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Difficulty: Very hardLabor, Delivery, and Puerperium

A 3333-year-old pregnant patient (G 22 P 11) at 3838 weeks of gestation is currently on the labor and delivery unit undergoing induction for chronic hypertension. An intravenous oxytocin infusion is ongoing. Six hours after starting the induction, her cervical examination shows 55 cm dilation, 90%90\% effacement, and the fetal vertex at a −1-1 station. Over the past 1515 minutes, she has developed sudden, severe, unremitting lower abdominal pain that does not subside between contractions. This is accompanied by a scant amount of dark red vaginal bleeding. Vital signs show a blood pressure of 155/95155/95 mm Hg and a heart rate of 110110/min.

The external tocodynamometer records 66 uterine contractions in a 1010-minute window along with a persistently elevated resting uterine tone. The fetal heart rate tracing displays a baseline of 165165/min, minimal variability, and recurrent late decelerations.

The nursing staff immediately discontinues the oxytocin infusion, repositions her to the left lateral decubitus position, and administers an intravenous fluid bolus. Ten minutes later, the unremitting abdominal pain and the tetanic contraction pattern persist. The fetal heart rate tracing remains identical.

Which of the following is the most appropriate next step in management?

  1. Emergency cesarean deliveryAnswer
  2. B
    Intravenous terbutaline administration
  3. C
    Transcervical amnioinfusion
  4. D
    Intravenous hydralazine administration
  5. E
    Continuation of left lateral positioning and observation

Answer

The most appropriate next step in management is emergency cesarean delivery.
The correct answer is emergency cesarean delivery. This patient's presentation of sudden-onset, severe, unremitting abdominal pain between contractions, dark vaginal bleeding, and a persistently elevated resting uterine tone is highly suspicious for placental abruption (premature separation of the placenta). The fetal heart rate tracing shows fetal tachycardia (165165/min), minimal variability, and recurrent late decelerations, indicating severe uteroplacental insufficiency and fetal hypoxia. Although the tocodynamometer shows uterine tachysystole (66 contractions in 1010 minutes)—which normally prompts the administration of a tocolytic like terbutaline after initial resuscitative measures fail—the presence of a clinical placental abruption makes tocolysis strictly contraindicated. Because the cervix is only 55 cm dilated and vaginal delivery is not imminent, an emergency cesarean delivery is the most appropriate next step to prevent fetal demise and control maternal hemorrhage.

Step-by-Step Solution

1
Analyze the patient's acute physical symptoms and vital signs.
The patient presents with sudden, unremitting abdominal pain, dark vaginal bleeding, and an elevated resting uterine tone.
These findings represent the classic clinical triad for placental abruption, which is a life-threatening obstetric emergency.
2
Evaluate the fetal heart rate tracing and the contraction pattern.
The monitor shows uterine tachysystole (66 contractions in 1010 minutes) combined with a non-reassuring fetal heart rate tracing (tachycardia, minimal variability, late decelerations).
Placental abruption reduces the surface area for oxygen exchange leading to fetal hypoxia (late decelerations) and causes an irritable uterus that contracts frequently (tachysystole).
3
Determine the appropriate management for placental abruption with fetal distress.
Standard intrauterine resuscitation failed. Because the cervix is only 55 cm dilated, rapid vaginal delivery is impossible, necessitating an emergency cesarean delivery.
While tocolytics are typically given for iatrogenic tachysystole, they are strictly contraindicated when abruption is present because they delay necessary delivery and can worsen maternal hemorrhage.

Key Concept

Management of placental abruption mimicking pure oxytocin-induced tachysystole
Estimated Time:1m 30s
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Topics

Labor, Delivery, and Puerperium

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