Approach to third trimester bleeding Quiz: Ace Your Exams

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A 32-year-old woman, gravida 2, para 1, at 39 weeks of estimated gestational age (EGA) with an uncomplicated pregnancy, is admitted for a trial of labor after cesarean (TOLAC). She is contracting every 2 to 4 minutes, and the cervix is 6 cm dilated, 75% effaced, and at +1 cm station on admission. She has a history of one prior uncomplicated cesarean birth 3 years ago for breech presentation at term. An epidural is placed per patient request, which provides excellent pain relief for 2 hours. The patient suddenly develops moderate vaginal bleeding and intense abdominal pain. Maternal pulse is 112/min, respirations are 18/min, and blood pressure is 94/58 mmHg. The abdomen is firm to palpation, and a repeat cervix exam is 5 cm dilated, 75% effaced, and –3 cm station. The baseline fetal heart rate decreases from 150 bpm with moderate variability to 110 bpm and minimal variability. The last contraction on the monitor was seen 8 minutes ago. Which of the following is the most appropriate next step in management? 

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