A 30-year-old gravida 1 para at 38 weeks of gestation presents to you with contractions and vaginal bleeding. She notes that she has filled a medium-sized sanitary napkin with blood in the past hour and that she feels painful contractions every 2 minutes. Electronic fetal monitoring and tocometry are started. Vital signs are: temperature 37 °C, heart rate 100 beats/minute, blood pressure 170/95 mm Hg, respiratory rate 20 breaths/minute, and oxygen saturation 99% on room air. Fetal heart tracing is 130 beats/minute with minimal variability and occasional late decelerations. Contractions are every 1 to 2 minutes.
Upon vaginal examination, you note dime-sized clots in the vaginal vault. Her cervical examination shows complete dilation, 100% effacement, and station +3/5. She feels an urge to push 5 minutes later and precipitously delivers a viable neonate, followed immediately by the placenta; it appears to have a large amount of adherent clot. The patient has several gushes of blood and expresses at least 500 cc of blood clots. While you evacuate more clots from inside her uterus, her brisk bleeding continues and more blood clots are expressed.
Vital signs are again obtained and are: temperature 37 °C, heart rate 120 beats/minute, blood pressure 85/55 mm Hg, respiratory rate 24 breaths/minute, and oxygen saturation 100% on 2 L oxygen by nasal cannula.
Which of the following is the next most appropriate step in management?
This question appears in Med-Challenger OBGYN Exam Review with CME
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