What is the best next step in managing a 34-year-old woman, gravida 3 para 2, at 35 weeks gestation with increasing mucoid vaginal bleeding, contractions, and fetal growth restriction due to chronic hypertension, currently 8 cm dilated and 100% effaced?

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 vaginal delivery. The patient is making appropriate cervical progress (from 6 cm to 8 cm dilation) with regular contractions every 2 minutes. The bloody mucoid discharge is consistent with normal bloody show during labor, and the fetal heart rate tracing shows reassuring features with moderate variability and early decelerations that are physiologic responses to contractions 1. While the patient has chronic hypertension with a current blood pressure of 150/90 mmHg, this does not require immediate intervention during active labor as long as it remains stable and below severe range (160/110 mmHg) 1. The patient's temperature is normal, and her negative Group B Streptococcus status means prophylactic antibiotics are not needed.

Key considerations in the management of this patient include:

• Continued monitoring of maternal vital signs, cervical dilation, and continuous fetal heart rate monitoring
• Quantification of the bloody discharge to ensure it remains within normal limits for labor and does not progress to concerning hemorrhage
• Preparation for potential complications such as severe hypertension or fetal distress, with antihypertensive medication such as labetalol or hydralazine available if needed 1
• Consideration of the guidelines for management of fetal growth restriction, including the recommendation for delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile 1.

Given the patient's current gestational age of 35 weeks and the presence of fetal growth restriction, close monitoring and preparation for potential complications are crucial, with consideration of the guidelines for management of fetal growth restriction and the patient's individual clinical scenario 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. The oxytocin infusion should be discontinued immediately in the event of uterine hyperactivity or fetal distress

• The patient is experiencing increasing bloody discharge and contractions have also increased in intensity and frequency.
• The fetal heart rate tracing shows a baseline of 120/min, moderate variability, multiple early decelerations, and no accelerations.
• The best next step in management of this patient is to discontinue the oxytocin infusion due to potential uterine hyperactivity or fetal distress 2.

From the Research

Assessment of the Situation

• The patient is a 34-year-old woman, gravida 3 para 2, at 35 weeks gestation with increasing mucoid vaginal bleeding and contractions.
• She has been undergoing induction of labor for fetal growth restriction due to chronic hypertension.
• The patient's cervix is 8 cm dilated and 100% effaced with a moderate amount of mucus and blood on examination.
• Fetal heart rate tracing shows a baseline of 120/min, moderate variability, multiple early decelerations, and no accelerations.

Consideration of Fetal Growth Restriction

• Fetal growth restriction is a common complication of pregnancy that has been associated with a variety of adverse perinatal outcomes 3.
• The purpose of the document is to review the topic of fetal growth restriction with a focus on terminology, etiology, diagnostic and surveillance tools, and guidance for management and timing of delivery 3.
• Fetal growth restriction is associated with an increased risk of adverse short- and long-term outcomes, including hypoxemic events and neurodevelopmental delay compared to normally grown fetuses 4.

Management of Labor

• The rate of vaginal delivery is high in cases of fetal growth restriction undergoing a trial of labor 5.
• Patients with oligohydramnios and those requiring prostaglandins for cervical ripening should be counseled regarding a significantly higher risk of cesarean delivery 5.
• The main fetal reasons for abdominal delivery include abnormal fetal heart rate patterns in labor, malpresentation, fetal macrosomia, multiple gestation, and both functional and structural fetal abnormalities 6.

Next Steps in Management

• Given the patient's situation, the next step in management would be to continue monitoring the fetal heart rate and the patient's condition.
• Consideration should be given to the potential need for cesarean delivery if the fetal heart rate tracing continues to show signs of distress or if the patient's condition worsens.
• The use of ultrasound to assess fetal head position and station may be beneficial in reducing the risk of incorrect diagnosis, but it may not necessarily improve maternal or neonatal outcomes 7.