Examkin

Soru

Zorluk: OrtaLabor, Delivery, and Puerperium

A 26-year-old woman, G1P0, at 40 weeks and 2 days gestation, is currently in the active phase of the first stage of labor. Cervical examination reveals 7 cm dilation, complete effacement, and +1 station. Spontaneous rupture of membranes occurred four hours ago, revealing clear fluid. The patient is receiving an epidural for analgesia and an intravenous oxytocin drip to optimize uterine contractility. Maternal vital signs are within normal limits. The continuous fetal monitor shows a baseline heart rate of 142/min with moderate variability. The tracing also reveals gradual, symmetric drops in the fetal heart rate that consistently start after the peak of each uterine contraction, with the lowest point of the drop occurring after the contraction resolves. These drops are observed with more than half of the contractions. Which of the following is the most appropriate next action in the care of this patient?

  1. A
    Transcervical instillation of normal saline
  2. B
    Transfer to the operating room for immediate cesarean delivery
  3. Cessation of the intravenous oxytocin infusionCevap
  4. D
    Observation with uninterrupted electronic fetal monitoring
  5. E
    Placement of an internal fetal heart rate monitor

Cevap

Cessation of the intravenous oxytocin infusion
The patient's fetal heart rate tracing demonstrates recurrent late decelerations, which are defined as gradual, symmetric decreases in the fetal heart rate that begin after the peak of a contraction and reach their nadir after the contraction has ended. Late decelerations are a sign of uteroplacental insufficiency. When they occur in more than 50% of contractions, they require immediate intervention. The initial management consists of intrauterine resuscitation measures aimed at improving placental blood flow and fetal oxygenation. These measures include maternal repositioning (typically left lateral decubitus), administering an intravenous fluid bolus, providing supplemental oxygen, and immediately discontinuing any uterotonic agents. Because this patient is receiving an oxytocin infusion, which stimulates uterine contractions and temporarily decreases blood flow to the intervillous space, stopping the oxytocin is the most critical and appropriate next action.

Adım Adım Çözüm

1
Interpret the fetal heart rate (FHR) tracing described in the clinical vignette.
The FHR tracing shows recurrent late decelerations (gradual decreases starting after the contraction peak).
Accurate interpretation of the FHR pattern is essential to determine the underlying pathophysiology and guide management.
2
Determine the pathophysiologic cause of the FHR pattern.
Late decelerations are caused by uteroplacental insufficiency, which can be exacerbated by uterine contractions, especially when augmented by oxytocin.
Understanding that uterine contractions temporarily decrease placental blood flow explains why modifying contraction frequency or intensity is therapeutic.
3
Select the most appropriate initial management step for this condition.
The first step in intrauterine resuscitation is to alleviate uteroplacental insufficiency by stopping uterotonic agents like oxytocin, repositioning the mother, and administering intravenous fluids or oxygen.
Stopping oxytocin immediately reduces the frequency and strength of contractions, restoring placental blood flow and improving fetal oxygenation without prematurely resorting to surgical delivery.

Anahtar Kavram

Recurrent late decelerations indicate uteroplacental insufficiency and should be initially managed with intrauterine resuscitation, starting with the discontinuation of any uterotonic agents like oxytocin.
Bu soruyu puanla

Konular

Labor, Delivery, and Puerperium

Bu konudan daha fazla soru