A 26-year-old woman, gravida 1 para 0, at 39 weeks gestation is admitted to the hospital with painful contractions. The patient has had no vaginal bleeding or rupture of membranes. Fetal movement is normal. Her pregnancy has been complicated by diet-controlled gestational diabetes mellitus. She has no other chronic medical conditions and has had no surgeries. Blood pressure is 120/70 mm Hg and pulse is 84/min. Fetal heart rate tracing shows a baseline of 140/min, moderate variability, accelerations, and no decelerations. The tocodynamometer shows contractions every 3 minutes. Cervical examination reveals the cervix to be 7 cm dilated and 100% effaced, with the fetal head at 0 station. Epidural anesthesia is administered. Two hours later, the patient is reevaluated for labor progression. Fetal heart tracing continues to be normal. The tocodynamometer now shows contractions every 4-6 minutes. Examination reveals the cervix to be 7 cm dilated and 100% effaced with the fetal head at 0 station, unchanged from the previous examination. Which of the following is the best next step in management of this patient?

Question

A 26-year-old woman, gravida 1 para 0, at 39 weeks gestation is admitted to the hospital with painful contractions.  The patient has had no vaginal bleeding or rupture of membranes.  Fetal movement is normal.  Her pregnancy has been complicated by diet-controlled gestational diabetes mellitus.  She has no other chronic medical conditions and has had no surgeries.  Blood pressure is 120/70 mm Hg and pulse is 84/min.  Fetal heart rate tracing shows a baseline of 140/min, moderate variability, accelerations, and no decelerations.  The tocodynamometer shows contractions every 3 minutes.  Cervical examination reveals the cervix to be 7 cm dilated and 100% effaced, with the fetal head at 0 station.  Epidural anesthesia is administered.  Two hours later, the patient is reevaluated for labor progression.  Fetal heart tracing continues to be normal.  The tocodynamometer now shows contractions every 4-6 minutes.  Examination reveals the cervix to be 7 cm dilated and 100% effaced with the fetal head at 0 station, unchanged from the previous examination.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: The first stage of labor begins with the onset of regular, painful contractions and ends at complete (10 cm) cervical dilation. The first stage consists of 2 phases: Latent phase: From beginning of regular contractions to 6 cm cervical dilation; characterized by slow cervical change. Active phase: From 6 cm to 10 cm (complete) cervical dilation; characterized by rapid (>1 cm/2 hr) cervical change. Active phase protraction is defined as cervical dilation ≤1 cm/2 hr. The most common cause of labor protraction in the active phase is inadequate (hypotonic) uterine contractions. To be adequate, contractions typically have to occur every 2-3 minutes. This patient has had no cervical change over 2 hours and has inadequate contractions (every 4-6 minutes) in the active phase of labor (ie, cervix ≥6 cm). Patients with inadequate contractions require labor augmentation to increase contraction frequency and/or intensity after spontaneous labor has begun. Administration of oxytocin and an amniotomy (artificial rupture of membranes) are first-line treatments for labor protraction. Without adequate contractions, this patient is unlikely to have labor progression (Choice E). amniotomy (Choice A) Variable decelerations, abrupt drops in the fetal heart rate that last <2 minutes, are the result of umbilical cord compression. An amnioinfusion involves placing a catheter inside the uterus to instill fluid, thereby relieving umbilical cord compression and resolving variable decelerations. This patient's fetal heart rate tracing has no decelerations. Variable decelerations (Choice C) Misoprostol, a prostaglandin E1 analog, is used for cervical ripening and labor induction (stimulation of contractions prior to spontaneous labor), not for labor augmentation. (Choice D) Cesarean delivery is indicated for arrest of labor (ie, no cervical change in the active phase of labor for >4 hours with adequate contractions or >6 hours without adequate contractions). This patient does not yet meet the criteria for arrested labor. Educational objective: Protracted active phase of labor occurs at ≥6 cm cervical dilation when the rate of cervical change is slower than expected (≤1 cm/2 hr). The most common cause of a protracted active phase of labor is contraction inadequacy. First-line interventions are oxytocin and amniotomy. References: Safe prevention of the primary cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/24565430) Evidence-based guidelines in labor management. (http://www.ncbi.nlm.nih.gov/pubmed/25101596)

A 26-Year-Old Woman, Gravida 1 Para 0, at 39 Weeks