A 16-year-old girl, gravida 1 para 0, at 40 weeks gestation comes to the emergency room with her mother due to several hours of contractions and increasing rectal pressure. The patient's pregnancy has been uncomplicated. She has no chronic medical conditions and has had no previous surgeries. She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. The fetal heart rate tracing is category 1. The tocometer shows contractions every 2-3 minutes. On digital cervical examination, the cervix is 10 cm dilated, with the fetal head at −1 station and in occiput anterior position. The patient is admitted and instructed to start pushing. An hour after pushing, she receives oxytocin to increase the strength and frequency of the contractions. Despite 3 hours of correct pushing technique, significant maternal effort, and frequent contractions, the fetal vertex does not descend past −1 station. Fetal heart rate monitoring continues to show a category 1 tracing. The patient feels fatigued, but her mother encourages her to continue pushing. In most states, which of the following is the best next step in management of this patient?

Question

A 16-year-old girl, gravida 1 para 0, at 40 weeks gestation comes to the emergency room with her mother due to several hours of contractions and increasing rectal pressure.  The patient's pregnancy has been uncomplicated.  She has no chronic medical conditions and has had no previous surgeries.  She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  The fetal heart rate tracing is category 1.  The tocometer shows contractions every 2-3 minutes.  On digital cervical examination, the cervix is 10 cm dilated, with the fetal head at −1 station and in occiput anterior position.  The patient is admitted and instructed to start pushing.  An hour after pushing, she receives oxytocin to increase the strength and frequency of the contractions.  Despite 3 hours of correct pushing technique, significant maternal effort, and frequent contractions, the fetal vertex does not descend past −1 station.  Fetal heart rate monitoring continues to show a category 1 tracing.  The patient feels fatigued, but her mother encourages her to continue pushing.  In most states, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c02c_4637_8f63_2d1e8ce47a27_MD0005_00 The second stage of labor begins at complete (10 cm) cervical dilation and ends with fetal delivery. The duration of the second stage is affected by parity and use of neuraxial anesthesia. However, the longer the duration of the second stage, the higher the risk for neonatal (eg, sepsis) and maternal (eg, postpartum hemorrhage, chorioamnionitis) complications. An arrested second stage of labor occurs when there is no fetal descent (ie, no change in fetal station) after nulliparous patients push for >3 hours without an epidural (or >4 hours with an epidural). Second-stage labor arrest is most commonly caused by cephalopelvic disproportion, which is typically the result of fetal malposition (eg, occiput transverse position) or macrosomia. Management of second-stage labor arrest due to cephalopelvic disproportion is with cesarean delivery. occiput transverse position In most states, minors generally require a parent or legal guardian to provide consent for medical treatment. However, emancipated minors have obtained legal adulthood and can provide their own consent. Some medical conditions, such as pregnancy or a medical emergency, result in a medical emancipation status that also allows adolescents to provide their own consent (Choice D). Therefore, in most states, consent for cesarean delivery can be provided by an adolescent patient. (Choices A and B) Increasing the oxytocin infusion rate is indicated for inadequate contractions; this patient has adequate contractions, based on a spontaneous progression to complete dilation. Given the adequate maternal effort, the lack of fetal descent (ie, high fetal station) is due to cephalopelvic disproportion and is unlikely to respond to maternal rest or increased oxytocin. (Choice E) Operative vaginal delivery (eg, vacuum, forceps) is an option for second-stage labor arrest; however, it is contraindicated if cephalopelvic disproportion is suspected. In addition, a prerequisite for operative vaginal delivery is engagement of the fetal head (ie, fetal station >0). Educational objective: Second-stage labor arrest occurs when there is no fetal descent (ie, no change in fetal station) after nulliparous patients push for >3 hours without an epidural (or >4 hours with an epidural). Management is via cesarean delivery. In most states, adolescents can provide their own consent for pregnancy-related care. References: Safe prevention of the primary cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/24565430) Sexual and reproductive health care for adolescents: legal rights and policy challenges. (http://www.ncbi.nlm.nih.gov/pubmed/18453235)

A 16-Year-Old Girl, Gravida 1 Para 0, at 40 Weeks