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Soru

Zorluk: KolayLabor, Delivery, and Puerperium

A healthy 24-year-old patient is admitted in active labor at 39 weeks' gestation. She requests pain management and receives continuous lumbar epidural analgesia when her cervix is dilated to 5 cm. Fifteen minutes following the epidural bolus, the patient begins to feel lightheaded and nauseous. Her blood pressure drops from an admission baseline of 118/74 mm Hg to 82/45 mm Hg. Simultaneous continuous fetal monitoring demonstrates a baseline heart rate of 145/min that suddenly decreases to 85/min and has remained there for the past 3 minutes. The nurse immediately turns the patient onto her left side and administers a rapid intravenous bolus of isotonic crystalloid, but the maternal blood pressure remains 84/48 mm Hg and the prolonged fetal bradycardia persists. Which of the following is the most appropriate next step in management?

  1. Administer intravenous ephedrineCevap
  2. B
    Transfer to the operating room for immediate cesarean delivery
  3. C
    Initiate transcervical amnioinfusion
  4. D
    Administer subcutaneous terbutaline
  5. E
    Perform artificial rupture of membranes

Cevap

Administer intravenous ephedrine to correct the maternal hypotension and restore uteroplacental blood flow.
The correct response is to administer an intravenous vasopressor, such as ephedrine (or phenylephrine). Sympathetic blockade is a common complication of epidural analgesia, resulting in systemic vasodilation and a rapid drop in maternal blood pressure. This hypotension drastically reduces uteroplacental perfusion, leading to fetal hypoxemia and a prolonged fetal heart rate deceleration. The initial management of epidural-induced hypotension involves placing the patient in the left lateral decubitus position to relieve aortocaval compression and administering an intravenous fluid bolus. Because these initial measures were unsuccessful in this patient, the next best step is to administer a vasopressor to restore maternal hemodynamics and placental blood flow.

Adım Adım Çözüm

1
Identify the primary complication.
The patient developed acute maternal hypotension immediately following an epidural, leading to a prolonged fetal heart rate deceleration.
Epidural anesthesia blocks the sympathetic nervous system, commonly causing peripheral vasodilation and decreased venous return.
2
Evaluate the response to initial conservative management.
The patient's blood pressure did not improve after left lateral positioning (to relieve aortocaval compression) and intravenous fluid boluses.
When mechanical and fluid volume interventions fail to restore adequate blood pressure, pharmacological support is required.
3
Select the appropriate definitive pharmacological intervention.
An intravenous vasopressor, such as ephedrine or phenylephrine, is indicated.
Vasopressors counteract the sympathetic blockade, constricting blood vessels to elevate maternal blood pressure, thereby restoring perfusion to the placenta and resolving the fetal deceleration.

Anahtar Kavram

Epidural-induced maternal hypotension is a common cause of prolonged fetal decelerations and is managed sequentially with left lateral positioning, intravenous fluid boluses, and vasopressors (e.g., ephedrine or phenylephrine).
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Labor, Delivery, and Puerperium

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