In a 38‑week pregnant woman with spontaneous rupture of membranes, an engaged fetal head, and sudden maternal hypotension, what is the most appropriate immediate management?

Emergency Cesarean Section is Indicated

In a 38-week pregnant woman with spontaneous rupture of membranes, engaged fetal head, and sudden maternal hypotension, proceed immediately to emergency cesarean section (Option B) without delay for amniotomy, oxytocin, or induction of labor. 1, 2, 3

Clinical Diagnosis

The sudden onset of hypotension following rupture of membranes with an engaged fetal head at term strongly suggests placental abruption with maternal hemodynamic compromise, which is a life-threatening emergency requiring immediate delivery. 2, 3

• This presentation—gush of fluid followed by hypotension—indicates severe abruption where the placenta has separated from the uterine wall, causing concealed or revealed hemorrhage. 2
• Maternal hypotension signals significant blood loss and hemodynamic instability that will rapidly compromise both maternal and fetal perfusion. 1, 3
• The engaged fetal head does not permit safe vaginal delivery in this emergency context, as attempts at induction or augmentation will delay definitive hemorrhage control. 1

Immediate Management Algorithm

Step 1: Concurrent Resuscitation (Do Not Delay Surgery)

• Position the patient with left uterine displacement immediately to relieve aortocaval compression and improve cardiac output. 4, 1, 2
• Begin aggressive crystalloid resuscitation (20 mL/kg boluses, repeated as needed) through large-bore IV access. 4, 2, 3
• Activate massive transfusion protocol with packed red blood cells, fresh frozen plasma, and platelets in 1:1:1 ratio—do not wait for laboratory results. 1, 3
• Administer tranexamic acid 1 g IV immediately to reduce blood loss. 3
• Provide supplemental oxygen at 6–10 L/min. 1

Step 2: Proceed Directly to Operating Room

• Do not delay for amniotomy, oxytocin, or induction of labor—these interventions are contraindicated in severe abruption with hemodynamic instability. 2, 3
• General anesthesia is preferred when severe hemorrhage and maternal hypotension coexist, as it allows the fastest route to delivery. 1
• Target decision-to-delivery interval of ≤15–25 minutes for optimal maternal and neonatal outcomes. 3, 5, 6
• Continue manual left uterine displacement and resuscitative efforts throughout transport and until fetal delivery. 2

Why Other Options Are Incorrect

Option A (Amniotomy) is Contraindicated

• Amniotomy has already occurred spontaneously (the "gush of fluid"). 2
• Even if membranes were intact, performing amniotomy in the setting of severe hemorrhage and hypotension delays definitive treatment and worsens maternal outcome. 2, 3

Option C (Induction of Labor) is Contraindicated

• Induction of labor is absolutely contraindicated in placental abruption with maternal hemodynamic compromise, as it delays hemorrhage control and risks maternal death. 2, 3
• The time required for cervical ripening and labor progression (hours) is incompatible with the minutes available before irreversible maternal shock. 3

Option D (Oxytocin) is Contraindicated

• Oxytocin augmentation is inappropriate in this emergency, as it attempts vaginal delivery when immediate cesarean section is required. 2, 3
• Oxytocin may be used after delivery to prevent uterine atony, but only as slow IV infusion (<2 U/min) to avoid systemic hypotension. 3

Critical Pitfalls to Avoid

• Do not wait for laboratory results (CBC, coagulation studies) before proceeding to surgery—treat based on clinical presentation. 4, 3
• Do not attempt operative vaginal delivery (forceps or vacuum), as this delays definitive hemorrhage control and endangers maternal stability. 1
• Do not use crystalloid alone for volume replacement—use blood products to avoid dilutional coagulopathy. 3
• Anticipate disseminated intravascular coagulation (DIC) in >80% of severe abruption cases and prepare for potential hysterectomy if bleeding is uncontrollable. 3

Perimortem Considerations

• If maternal cardiac arrest occurs despite resuscitation, perform perimortem cesarean section within 4 minutes to improve both maternal resuscitation outcomes and neonatal survival. 4, 1, 7
• Delivery of the fetus should be accomplished within 5 minutes of arrest if usual resuscitation measures have not achieved return of spontaneous circulation. 4, 5

Postoperative Management

• Continue intensive monitoring in ICU for at least 24 hours postoperatively due to ongoing risk of hemorrhage, coagulopathy, and fluid shifts. 4, 3
• Maintain vigilance for ongoing bleeding with a low threshold for reoperation or interventional radiology. 4, 3
• Monitor for complications including renal failure, DIC, pulmonary edema, and unrecognized visceral injury. 4