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Question 165
Delivery suite → Haemorrhage
Classification
Question
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A woman at 38 weeks presents with placental abruption and intrauterine fetal death. After initial resuscitation she is cardiovascularly stable. She has continuing but modest vaginal bleeding. Cervix is 3 cm dilated. Laboratory results show evolving coagulopathy. Which consideration most strongly favours vaginal rather than routine caesarean birth?
Question Stem
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Options
A
Vaginal birth prevents further consumption of coagulation factors immediately
B
Caesarean birth is contraindicated whenever fetal death has occurred
C
Vaginal birth eliminates the need to correct maternal coagulopathy
D
Caesarean birth would provide no fetal benefit and may expose a coagulopathic mother to additional operative haemorrhagic risk
E
Fetal death guarantees that maternal condition cannot subsequently deteriorate
Explanation
Following fetal death associated with placental abruption, the balance of benefit from operative delivery changes substantially. When the mother is sufficiently stable and there is no separate obstetric indication for caesarean birth, vaginal delivery is generally preferred. Caesarean birth cannot improve fetal outcome and may expose a woman with evolving coagulopathy to substantial operative bleeding. This does not make vaginal delivery absolute: maternal resuscitation, correction of coagulopathy and surveillance must continue, and deterioration may necessitate reassessment.
Option Validity
A) Vaginal birth does not guarantee immediate cessation of the consumptive process.
B) Fetal death does not make caesarean birth absolutely contraindicated; separate maternal or obstetric indications may exist.
C) Maternal coagulopathy still requires active assessment and correction irrespective of route of birth.
E) Severe abruption may continue to cause maternal haemorrhage and coagulopathy after fetal death.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.