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Question 171
Delivery suite → Haemorrhage
Classification
Question
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A woman at 39 weeks develops a major placental abruption during labour. Resuscitation is underway. CTG demonstrates persistent fetal bradycardia. The cervix is fully dilated and the fetal head is occipito-anterior at +1 station. A technically straightforward assisted vaginal birth is considered immediately achievable. Which principle should determine the route of birth?
Question Stem
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Options
A
Caesarean birth is mandatory because abruption plus fetal bradycardia always overrides labour progress
B
The route should be determined solely by the measured volume of maternal bleeding
C
Vaginal birth should be avoided because operative vaginal delivery increases placental separation
D
Wait for recovery of the fetal heart rate before deciding because maternal resuscitation has commenced
E
Use the fastest safe route of birth; immediate assisted vaginal birth may be preferable when it can be achieved more rapidly than caesarean birth
Explanation
Fetal compromise associated with APH requires expedited delivery, but caesarean section is not an end in itself. The clinically relevant objective is the fastest safe birth. When the cervix is fully dilated, the fetal head is low and immediate assisted vaginal birth is technically achievable, this may accomplish delivery faster than transfer and preparation for emergency caesarean section. Conversely, when vaginal birth is not imminent, fetal compromise would usually require caesarean birth. Maternal resuscitation must continue simultaneously regardless of route.
Option Validity
A) Caesarean birth is generally appropriate when rapid vaginal delivery is not achievable; it is not mandatory irrespective of labour progress.
B) Route of delivery depends on maternal and fetal condition and obstetric circumstances, not measured blood loss alone.
C) An immediately achievable assisted vaginal birth may be the fastest safe route in advanced labour.
D) Persistent fetal bradycardia in abruption requires expedited birth rather than waiting for spontaneous recovery.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.