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Question 157
Delivery suite → Haemorrhage
Classification
Question
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A woman at 37+4 weeks presents with placental abruption and confirmed intrauterine fetal death. After resuscitation she is haemodynamically stable. Coagulation results are satisfactory, bleeding is not increasing, the fetus is cephalic and there is no independent indication for caesarean birth. Which management principle best minimises additional maternal risk?
Question Stem
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Options
A
Perform immediate caesarean birth because placental abruption is an absolute indication for abdominal delivery
B
Perform caesarean birth because fetal death increases the risk of labour-associated DIC
C
Delay delivery indefinitely provided maternal observations remain stable
D
Use ultrasound evidence of retroplacental clot size to determine the route of birth
E
Aim for vaginal birth, with continued close maternal surveillance and readiness to escalate if her condition deteriorates
Explanation
When fetal death has occurred following placental abruption and the mother is stable, vaginal birth is generally the preferred route unless there is a separate obstetric indication for caesarean delivery. Caesarean birth provides no fetal benefit in this situation and exposes the mother to operative haemorrhagic risk, which may become particularly important if abruption-associated coagulopathy develops. This preference is conditional rather than absolute: maternal haemodynamic status, bleeding and coagulation must continue to be monitored, and management should change promptly if maternal deterioration occurs.
Option Validity
A) Placental abruption is not an absolute indication for caesarean birth following fetal death when the maternal condition permits vaginal delivery.
B) Fetal death does not itself create a maternal benefit from caesarean birth, while operative delivery may add haemorrhagic risk.
C) Pregnancy should not simply be continued indefinitely following placental abruption and intrauterine fetal death.
D) Ultrasound measurement of a retroplacental collection does not determine the route of delivery; placental abruption remains primarily a clinical diagnosis.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.