Examkin

Soru

Zorluk: ZorLabor, Delivery, and Puerperium

A 31-year-old gravida 2, para 1 at 39 weeks and 4 days gestation is evaluated on the labor and delivery unit. Her prenatal course was uncomplicated. She is currently in the second stage of labor and has been actively pushing for 45 minutes with adequate epidural analgesia. The cervix is completely dilated and 100% effaced. The fetal presenting part is the vertex in the direct occiput anterior position at +3 station. Maternal vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 118/76 mmHg, and a heart rate of 88/min. Uterine contractions are occurring every 3 minutes. Over the past 5 minutes, the continuous fetal heart rate monitor demonstrates an abrupt decrease in the baseline to 75/min with absent variability and no return to the previous baseline of 145/min. Immediate repositioning of the patient to the left lateral decubitus position and administration of an intravenous normal saline bolus do not improve the tracing. Which of the following is the most appropriate next step in management?

  1. Perform an operative vaginal deliveryCevap
  2. B
    Initiate emergency cesarean delivery
  3. C
    Administer subcutaneous terbutaline
  4. D
    Continue coached maternal pushing
  5. E
    Administer a therapeutic amnioinfusion

Cevap

Perform an operative vaginal delivery
The correct choice is to perform an operative vaginal delivery. The clinical scenario describes a Category III fetal heart rate tracing (prolonged bradycardia with absent variability) that has failed to improve with standard intrauterine resuscitation, including maternal repositioning and fluid administration. This constitutes an obstetric emergency requiring immediate delivery to prevent severe fetal hypoxia and acidemia. To determine the fastest and safest route of delivery, the maternal cervical exam and fetal station must be evaluated. This patient is fully dilated (10 cm) and the fetal head is at +3 station in an occiput anterior position. These parameters fulfill the criteria for an operative vaginal delivery (using forceps or a vacuum extractor). Performing an operative vaginal delivery at the bedside is significantly faster than preparing the patient for abdominal surgery in the operating room, making it the most appropriate and safest next step.

Adım Adım Çözüm

1
Analyze the fetal heart rate tracing.
The tracing shows a prolonged deceleration (bradycardia of 75/min for >5 minutes) with absent variability, constituting a Category III tracing.
A Category III tracing indicates an abnormal fetal acid-base status and a high risk of hypoxic-ischemic encephalopathy, necessitating expedited delivery.
2
Evaluate the response to intrauterine resuscitation.
Repositioning and fluid bolus failed to resolve the bradycardia.
When initial corrective measures fail in the setting of severe fetal distress, immediate provider-assisted delivery becomes the definitive management.
3
Assess the labor progress and pelvic station to choose the delivery method.
The patient is in the second stage of labor (10 cm dilated), and the fetal head is very low in the pelvis (+3 station) in a direct occiput anterior position.
These findings meet the prerequisites for an operative (instrumental) vaginal delivery, which can be executed far more rapidly in the labor room than transferring the patient to the operating room for a cesarean delivery.

Anahtar Kavram

Management of Category III fetal heart rate tracing in the second stage of labor when criteria for operative vaginal delivery are met.
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Konular

Labor, Delivery, and Puerperium

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