A 32-year-old primigravid woman at 37 weeks gestation and in active labor is admitted to the labor and delivery unit. On admission, the cervix is 4 cm dilated and 80% effaced, with the fetal vertex at 0 station. The membranes are grossly ruptured with thin, clear amniotic fluid. Fetal heart rate tracing is category I, and the patient receives epidural anesthesia for pain management; she reports complete pain relief. The fetal heart rate tracing 10 minutes later is shown in the following image: Maternal blood pressure is 60/40 mm Hg and pulse is 60/min. Repeat cervical examination shows the cervix to be 5 cm dilated and 100% effaced and the fetal vertex at +1 station. In addition to intravenous fluids, which of the following is the best next step in management of this patient?

Question

A 32-year-old primigravid woman at 37 weeks gestation and in active labor is admitted to the labor and delivery unit.  On admission, the cervix is 4 cm dilated and 80% effaced, with the fetal vertex at 0 station.  The membranes are grossly ruptured with thin, clear amniotic fluid.  Fetal heart rate tracing is category I, and the patient receives epidural anesthesia for pain management; she reports complete pain relief.  The fetal heart rate tracing 10 minutes later is shown in the following image:  Maternal blood pressure is 60/40 mm Hg and pulse is 60/min.  Repeat cervical examination shows the cervix to be 5 cm dilated and 100% effaced and the fetal vertex at +1 station.  In addition to intravenous fluids, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da10_bee1_bc81_2b04930a0f63_MD0003_00 This patient's fetal heart rate tracing shows late decelerations, a sign of decreased placental perfusion (ie, uteroplacental insufficiency) and impending fetal hypoxemia and acidemia. A common cause of decreased placental perfusion is maternal hypotension, a common side effect of neuraxial anesthesia (eg, epidural). Epidural anesthesia typically consists of a local anesthetic (eg, bupivacaine) and an opioid (eg, fentanyl) for a targeted block of pain fibers associated with labor and delivery. However, epidurals can also cause sympathetic nerve blockade, which results in vasodilation, decreased venous return to the heart, decreased cardiac output, and resultant maternal hypotension. Therefore, patients are often given an intravenous fluid bolus prior to epidural placement, but hypotension still commonly occurs. Treatment of maternal hypotension and uteroplacental insufficiency includes left uterine displacement (positioning the patient on her left side) to improve venous return, intravenous fluid bolus, and vasopressor administration (eg, phenylephrine, ephedrine) to improve blood pressure. Patients who continue to have late fetal decelerations despite these measures require cesarean delivery to prevent fetal hypoxemia. (Choice A) Amnioinfusion is used to reduce umbilical cord compression, which can occur after rupture of membranes and is evidenced by variable decelerations. It is not used in the management of late decelerations. variable decelerations (Choice B) Opioids are used in neuraxial anesthesia and very rarely may cause systemic overdose, which can be treated with naloxone. However, patients rarely have profound hypotension, and the fetal heart rate tracing typically shows minimal variability rather than recurrent late decelerations. minimal variability (Choice D) Terbutaline is a tocolytic used to treat recurrent late decelerations due to uterine tachysystole, defined as >5 contractions/10 min. This patient's contraction frequency is normal. In addition, terbutaline is a beta-2 agonist and can cause vasodilation and hypotension, which would worsen this patient's condition. uterine tachysystole Educational objective: Neuraxial anesthesia (eg, epidural) can cause sympathetic block, resulting in maternal hypotension and decreased placental perfusion, as evidenced by recurrent late fetal heart rate decelerations. Management is with left lateral patient positioning, intravenous fluid bolus, and vasopressors (eg, phenylephrine). References: Spinal anaesthesia-induced hypotension in obstetrics: prevention and therapy. (http://www.ncbi.nlm.nih.gov/pubmed/31741565) Techniques for preventing hypotension during spinal anaesthesia for caesarean section. (http://www.ncbi.nlm.nih.gov/pubmed/28976555)

A 32-Year-Old Primigravid Woman at 37 Weeks Gestation and in Active