In the context of suspected abruption, any delay for vaginal delivery—operative or spontaneous—places both mother and fetus at unacceptable risk. 1

Why Observation is Dangerous (Option C is Wrong)

• Expectant (observation) management of suspected placental abruption is never appropriate because the condition can rapidly evolve to maternal shock, disseminated intravascular coagulation, fetal death, and maternal death. 1

• When vaginal bleeding suggests abruption, clinical guidelines emphasize immediate expedited delivery rather than observation, as the window for safe intervention may close rapidly. 1

• The patient is already demonstrating signs of active abruption (bleeding + tender abdomen); waiting for further deterioration before acting is contraindicated. 1

Immediate Management Algorithm

Step 1: Discontinue any interventions that increase uterine activity

• Stop any oxytocin infusion if running. 1
• Avoid any maneuvers that stimulate contractions. 1

Step 2: Prepare for emergency cesarean delivery

• Establish large-bore intravenous access (two sites) and begin fluid resuscitation. 1
• Type and cross-match blood products for potential transfusion—anticipate need for packed red blood cells, fresh-frozen plasma, and platelets at 1:1:1 ratio. 3
• Notify anesthesia and operating-room staff immediately to prepare for emergency cesarean delivery. 1

Step 3: Continue monitoring during preparation

• Maintain continuous fetal heart rate monitoring, recognizing that rapid deterioration may occur. 1
• Monitor maternal vital signs closely for signs of hemorrhagic shock. 3

Step 4: Proceed to cesarean delivery without delay

• In the setting of active hemorrhage from placental abruption, general anesthesia is typically preferred over epidural anesthesia, which may cause hypotension. 1
• Do not wait for laboratory results before proceeding to delivery—treat based on clinical presentation. 3

Critical Pitfalls to Avoid

• Do not be falsely reassured by a normal CTG—fetal heart rate patterns can remain reassuring until sudden decompensation occurs with abruption. 1

• Do not attempt to "augment" labor with oxytocin—this is the most dangerous error, as it will accelerate placental separation and maternal bleeding. 1

• Do not delay for further cervical dilation—the patient is only 4 cm dilated with the fetus at +1 station, meaning hours would be required for vaginal delivery during which catastrophic hemorrhage could occur. 1

• Do not assume the bleeding is from another source (such as cervical dilation or "bloody show")—the combination of bleeding with a tender abdomen is pathognomonic for abruption until proven otherwise. 1

Postoperative Hemorrhage Management

• Uterine atony is common with amniotic fluid embolism and abruption; aggressive management with uterotonics such as oxytocin, ergot derivatives, and prostaglandins is appropriate after delivery. 3

• Active management of the third stage with uterotonics reduces bleeding risk in patients who may have received anticoagulants or have coagulopathy. 3

• Maintain normothermia (body temperature >36°C) and avoid acidosis, as clotting factors function poorly under these conditions. 3