Emergency Cesarean Delivery is Indicated
This patient requires immediate emergency cesarean delivery for suspected placental abruption. The combination of vaginal bleeding with abdominal tenderness during active labor represents a classic presentation of placental abruption, which constitutes an obstetric emergency requiring expedited delivery regardless of reassuring fetal monitoring 1.
Why This is Placental Abruption
Vaginal bleeding with a tender abdomen during active labor constitutes the hallmark presentation of placental abruption and demands urgent assessment and expedited delivery, even when cardiotocography appears normal 1.
A reassuring CTG does NOT exclude significant abruption—fetal compromise can develop rapidly despite normal tracings because the fetus may initially compensate for reduced placental perfusion 1.
The clinical scenario (37 weeks gestation, active labor with bleeding and tenderness) fits the classic pattern requiring immediate intervention to prevent maternal hemorrhage, fetal hypoxia, and death 1.
Why Each Option is Wrong or Right
A. Oxytocin - ABSOLUTELY CONTRAINDICATED
Oxytocin augmentation is absolutely contraindicated when placental abruption is suspected because uterine contractions worsen placental separation, increase maternal hemorrhage, and accelerate fetal hypoxia 1.
Guidelines for abnormal fetal monitoring specifically mandate discontinuing any oxytocin infusion when vaginal bleeding suggestive of abruption is identified 1.
B. Surgical Vaginal Delivery - TECHNICALLY IMPOSSIBLE
Operative vaginal delivery requires the fetal head to be at least at +2 station; at +1 station, forceps or vacuum delivery is technically impossible and hazardous 1.
The additional time needed for further cervical dilation (currently only 4 cm) and fetal descent would permit further placental separation and worsening maternal-fetal compromise, making cesarean delivery the definitive intervention 1.
C. Observation - NEVER APPROPRIATE
Expectant 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 1.
D. Anesthesia - PART OF THE SOLUTION, NOT THE ANSWER
While anesthesia consultation is essential for emergency cesarean delivery, simply calling anesthesia without proceeding to surgery is inadequate 1.
In active hemorrhage from placental abruption, general anesthesia is typically preferred over epidural anesthesia to avoid hypotension 1.
Immediate Management Steps
Discontinue any oxytocin if running 1.
Establish large-bore IV access (two sites) and begin fluid resuscitation 1.
Type and cross-match blood products for potential transfusion, anticipating packed red blood cells, fresh-frozen plasma, and platelets in a 1:1:1 ratio 1.
Notify anesthesia and operating room staff to prepare for emergency cesarean delivery 1.
Do not await laboratory results—immediate cesarean delivery should be performed based on clinical presentation 1.
Continue fetal monitoring during preparation, recognizing that rapid deterioration may occur 1.
Critical Pitfall to Avoid
The most dangerous error would be reassurance from the normal CTG and choosing observation or attempting to augment labor with oxytocin. Normal fetal heart tracings provide false reassurance in placental abruption—the fetus can decompensate suddenly, and maternal hemorrhage can progress rapidly to life-threatening coagulopathy 1.