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Question 163
Delivery suite → Haemorrhage
Classification
Question
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A woman at 36+1 weeks presents with suspected placental abruption. She has approximately 500 mL visible bleeding, severe continuous abdominal pain and a tense uterus. Her pulse is 128 beats/min and blood pressure 86/48 mmHg. CTG demonstrates persistent fetal bradycardia. The cervix is 4 cm dilated. Ultrasound shows no retroplacental clot. Which management sequence is most appropriate?
Question Stem
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Options
A
Immediate transfer to theatre for caesarean birth before establishing intravenous access because fetal bradycardia takes absolute priority
B
Stabilise the mother completely before considering delivery, even if fetal bradycardia persists
C
Repeat ultrasound to establish the diagnosis before committing to operative delivery
D
Commence simultaneous maternal resuscitation and preparation for immediate delivery, with caesarean birth because rapid vaginal birth is not imminent
E
Attempt tocolysis while resuscitating the mother to determine whether the fetal bradycardia resolves
Explanation
This scenario requires simultaneous rather than sequential management. The woman has clinical placental abruption with maternal shock and severe fetal compromise. Maternal resuscitation is the first physiological priority, but this does not mean waiting for complete normalisation before addressing the ongoing obstetric cause. Resuscitation and preparation for immediate delivery should proceed concurrently. With persistent fetal bradycardia and vaginal birth not imminent at 4 cm dilatation, emergency caesarean birth is appropriate. A negative ultrasound does not exclude abruption and must not delay treatment.
Option Validity
A) Fetal compromise requires urgent delivery, but maternal resuscitation must commence immediately rather than being deferred until after transfer to theatre.
B) Maternal stabilisation is the priority, but complete normalisation should not be awaited while abruption and profound fetal compromise continue.
C) Ultrasound has poor sensitivity for abruption and repeat imaging would delay necessary treatment.
E) Tocolysis is inappropriate when maternal and fetal compromise require delivery.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.