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Zorluk: OrtaLabor, Delivery, and Puerperium

A 29-year-old woman, gravida 2, para 1, at 41 weeks gestation is admitted to the labor and delivery unit for induction of labor due to a post-term pregnancy. She is started on an intravenous oxytocin infusion. Two hours later, the electronic fetal monitor displays contractions occurring every 1 to 1.5 minutes and lasting 60 to 75 seconds. The fetal heart rate baseline is 135/min with minimal variability. The tracing also demonstrates recurrent, smooth, gradual decreases in the fetal heart rate that begin after the peak of each contraction and return to baseline after the contraction ends. The patient's blood pressure is 118/76 mm Hg, and her pulse is 88/min. Cervical examination reveals 5 cm dilation, 80% effacement, and -1 station. Which of the following is the most appropriate next step in management?

  1. Discontinue the oxytocin infusionCevap
  2. B
    Administer subcutaneous terbutaline
  3. C
    Proceed to emergency cesarean delivery
  4. D
    Place the patient in the supine position
  5. E
    Perform artificial rupture of membranes

Cevap

Discontinue the oxytocin infusion.
The correct answer is to discontinue the oxytocin infusion. The patient is experiencing uterine tachysystole (defined as >5 contractions in a 10-minute period, averaged over 30 minutes). Uterine contractions temporarily compress the spiral arteries, reducing uteroplacental blood flow. When contractions are too frequent, there is inadequate relaxation time for placental perfusion to recover, leading to fetal hypoxemia and late decelerations. Because this tachysystole is iatrogenic (caused by the oxytocin infusion), the immediate and most appropriate first step in management is to stop the oxytocin. Additional resuscitative measures include repositioning the mother (e.g., left lateral decubitus position) to relieve aortocaval compression and administering an intravenous fluid bolus.

Adım Adım Çözüm

1
Analyze the uterine contraction pattern.
The patient is experiencing contractions every 1 to 1.5 minutes, which equates to more than 5 contractions in a 10-minute window. This is diagnostic of uterine tachysystole.
Identifying tachysystole is crucial because excessively frequent contractions do not allow adequate time for placental blood flow to recover between contractions.
2
Interpret the fetal heart rate tracing.
The tracing shows recurrent, gradual decreases in the fetal heart rate with the nadir occurring after the peak of the contraction. These are late decelerations.
Late decelerations indicate uteroplacental insufficiency and fetal hypoxemia, which in this case is directly driven by the uterine tachysystole.
3
Determine the appropriate initial management step.
The most appropriate next step is intrauterine resuscitation, primarily by removing the offending agent causing the tachysystole.
Since the patient is receiving an oxytocin infusion, stopping it immediately is the most direct and effective way to halt the tachysystole and restore adequate placental perfusion.

Anahtar Kavram

Management of Uterine Tachysystole with Late Decelerations
Tahmini Süre:1m 0s
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Konular

Labor, Delivery, and Puerperium

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