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Soru

Zorluk: ZorLabor, Delivery, and Puerperium

A 27-year-old primigravid woman at 39 weeks gestation is admitted to the labor and delivery unit in spontaneous labor. She requests and receives epidural anesthesia for pain management. Her labor progresses without complication, and her cervix becomes completely dilated. She is instructed to begin pushing. Three hours later, a vaginal examination reveals the cervix is 10 cm dilated and 100% effaced, and the fetal head is at +2 station in the direct occiput anterior position. The maternal temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, and pulse is 84/min. Uterine contractions occur every 2 to 3 minutes and are strong to palpation. Continuous fetal heart rate monitoring demonstrates a baseline of 135/min, moderate variability, and symmetric, gradual decreases in the fetal heart rate that begin and end with each uterine contraction. The nadir of these decreases coincides precisely with the peak of each contraction. Which of the following is the most appropriate next step in management?

  1. Continued maternal pushingCevap
  2. B
    Cesarean delivery
  3. C
    Vacuum-assisted vaginal delivery
  4. D
    Intravenous oxytocin administration
  5. E
    Maternal repositioning to the left lateral decubitus position

Cevap

The correct answer is continued maternal pushing.
The correct answer is continued maternal pushing because the patient has not yet met the diagnostic criteria for second-stage labor arrest. According to current American College of Obstetricians and Gynecologists (ACOG) guidelines, an arrest of the second stage in a nulliparous woman with epidural anesthesia is diagnosed only after at least 4 hours of pushing. Because she has been pushing for 3 hours, has adequate contractions, and has a Category I fetal heart rate tracing (baseline 135/min, moderate variability, and early decelerations due to head compression), the most appropriate management is to allow her to continue pushing.

Adım Adım Çözüm

1
Interpret the fetal heart rate (FHR) tracing to determine fetal status.
The FHR shows a normal baseline, moderate variability, and early decelerations (gradual decreases that mirror the contractions). This is a reassuring Category I tracing.
Early decelerations are a benign result of fetal head compression during the second stage of labor and do not require intervention.
2
Assess the adequacy of uterine contractions.
Contractions are occurring every 2 to 3 minutes and are palpated as strong, indicating adequate uterine activity.
This rules out the need for uterotonic augmentation (e.g., oxytocin).
3
Apply the diagnostic criteria for second-stage arrest based on parity and epidural status.
The patient is a nulliparous woman with an epidural. Current guidelines define second-stage arrest in this population as the lack of progress after 4 hours of pushing.
Since she has only been pushing for 3 hours, she has not yet met the criteria for an arrest disorder.
4
Determine the next best step in management.
Expectant management with continued maternal pushing.
Because both maternal and fetal statuses are reassuring and the patient is within the normal temporal limits for the second stage of labor, no medical or surgical intervention is indicated at this time.

Anahtar Kavram

The diagnosis of second-stage arrest of labor requires specific time limits: at least 4 hours of pushing in nulliparous women with an epidural (or 3 hours without), and at least 3 hours in multiparous women with an epidural (or 2 hours without).
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Labor, Delivery, and Puerperium

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