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Difficulty: MediumObstetric Complications

An obstetric patient at 39 weeks gestation is admitted to the labor suite for induction of labor due to chronic hypertension. A continuous oxytocin infusion is currently being administered to augment uterine contractions. The patient's blood pressure is 138/88 mmHg. The continuous electronic fetal monitor displays a baseline heart rate of 145/min with moderate variability. The tracing demonstrates recurrent, gradual decreases in the fetal heart rate, with each deceleration starting after the peak of a uterine contraction and returning to baseline only after the contraction has completely finished. The contractions are occurring every 2 to 3 minutes. Cervical examination shows 5 cm dilation and 90% effacement. Which of the following is the most appropriate initial step in the management of this patient?

  1. Discontinue the continuous oxytocin infusionAnswer
  2. B
    Proceed immediately to operative delivery
  3. C
    Administer a transcervical amnioinfusion
  4. D
    Position the patient in a supine posture
  5. E
    Maintain current management and continue monitoring

Answer

Discontinue the continuous oxytocin infusion
The patient is experiencing recurrent late decelerations, which are characterized by a gradual decrease in the fetal heart rate that begins after the peak of the uterine contraction. This pattern indicates uteroplacental insufficiency, resulting in transient fetal hypoxemia. The most appropriate initial step is intrauterine resuscitation aimed at maximizing uteroplacental blood flow and fetal oxygenation. Essential steps include maternal repositioning (typically left lateral decubitus), administering intravenous fluids, providing supplemental oxygen, and immediately discontinuing any uterotonic agents. Therefore, stopping the oxytocin infusion is a critical and necessary intervention.

Step-by-Step Solution

1
Analyze the fetal heart rate tracing description.
The gradual decreases starting after the peak of a contraction and ending after the contraction finishes are defined as late decelerations.
Accurate identification of the deceleration type is required to determine the underlying pathophysiology.
2
Determine the etiology of the identified decelerations.
Late decelerations are caused by uteroplacental insufficiency, meaning the fetus is experiencing transient hypoxemia during contractions.
Understanding the cause guides the specific resuscitative interventions.
3
Select the most appropriate initial management step.
The immediate goal is to improve uteroplacental blood flow through intrauterine resuscitation. A key step is decreasing uterine work by stopping any uterotonic agents.
Oxytocin stimulates contractions which reduce blood flow to the placenta; stopping it allows the uterus to relax and restores fetal oxygenation.

Key Concept

Recurrent late decelerations indicate uteroplacental insufficiency. Initial management involves intrauterine resuscitation, which includes maternal repositioning, supplemental oxygen, intravenous fluids, and discontinuation of uterotonic agents like oxytocin.
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Topics

Obstetric Complications

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