A primi-gravida at 37 weeks reported to labour room with central placenta previa with heavy bleeding per vagina. The FHS was normal at time of examination. The best management option for her is?

1. A

   Expectant management

2. B

   Caesarean section

3. C

   Induction and vaginal delivery

4. D

   Induction and forceps delivery

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

• Central placenta previa at term (37 weeks) with active, heavy bleeding is an obstetric emergency that requires immediate delivery to prevent maternal hemorrhage and fetal compromise.
• A Caesarean section is the only safe method of delivery because the placenta completely covers the internal cervical os. Any attempt at vaginal delivery would cause the dilating cervix to tear the placenta, leading to catastrophic bleeding.
• The primary goal is to ensure maternal safety by controlling the hemorrhage and delivering the fetus. A normal Fetal Heart Sound (FHS) at the time of examination does not reduce the urgency, as the situation can deteriorate rapidly.

Why Other Options Were Wrong

• Option A: Expectant management is only appropriate for preterm pregnancies (typically less than 36-37 weeks) with minimal or no active bleeding. In a term pregnancy with heavy bleeding, delaying delivery is dangerous and increases the risk of severe maternal hemorrhage and fetal distress.
• Option C: Induction of labor and vaginal delivery are absolutely contraindicated in central (complete) placenta previa. The process of cervical dilation would cause the placenta to tear away from the uterine wall, resulting in massive, life-threatening hemorrhage for both the mother and fetus.
• Option D: Like a normal vaginal delivery, a forceps-assisted delivery is contraindicated. Forceps are used in the second stage of labor to assist with delivering the fetal head, but in central placenta previa, a safe vaginal delivery is not possible, so the second stage would not be reached without causing severe hemorrhage.

Related Visual

Clinical Relevance

• Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Management of Placenta Previa as background academic context rather than a clinical decision trigger.
• Nurses in a labor and delivery setting must recognize that a term pregnancy with placenta previa and heavy bleeding is a code-red emergency. Immediate preparation for a Caesarean section is critical, which includes establishing two large-bore IV lines, ensuring blood products are available, and continuously monitoring maternal vital signs and fetal heart rate.
• A crucial nursing intervention is to strictly avoid any vaginal examinations in a patient with suspected or confirmed placenta previa who is actively bleeding. A digital exam can disrupt the placenta and provoke a catastrophic hemorrhage.
• What if? If the same patient presented at 32 weeks with only a minor episode of spotting that resolved, the management would change to expectant management. This would involve hospitalization for observation, administration of corticosteroids to promote fetal lung maturity, and a plan for a scheduled Caesarean section around 36-37 weeks, provided no further significant bleeding occurs.

How to Approach the Question

• First, identify the key components of the clinical scenario: a term pregnancy (37 weeks), a diagnosis of central placenta previa, and the presence of heavy vaginal bleeding.
• Recognize that this combination constitutes a severe obstetric emergency. The primary risk is life-threatening maternal hemorrhage.
• Evaluate the delivery options based on the anatomical problem. In central placenta previa, the placenta completely obstructs the birth canal.
• Conclude that any form of vaginal delivery (induced, spontaneous, or instrument-assisted) is impossible and would lead to severe bleeding.
• Determine that the only safe and definitive management is to bypass the placenta via a Caesarean section to deliver the fetus and control the bleeding.
• The fact that the FHS is normal is a temporary state and does not change the need for immediate action to prevent impending maternal and fetal compromise.

Concept Tested & Keywords

• Concept Tested: Management of Placenta Previa
• Stem keywords: primi-gravida, 37 weeks, central placenta previa, heavy bleeding
• Lead-in keywords: best management
• Clinical cues: Patient is at term (37 weeks), which minimizes concerns about fetal prematurity.
• Clinical cues: The bleeding is described as 'heavy,' indicating an acute, life-threatening situation.

Question ID

QU8EVY-3tuY5s9evwzE5Cx

Copy ID

Reference Book

E6 Obstetrics Williams p. 68-93