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Zorluk: ZorLabor, Delivery, and Puerperium

An adolescent primigravida at 39 weeks gestation is currently in the active phase of labor following spontaneous rupture of membranes 24 hours ago. Over the last hour, she has developed a new-onset fever. She is currently receiving continuous epidural analgesia. Her temperature is 39.2°C (102.6°F), blood pressure is 112/70 mm Hg, pulse is 115/min, and respirations are 18/min. Physical examination reveals a uterus that is tender to palpation between contractions. Pelvic examination shows the cervix is 6 cm dilated and 90% effaced, with the fetal presenting part at +1 station. Uterine contractions are occurring every 5 to 6 minutes. Continuous fetal monitoring displays a baseline heart rate of 175/min with moderate variability and occasional early decelerations. Which of the following is the most appropriate next step in the management of this patient?

  1. Intravenous ampicillin, gentamicin, and oxytocinCevap
  2. B
    Intravenous ampicillin, gentamicin, and immediate cesarean delivery
  3. C
    Administration of acetaminophen and continued observation
  4. D
    Transcervical amnioinfusion and expectant management
  5. E
    Intravenous clindamycin and magnesium sulfate

Cevap

The correct answer is the administration of intravenous ampicillin, gentamicin, and oxytocin.
The correct answer combines both the necessary medical treatment and the appropriate obstetric management. The patient has clinical intra-amniotic infection (fever, fetal tachycardia, uterine tenderness) occurring after prolonged rupture of membranes. Standard treatment includes broad-spectrum antibiotics (such as ampicillin and gentamicin). Additionally, because her contractions are inadequate (every 5-6 minutes in the active phase) and the fetal heart rate tracing is reassuring (Category I/II with moderate variability and early decelerations), the most appropriate obstetric step is to expedite vaginal delivery via oxytocin augmentation. Intra-amniotic infection alone is not an indication for cesarean delivery.

Adım Adım Çözüm

1
Diagnose the underlying condition based on maternal vital signs and physical examination.
The maternal temperature of 39.2°C (102.6°F), accompanied by uterine tenderness and fetal tachycardia, confirms the diagnosis of intra-amniotic infection (chorioamnionitis).
Maternal fever greater than 39.0°C in labor, especially with prolonged rupture of membranes and additional infectious signs, meets the criteria for clinical intra-amniotic infection.
2
Select the appropriate pharmacologic intervention for the infection.
Intravenous broad-spectrum antibiotics, typically ampicillin and gentamicin, are required.
Prompt antibiotic administration prevents maternal morbidity (e.g., sepsis) and neonatal infectious complications.
3
Determine the appropriate obstetric management by evaluating labor progression and fetal status.
The contractions are inadequate (every 5-6 minutes) for the active phase of labor, and the fetal heart rate tracing is reassuring (moderate variability, no late/variable decelerations). Therefore, labor augmentation with oxytocin is indicated.
Intra-amniotic infection requires expeditious delivery. Because the fetus is tolerating labor well, vaginal delivery should be facilitated with oxytocin rather than proceeding to an unnecessary cesarean delivery.

Anahtar Kavram

Intra-amniotic infection (chorioamnionitis) is managed with broad-spectrum antibiotics and augmentation of labor to expedite vaginal delivery; it is not an absolute indication for cesarean delivery.
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Labor, Delivery, and Puerperium

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