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Question 137
Delivery suite → Haemorrhage
Classification
Question
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A woman at 38+2 weeks develops a clinically significant placental abruption in established labour. She is being resuscitated and is currently haemodynamically stable. CTG demonstrates persistent profound fetal bradycardia. The cervix is fully dilated, the fetal head is at +2 station in an occipito-anterior position and immediate assisted vaginal birth is considered achievable. What is the most appropriate obstetric strategy?
Question Stem
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Options
A
Proceed automatically to category 1 caesarean birth because fetal compromise with abruption always mandates caesarean delivery
B
Expedite vaginal birth if it can be achieved immediately and safely
C
Continue observation because maternal stability permits further assessment of the CTG
D
Commence tocolysis while preparing theatre
E
Await spontaneous vaginal birth because operative intervention may worsen the abruption
Explanation
Maternal or fetal compromise associated with APH requires immediate delivery. However, the requirement is for the fastest safe route of birth, not caesarean section irrespective of obstetric circumstances. When vaginal birth is not imminent, fetal compromise generally necessitates emergency caesarean delivery. In this case, however, the cervix is fully dilated, the head is low and immediate assisted vaginal birth is achievable. This may provide more rapid fetal delivery than transfer and preparation for caesarean section. Maternal resuscitation must continue concurrently.
Option Validity
A) Caesarean birth is generally required when rapid vaginal birth is not achievable; it is not mandatory irrespective of the stage of labour and feasibility of immediate assisted vaginal birth.
C) Persistent profound fetal bradycardia in the setting of placental abruption requires immediate delivery rather than continued observation.
D) Tocolysis would delay necessary delivery and is inappropriate in the presence of fetal compromise.
E) Waiting for spontaneous birth would unnecessarily delay delivery when immediate assisted vaginal birth can be achieved safely.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.