In a 37‑week pregnant woman in active labor with a 4‑cm cervix, cephalic presentation at +1 station, who develops painful vaginal bleeding and a tender abdomen but has a reassuring cardiotocograph and stable maternal‑fetal status, what is the most appropriate immediate management?

Emergency Cesarean Delivery is Indicated

This patient requires immediate emergency cesarean delivery for suspected placental abruption. The combination of painful vaginal bleeding with abdominal tenderness during active labor constitutes a classic presentation of placental abruption, which demands urgent surgical intervention regardless of reassuring fetal monitoring 1.

Clinical Recognition of Placental Abruption

• Vaginal bleeding plus a tender abdomen during labor is pathognomonic for placental abruption and requires immediate assessment and expedited delivery, even when the CTG appears normal 1.
• A reassuring cardiotocograph does not exclude significant abruption; fetal compromise can develop rapidly despite normal tracings because the fetus may initially compensate until decompensation occurs suddenly 1.
• The clinical presentation—bleeding with uterine tenderness at 37 weeks in active labor—warrants immediate cesarean delivery to prevent maternal hemorrhage, fetal hypoxia, and death 1.

Why Oxytocin (Option A) is 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.
• Administering oxytocin in this scenario would directly harm both mother and fetus by exacerbating the underlying pathology.

Why Operative Vaginal Delivery (Option B) is Inappropriate

• 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 4 cm) and fetal descent would permit further placental separation and worsening maternal-fetal compromise, making cesarean delivery the definitive intervention 1.
• Even if the station were adequate, attempting operative vaginal delivery in the setting of suspected abruption delays definitive management and increases risk.

Why Observation (Option C) is 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.
• The unpredictable nature of abruption progression makes any delay in definitive management unacceptable.

Why "Anesthesia" (Option D) Alone is Incomplete

• While anesthesia preparation is essential, it is not the primary management decision—it is a component of preparing for emergency cesarean delivery 1.
• In active hemorrhage from placental abruption, general anesthesia is typically preferred over epidural anesthesia, which may cause hypotension 1.
• The correct answer prioritizes the surgical intervention itself, not merely one aspect of perioperative care.

Immediate Management Algorithm

Upon suspicion of placental abruption:

1. Discontinue any oxytocin if running 1.
2. Establish large-bore IV access (two sites) and begin fluid resuscitation 1.
3. 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.
4. Notify anesthesia and operating-room staff to prepare for emergency cesarean delivery 1.
5. Continue fetal heart rate monitoring during preparation, recognizing that rapid deterioration may occur 1.
6. Do not await laboratory results; immediate cesarean delivery should be performed based on clinical presentation 1.

Critical Pitfall to Avoid

• Never reassure yourself with a normal CTG in the setting of bleeding and abdominal tenderness—this combination mandates immediate action regardless of fetal monitoring 1.
• The window for intervention may be brief; placental abruption can progress from compensated to catastrophic within minutes.