What is the best next step in managing a 32-year-old woman at 40 weeks gestation with spontaneous rupture of membranes and regular contractions?

From the Guidelines

The best next step in management for this patient is to initiate oxytocin augmentation, as her labor has arrested in the active phase, and there is no evidence of cephalopelvic disproportion (CPD) or other contraindications to continuing labor. This 32-year-old woman at term with spontaneous rupture of membranes and regular contractions is experiencing labor arrest in the active phase, as indicated by her cervical examinations showing no progress in dilation for a certain period. According to the most recent and highest quality study, oxytocin augmentation is the standard of care for active phase arrest before considering cesarean delivery 1. Oxytocin should be started with a low dose (typically 1-2 mU/min) and increased gradually every 30-60 minutes until adequate contractions (3-5 contractions in 10 minutes) are achieved. The maximum dose is usually 20-40 mU/min depending on institutional protocols.

• Key considerations in this patient's management include:
  • Ruling out CPD, which is a strong association with active-phase protraction or arrest disorder, as it increases the risk of complications and necessitates cesarean delivery 1
  • Monitoring fetal heart rate and uterine contractions to ensure the safety of continuing labor
  • Assessing for other factors that may signal concern, such as maternal diabetes and obesity, pelvic shape and size, fetal macrosomia, malposition, malpresentation, asynclitism, and excess molding 1
• The goal of oxytocin augmentation is to achieve adequate uterine contractions that can facilitate cervical dilation and fetal descent. If the patient fails to progress despite 4-6 hours of adequate contractions with oxytocin augmentation, then cesarean delivery would be the next consideration, as the risks of damage to the mother and fetus are too great to contemplate an attempt at vaginal delivery that is unlikely to be achievable or safe 1.

From the FDA Drug Label

INDICATIONS AND USAGE IMPORTANT NOTICE Oxytocin Injection, USP (synthetic) is indicated for the medical rather than the elective induction of labor. Antepartum Oxytocin Injection, USP (synthetic) is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable, in order to achieve early vaginal delivery for fetal or maternal reasons It is indicated for (1) induction of labor in patients with a medical indication for the initiation of labor, such as Rh problems, maternal diabetes, pre-eclampsia at or near term, when delivery is in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated;

The best next step in management of this patient is to induce labor with oxytocin, as the patient has a medical indication for induction of labor (premature rupture of membranes at term) 2.

• The patient is at 40 weeks gestation with ruptured membranes and regular contractions, which is a medical indication for induction of labor.
• Oxytocin can be used to initiate or improve uterine contractions to achieve early vaginal delivery for fetal or maternal reasons.
• The dosage and administration of oxytocin should be determined by uterine response, with accurate control of the rate of infusion flow and frequent monitoring of fetal heart rate and uterine contractions 2.

From the Research

Patient Assessment and Monitoring

• The patient is a 32-year-old woman, gravida 2 para 1, at 40 weeks gestation, admitted to the hospital due to spontaneous rupture of membranes and regular, painful contractions 3.
• Her current temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, and pulse is 68/min, with fetal heart rate monitoring showing category I and tocodynamometer showing contractions every 2-3 minutes.

Fetal Heart Rate Monitoring

• Fetal heart rate monitoring is crucial in identifying and preventing hypoxic-ischemic encephalopathy, especially during critical times of labor and delivery 3, 4.
• The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury, and clinicians should individualize care to optimize outcomes 4.
• Recognition and response to electronic fetal heart rate patterns can impact newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor 5.

Next Steps in Management

• Considering the patient's fetal heart rate monitoring is category I, and the tocodynamometer shows contractions every 2-3 minutes, the best next step in management would be to continue monitoring the patient's vital signs and fetal heart rate, and to be prepared for potential interventions if necessary 3, 4, 5.
• The patient's temperature, blood pressure, and pulse should be continuously monitored, and additional assessments such as pain, level of consciousness, and urine output should be considered as part of routine patient assessment 6, 7.