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Question

Difficulty: EasyLabor, Delivery, and Puerperium

A 27-year-old woman, gravida 1, para 0, is admitted to the hospital at 39 weeks gestation in active labor. Her prenatal course was uncomplicated. Epidural analgesia is initiated for pain management when her cervical dilation is 5 cm. Fifteen minutes after the epidural placement, the patient complains of sudden dizziness and nausea. Her blood pressure drops to 88/55 mm Hg, and her pulse increases to 105/min. The external fetal monitor reveals a baseline fetal heart rate of 145/min with moderate variability. There are recurrent, symmetric, gradual decreases in the fetal heart rate that reach their nadir after the peak of each uterine contraction; the heart rate returns to baseline only after the contraction has ended. Which of the following is the most appropriate initial step in the management of this patient?

  1. Repositioning the patient to the left lateral decubitus positionAnswer
  2. B
    Preparation for an immediate emergency cesarean delivery
  3. C
    Initiation of a transcervical amnioinfusion
  4. D
    Administration of subcutaneous terbutaline
  5. E
    Performance of artificial rupture of membranes

Answer

Repositioning the patient to the left lateral decubitus position
The correct answer is repositioning the patient to the left lateral decubitus position. This patient is experiencing late decelerations caused by uteroplacental insufficiency secondary to maternal hypotension. Epidural anesthesia frequently causes a sympathetic blockade that leads to systemic vasodilation, venous pooling, and subsequent hypotension. This acute drop in maternal blood pressure directly decreases blood flow to the placenta, resulting in fetal hypoxia and late decelerations. The initial step in intrauterine resuscitation for this condition is maternal repositioning to the left lateral decubitus position. This simple maneuver physically displaces the heavy gravid uterus off the inferior vena cava, thereby increasing venous return, maternal cardiac output, and uteroplacental perfusion. This positional change is typically accompanied by an intravenous isotonic fluid bolus, and if refractory, a vasopressor like ephedrine or phenylephrine.

Step-by-Step Solution

1
Identify the cause of the maternal symptoms.
The patient developed sudden hypotension (88/55 mm Hg) shortly after epidural placement, which is a classic presentation of epidural-induced sympathetic blockade leading to vasodilation and decreased venous return.
Recognizing the etiology of hypotension dictates the intervention.
2
Interpret the fetal heart rate tracing.
The tracing shows symmetric decreases that nadir after the peak of the contraction, which defines late decelerations. Late decelerations are a sign of uteroplacental insufficiency.
Connecting maternal hypotension to decreased placental perfusion explains the fetal distress.
3
Determine the initial management step.
The first step in intrauterine resuscitation is to improve maternal cardiac output and placental perfusion. This is achieved by repositioning the patient to the left lateral decubitus position.
This position shifts the gravid uterus off the inferior vena cava, increasing venous return to the heart and subsequently improving blood flow to the placenta.

Key Concept

Epidural-induced maternal hypotension leading to late decelerations should be initially managed with intrauterine resuscitation, starting with maternal repositioning and intravenous fluid boluses.
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Topics

Labor, Delivery, and Puerperium

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