A 34-year-old woman, gravida 3 para 2, at 35 weeks gestation is evaluated in the labor and delivery unit due to increasing mucoid vaginal bleeding and contractions. The patient has been undergoing an induction of labor for fetal growth restriction due to chronic hypertension. Pelvic examination an hour ago showed the cervix to be 6 cm dilated and 100% effaced after spontaneous rupture of membranes. Since then, the patient has developed increasing bloody discharge with some clots. Contractions have also increased in intensity and frequency. Group B Streptococcus rectovaginal culture performed last week was negative. Temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, and pulse is 78/min. Fetal heart rate tracing shows a baseline of 120/min, moderate variability, multiple early decelerations, and no accelerations. Contractions occur every 2 minutes. The cervix is 8 cm dilated and 100% effaced with a moderate amount of mucus and blood on examination. Which of the following is the best next step in management of this patient?

Question

A 34-year-old woman, gravida 3 para 2, at 35 weeks gestation is evaluated in the labor and delivery unit due to increasing mucoid vaginal bleeding and contractions.  The patient has been undergoing an induction of labor for fetal growth restriction due to chronic hypertension.  Pelvic examination an hour ago showed the cervix to be 6 cm dilated and 100% effaced after spontaneous rupture of membranes.  Since then, the patient has developed increasing bloody discharge with some clots.  Contractions have also increased in intensity and frequency.  Group B Streptococcus rectovaginal culture performed last week was negative.  Temperature is 37.2 C (99 F), blood pressure is 150/90 mm Hg, and pulse is 78/min.  Fetal heart rate tracing shows a baseline of 120/min, moderate variability, multiple early decelerations, and no accelerations.  Contractions occur every 2 minutes.  The cervix is 8 cm dilated and 100% effaced with a moderate amount of mucus and blood on examination.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Patients in active labor can have benign or emergent causes of intrapartum bleeding (eg, abruptio placentae, uterine rupture), which are evaluated based on the following: Maternal hemodynamic stability Fetal stability (ie, fetal heart rate tracing) Labor progression and contraction pattern Although this patient has increasing vaginal bleeding and passage of clots, she has normal vital signs and evidence of fetal stability, including a category I fetal heart rate tracing (baseline 110-160/min, moderate variability, with no late or variable decelerations). Early decelerations, which occur due to fetal head compression, and the presence or absence of accelerations are normal for a category I tracing. In addition, this patient has had normal labor progression. Therefore, her pattern of bleeding is most consistent with bloody show, a benign cause of bleeding that occurs during the active phase of labor when the cervix dilates and stretches rapidly (eg, ≥1 cm/2 hr). The result is increased cervical mucus and bleeding (which may include passage of clots). Patients with bloody show can continue expectant management. Early decelerations (Choice A) A biophysical profile is an antepartum ultrasound test for fetal well-being; it is used in high-risk pregnancies (eg, growth restriction) or for evaluation of a nonreactive nonstress test (ie, 20- to 40-min fetal tracing with <2 accelerations). It is not used intrapartum. (Choice B) Broad-spectrum antibiotics can treat intraamniotic infection, which may trigger increased contractions and bleeding; however, patients typically have fever, fundal tenderness, and fetal tachycardia. (Choice C) Indications for cesarean delivery during the first stage of labor (ie, <10 cm dilation) include a category III fetal heart rate tracing (eg, bradycardia, late decelerations) or arrest of labor (ie, no cervical change for ≥4 hr despite adequate contractions), neither of which is seen in this patient. (Choice E) Forceps-assisted vaginal delivery can expedite delivery in cases of maternal exhaustion or acute fetal bradycardia during the second stage of labor (ie, after 10 cm dilation). This patient is 8 cm dilated. (Choice F) Tocolytic therapy (eg, terbutaline) inhibits contractions; it is indicated for fetal heart rate abnormalities (eg, late decelerations) caused by uterine tachysystole (ie, >5 contractions/10 min). This patient's contractions occur every 2 minutes and are normal. Educational objective: Normal labor can cause mucoid vaginal bleeding (ie, bloody show), particularly during active labor, due to rapid cervical dilation. Patients with increased bloody show and reassuring maternal-fetal status (ie, normal vital signs, category I tracing) can continue expectant management. References: Intrapartum fetal monitoring. (http://www.ncbi.nlm.nih.gov/pubmed/20000301)

A 34-Year-Old Woman, Gravida 3 Para 2, at 35 Weeks