Following the spontaneous onset of regular contractions, a multiparous patient at 38 weeks gestation is admitted to the delivery unit. She is 31 years old (gravida 2, para 1). Her prenatal history is significant for a mid-trimester anatomy ultrasound demonstrating a low-lying placenta; however, a follow-up transvaginal ultrasound at 32 weeks confirmed that the placental edge had migrated 4 cm away from the internal cervical os. Her vital signs upon admission are temperature 37.0°C (98.6°F), blood pressure 118/76 mm Hg, and heart rate 84/min.
Cervical examination demonstrates 6 cm dilation, 100% effacement, and 0 station with a tense, bulging amniotic sac. The baseline fetal heart rate is 140/min with moderate variability and no decelerations. Ten minutes later, the patient's membranes spontaneously rupture. Immediately following the rupture, a large gush of blood-tinged fluid is observed, rapidly followed by frank, bright red vaginal bleeding. The patient's uterine tone remains soft between contractions, and she explicitly denies any new, sudden, or tearing abdominal pain. Simultaneous evaluation of the fetal monitor reveals a precipitous drop in the fetal heart rate to 60/min. Three minutes later, the bradycardia persists without any sign of recovery.
Which of the following is the most appropriate next step in management?
- Emergent cesarean deliveryCevap
- BMaternal repositioning, oxygen administration, and intravenous fluid bolus
- CBedside transabdominal ultrasound
- DPlacement of an intrauterine pressure catheter and amnioinfusion
- EReassurance and continued expectant management