From the Guidelines
The best next step in management for this patient is to discharge her home with instructions for hydration and rest. This patient is experiencing false labor, also known as Braxton Hicks contractions, which are characterized by irregular uterine contractions without cervical dilation. The reassuring factors include a closed cervix on examination, irregular contractions on tocodynamometry, and a reassuring nonstress test with good fetal heart rate baseline, variability, and accelerations. Although the patient is Group B Streptococcus positive, intrapartum antibiotic prophylaxis is only indicated once she is in true labor with cervical changes or has rupture of membranes, as stated in the guidelines for prevention of perinatal group B streptococcal disease 1. Since she is not in active labor, there is no need for hospital admission or tocolysis at this time.
Some key points to consider in the management of this patient include:
- The patient's iron deficiency anemia, for which she is taking a prenatal vitamin and iron supplementation, does not directly impact the current management of her contractions.
- The patient's history of a vaginal delivery at term with her prior pregnancy suggests that she may be a candidate for a vaginal delivery in the current pregnancy, but this does not affect the current management of her false labor.
- The patient's positive rectovaginal culture for group B Streptococcus is an important consideration for intrapartum antibiotic prophylaxis, but as stated in the guidelines, this is only indicated once she is in true labor with cervical changes or has rupture of membranes 1.
The patient should be instructed to return if contractions become regular and more frequent (every 5 minutes for at least an hour), if she experiences rupture of membranes, vaginal bleeding, decreased fetal movement, or any other concerning symptoms. Adequate hydration is particularly important as dehydration from her day at the beach may have contributed to these contractions. According to the guidelines for management of preterm labor, hydration with intravenous fluids is a common initial step in management, but in this case, the patient can be managed with oral hydration at home 1.
From the Research
Patient Assessment
- The patient is a 41-year-old woman, gravida 2 para 1, at 35 weeks gestation with contractions that started 5 hours ago.
- She has iron deficiency anemia and is taking prenatal vitamins and iron supplementation.
- The patient has a history of a positive rectovaginal culture for group B Streptococcus and had a vaginal delivery at term with her prior pregnancy.
- Blood pressure is 110/80 mm Hg and pulse is 92/min, with a nonstress test showing a baseline of 120/min, moderate variability, and multiple accelerations.
Management Considerations
- The patient's contractions and gestational age suggest a potential preterm labor, but the cervix is closed on digital cervical examination.
- According to the studies, antenatal corticosteroids are recommended for fetal lung maturation in threatened preterm delivery between 24 and 34 weeks of gestation 2, 3.
- However, the patient is at 35 weeks gestation, which is outside the typical recommended range for antenatal corticosteroid administration.
- Some studies suggest that antenatal corticosteroids may be beneficial even at 35-36 weeks of gestation under particular circumstances 2, 4.
- The use of antenatal corticosteroids in late preterms is still debated, and further research is needed to determine the benefits and risks 4, 5.
Next Steps
- Given the patient's gestational age and the uncertainty surrounding the use of antenatal corticosteroids at this stage, the best next step in management would be to closely monitor the patient's condition and consider the potential benefits and risks of antenatal corticosteroid administration 2, 3, 4, 5.
- The patient's history of iron deficiency anemia and positive rectovaginal culture for group B Streptococcus should also be taken into account when determining the best course of management.