In a 37‑week pregnant woman in active labor (4 cm cervical dilation, fetal head at +1 station) who develops painful vaginal bleeding with a tender abdomen and a normal cardiotocograph, what is the most appropriate next step: oxytocin infusion, operative vaginal delivery, observation, or anesthesia?

Emergency Cesarean Section is Mandatory

This patient requires immediate cesarean delivery without delay—the combination of painful vaginal bleeding with abdominal tenderness in active labor indicates placental abruption, which demands urgent surgical intervention to prevent maternal and fetal mortality. 1

Why This is Placental Abruption

The clinical triad presented here is pathognomonic for placental abruption:

• Painful vaginal bleeding (versus painless bleeding in placenta previa) 1
• Tender, rigid abdomen (from concealed hemorrhage into the myometrium) 1
• Active labor with sudden onset (abruption often precipitates labor) 1

The normal CTG is falsely reassuring—fetal compromise can develop rapidly as placental separation progresses, and maternal hemodynamic instability precedes fetal decompensation 1.

Why Each Option is Wrong or Right

A. Oxytocin - CONTRAINDICATED and Dangerous

Oxytocin is absolutely contraindicated in placental abruption because:

• Augmenting contractions worsens placental separation, accelerating maternal hemorrhage and fetal hypoxia 1
• The American College of Obstetricians and Gynecologists explicitly states that proceeding directly to the operating room without delay for oxytocin is crucial in severe placental abruption 1
• Oxytocin-induced uterine hyperstimulation in this setting risks catastrophic hemorrhage and uterine rupture 2, 3

B. Surgical Vaginal Delivery (Forceps/Vacuum) - Inappropriate and Delays Definitive Care

Operative vaginal delivery is contraindicated because:

• The fetus is at +1 station, not at the perineum—forceps/vacuum require the fetal head to be at least at +2 station with visible scalp 4, 5
• Attempting instrumental delivery delays cesarean section, worsening maternal blood loss and fetal hypoxia 1
• The indication for operative vaginal delivery is to shorten the second stage when the head is low and delivery is imminent—not for obstetric emergencies requiring immediate delivery 4, 5

C. Observation - Negligent and Life-Threatening

Observation is unacceptable because:

• Placental abruption is a progressive emergency—maternal hemodynamic collapse and fetal death can occur within minutes 1
• The American College of Obstetricians and Gynecologists recommends immediate cesarean delivery without delay for additional testing in severe placental abruption 1
• Waiting for deterioration (maternal shock, fetal bradycardia, DIC) dramatically increases maternal and fetal mortality 1, 6

D. Anesthesia (Cesarean Section) - CORRECT

This is the only appropriate answer because:

• Immediate cesarean delivery is the definitive treatment for placental abruption with maternal compromise 1
• The European Society of Cardiology and American Heart Association recommend proceeding directly to the operating room without delay 1
• Maternal resuscitation and fetal delivery are interdependent—you cannot adequately resuscitate the mother while the abrupting placenta continues to bleed 1

Concurrent Resuscitation Protocol

While preparing for cesarean section, immediately initiate:

• Large-bore IV access (two lines) with crystalloid bolus (20 mL/kg, repeated as needed) 1
• Activate massive transfusion protocol and crossmatch at least 4 units of packed red blood cells 6
• Left uterine displacement (manually or with left lateral tilt) to prevent aortocaval compression 1
• Obtain baseline labs: CBC, type and crossmatch, coagulation panel, fibrinogen, platelets (to assess for DIC) 6

Critical Pitfall to Avoid

Do not wait for maternal hemodynamic instability (hypotension, tachycardia) or fetal distress (bradycardia) to develop before proceeding to cesarean section. The clinical diagnosis of placental abruption (painful bleeding + tender abdomen) is sufficient indication for immediate delivery 1. By the time vital signs deteriorate, significant blood loss has already occurred and maternal/fetal outcomes worsen dramatically 1, 6.