What is the best next step in managing a 35-year-old woman, gravida (number of times pregnant) 4, para (number of viable births) 3, at 37 weeks gestation, presenting with meconium-stained amniotic fluid, painful contractions, and a dilated cervix?

From the Guidelines

The best next step in management for this patient is to proceed with vaginal delivery with close monitoring of fetal heart rate. This 35-year-old woman at 37 weeks gestation presents with ruptured membranes for 2 days with meconium-stained amniotic fluid and is in active labor with a reassuring fetal heart rate pattern. The cervix is already 6 cm dilated with the fetal vertex at +1 station, indicating good progress. The fetal heart tracing shows moderate variability and early decelerations with contractions, which are reassuring signs of fetal well-being. Early decelerations are caused by fetal head compression during contractions and are not associated with fetal hypoxia. Although the presence of meconium-stained fluid raises concern for potential fetal distress, the reassuring fetal heart rate pattern suggests the fetus is currently stable. The patient should be continuously monitored throughout labor, with intravenous access established and preparations made for potential neonatal resuscitation due to the meconium-stained fluid, as recommended by the American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care 1. Antibiotics should be considered given the prolonged rupture of membranes (>24 hours), which increases the risk of chorioamnionitis. Labor should be allowed to progress naturally as the patient has a history of three uncomplicated vaginal deliveries, suggesting a high likelihood of another successful vaginal birth. Key considerations in the management of this patient include:

• Close monitoring of fetal heart rate
• Preparation for potential neonatal resuscitation
• Consideration of antibiotics due to prolonged rupture of membranes
• Allowance for labor to progress naturally given the patient's history of uncomplicated vaginal deliveries. It is essential to have a team present at the time of birth that includes an individual skilled in tracheal intubation, as the presence of meconium-stained amniotic fluid may indicate fetal distress and increases the risk that the infant will require resuscitation after birth 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage of oxytocin is determined by uterine response. The following dosage information is based upon the various regimens and indications in general use. Induction or Stimulation of Labor Intravenous infusion (drip method) is the only acceptable method of administration for the induction or stimulation of labor. The patient is already experiencing painful contractions and the cervix is 6 cm dilated, 60% effaced, which suggests that labor is already in progress.

• The best next step in management would be to continue monitoring the patient's uterine contractions, fetal heart rate, and overall condition, rather than initiating oxytocin infusion for induction or stimulation of labor.
• The patient's condition, with meconium-stained fluid and moderate variability and early decelerations on fetal heart tracing, requires close surveillance to ensure the well-being of both the mother and the fetus.
• The use of oxytocin for augmentation of labor may be considered if labor progress is slow, but this decision should be made by the responsible physician after evaluating the patient's condition and the fetal heart rate tracing 2.

From the Research

Patient Assessment

The patient is a 35-year-old woman, gravida 4 para 3, at 37 weeks gestation, presenting with leakage of fluid and painful contractions. She has had continuous vaginal leakage of clear fluid for the past 2 days, which has now turned green, indicating the presence of meconium. Her vital signs are within normal limits, and she has no chronic medical conditions or known drug allergies.

Fetal Assessment

The fetal heart tracing reveals moderate variability and early decelerations with each contraction, which may indicate fetal distress. The presence of meconium-stained fluid is also a concern, as it can be associated with poor neonatal outcomes, including meconium aspiration syndrome 3.

Management Options

Given the patient's presentation and fetal assessment, the best next step in management would be to:

• Continue to monitor the fetal heart rate and contractions closely
• Prepare for potential complications, such as meconium aspiration syndrome or fetal distress
• Consider the need for expedited delivery, either vaginally or via cesarean section, depending on the patient's progress and fetal well-being

Considerations for Delivery

The presence of meconium-stained fluid and fetal distress may increase the risk of complications during delivery. Studies have shown that meconium aspiration syndrome is more common in infants born with meconium-stained amniotic fluid 4. Additionally, chorioamnionitis, which may be present in this patient, can increase the risk of postpartum infectious complications and uterine atony 5, 6. The mode of delivery, either vaginal or cesarean, may impact neonatal and maternal outcomes, with some studies suggesting that cesarean delivery may be associated with a higher risk of early onset neonatal sepsis and maternal infectious morbidity 7.

Key Considerations

• Close monitoring of fetal heart rate and contractions
• Preparation for potential complications, such as meconium aspiration syndrome or fetal distress
• Consideration of expedited delivery, either vaginally or via cesarean section, depending on patient progress and fetal well-being
• Awareness of the potential risks and benefits of different modes of delivery, including the risk of postpartum infectious complications and uterine atony.