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Question 185
Delivery suite → Haemorrhage
Classification
Question
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A woman at 38+6 weeks develops placental abruption during labour. Maternal resuscitation is underway and she is currently cardiovascularly stable. CTG shows persistent profound fetal bradycardia. The cervix is 9 cm dilated, but the fetal head is occipito-posterior at −1 station and immediate vaginal birth is not considered achievable. Which is the most appropriate next step?
Question Stem
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Options
A
Await full dilatation because she is already in advanced labour
B
Attempt rotational operative vaginal delivery because any vaginal birth is preferable to caesarean section in abruption
C
Continue observation for 20 minutes to determine whether the bradycardia resolves after maternal resuscitation
D
Commence tocolysis to reduce further placental separation
E
Proceed to emergency caesarean birth because severe fetal compromise is present and vaginal birth is not imminent
Explanation
The crucial issue is not cervical dilatation alone but whether rapid vaginal birth is genuinely achievable. Persistent profound fetal bradycardia in placental abruption requires immediate delivery. At 9 cm with a high occipito-posterior head, vaginal birth is not imminent and an attempted operative vaginal delivery is not an appropriate shortcut. Emergency caesarean birth is therefore indicated while maternal resuscitation continues. This contrasts with a fully dilated woman with a low, favourably positioned head where immediate assisted vaginal birth may be faster.
Option Validity
A) Advanced labour does not justify delay when profound fetal compromise exists and vaginal birth is not imminent.
B) A high fetal head and incomplete dilatation do not support immediate operative vaginal birth.
C) Persistent profound bradycardia in abruption requires expedited birth rather than prolonged observation.
D) Tocolysis would delay necessary delivery in the presence of severe fetal compromise.
Further Reading
RCOG Green-top Guideline No. 63. Antepartum Haemorrhage. Royal College of Obstetricians and Gynaecologists; 2011.