From the Guidelines
The best next step in management for this patient is to continue close monitoring of labor progression and fetal status while preparing for imminent vaginal delivery. The patient is making appropriate progress in labor, with cervical dilation advancing from 6 cm to 8 cm, and the fetal heart rate tracing shows reassuring features including moderate variability without concerning decelerations 1. The bloody show and mucus discharge are normal findings during the active phase of labor. While the patient has chronic hypertension with a current blood pressure of 150/90 mm Hg, this is not severely elevated and doesn't require immediate intervention during active labor, as per the ISSHP guidelines which recommend treatment for severe hypertension (>160/110 mm Hg) 1. The early decelerations on fetal monitoring are a normal physiological response to head compression during contractions and don't indicate fetal distress. Since she is GBS negative, no antibiotic prophylaxis is needed. With contractions every 2 minutes and rapid cervical change, delivery is likely to occur soon, and the current management approach of allowing labor to continue with close monitoring is appropriate. The patient should be supported through the final stages of labor with regular vital sign checks, continuous fetal monitoring, and preparation for delivery.
Key considerations in the management of this patient include:
- Close monitoring of fetal heart rate and labor progression
- Preparation for imminent vaginal delivery
- Regular vital sign checks, including blood pressure monitoring
- Continuous fetal monitoring to assess for any signs of fetal distress
- Support and preparation for the final stages of labor and delivery.
It is essential to prioritize the patient's and fetus's well-being, ensuring that any interventions are guided by the most recent and highest-quality evidence, such as the ISSHP guidelines 1, to optimize outcomes and minimize risks.
From the Research
Assessment of the Patient's Condition
- The patient is a 34-year-old woman, gravida 3 para 2, at 35 weeks gestation, undergoing induction of labor for fetal growth restriction due to chronic hypertension.
- She has been experiencing increasing mucoid vaginal bleeding and contractions, with a pelvic examination showing the cervix to be 8 cm dilated and 100% effaced.
- The patient has a moderate amount of mucus and blood on examination, and the fetal heart rate tracing shows a baseline of 120/min, moderate variability, multiple early decelerations, and no accelerations.
Management of the Patient
- According to the study 2, evidence-based labor and delivery management favors hospital births, delayed admission, support by doula, and upright position in the second stage.
- The study 3 suggests that intermittent fetal auscultation may be considered as an alternative to continuous electronic fetal monitoring, which is associated with a high false-positive rate.
- Given the patient's condition, with increasing bloody discharge and contractions, it is essential to closely monitor the fetal heart rate and uterine activity, as stated in the study 4.
- The study 5 emphasizes the importance of understanding the physiology behind fetal heart rate changes and responding to them accordingly, rather than relying solely on guidelines for management.
Next Steps in Management
- The best next step in management would be to continue monitoring the patient's condition closely, with frequent checks on the fetal heart rate and uterine activity, as recommended by the studies 4 and 5.
- The patient's increasing bloody discharge and contractions may indicate a need for closer monitoring and potential intervention, such as oxytocin augmentation or preparation for a potential cesarean section, as suggested by the study 2.
- It is crucial to prioritize the well-being of both the mother and the fetus, and to be prepared for any potential complications that may arise during the labor and delivery process, as emphasized by the study 3.