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Zorluk: ZorLabor, Delivery, and Puerperium

A 27-year-old primigravida at 40 weeks gestation is undergoing induction of labor for oligohydramnios. She is currently receiving a continuous oxytocin drip and has a functioning epidural block. Her blood pressure is 118/76 mm Hg, pulse is 88/min, and temperature is 37.2°C (99.0°F). A cervical examination shows 5 cm dilation, 90% effacement, and -1 station. The fetal monitor records 7 uterine contractions per 10-minute window. The fetal heart rate baseline is 135/min with minimal variability and recurrent late decelerations. The oxytocin drip is immediately stopped, the patient is repositioned to her left side, and an intravenous fluid bolus is administered. Fifteen minutes later, the contraction frequency remains 7 per 10-minute window, and the fetal heart rate tracing is unchanged. Which of the following is the most appropriate next step in management?

  1. A
    Transcervical intraamniotic saline infusion
  2. B
    Urgent cesarean section
  3. Subcutaneous terbutaline injectionCevap
  4. D
    Intravenous ephedrine bolus
  5. E
    Artificial rupture of membranes

Cevap

The correct answer is subcutaneous terbutaline injection.
The correct answer is a subcutaneous terbutaline injection. This patient has uterine tachysystole (7 contractions per 10 minutes) complicated by a Category II fetal heart rate tracing (minimal variability with recurrent late decelerations). The initial management of oxytocin-induced tachysystole includes discontinuing the oxytocin infusion, maternal repositioning (e.g., left lateral decubitus), and administering an intravenous fluid bolus. If these conservative measures fail to resolve the tachysystole and fetal heart rate abnormalities, as seen in this patient after 15 minutes of observation, the next most appropriate step is the administration of a tocolytic agent, such as subcutaneous terbutaline. Terbutaline acts as a beta-2 adrenergic agonist, relaxing the uterine musculature and thereby resolving the hyperstimulation. This improves uteroplacental blood flow, which often normalizes the fetal heart rate tracing and avoids an unnecessary surgical delivery.

Adım Adım Çözüm

1
Identify the primary obstetrical complication from the clinical data.
The patient has uterine tachysystole (>5 contractions per 10 minutes) causing uteroplacental insufficiency, evidenced by recurrent late decelerations.
Accurate diagnosis of the fetal heart rate tracing and uterine activity dictates the resuscitative algorithm.
2
Evaluate the efficacy of the initial interventions.
The initial conservative measures (stopping oxytocin, maternal repositioning, intravenous fluids) failed to reduce the contraction frequency or improve the fetal heart rate tracing after 15 minutes.
Determines whether to continue observation, escalate medical therapy, or proceed to surgical intervention.
3
Select the appropriate secondary intervention based on the persistence of hyperstimulation.
Subcutaneous terbutaline injection is chosen as the next step.
Tocolysis rapidly relaxes the myometrium, resolving the hyperstimulation and improving placental perfusion before a cesarean section becomes necessary.

Anahtar Kavram

The management of uterine tachysystole with a Category II fetal heart rate tracing involves initial conservative measures (stopping uterotonics, repositioning, IV fluids) followed by medical tocolysis (e.g., terbutaline) if the hyperstimulation persists.
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Labor, Delivery, and Puerperium

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