What is the immediate management for a primigravida (first-time mother) in labor with recurrent late decelerations and reduced variability on cardiotocography (CTG) after oxytocin administration?

Immediate Management: Stop Oxytocin

The immediate first step is to discontinue the oxytocin infusion (Option D). This is a Category III fetal heart rate tracing requiring urgent intervention, and stopping oxytocin is the priority initial action before considering other measures or delivery. 1

Understanding the Clinical Scenario

This primigravida presents with a NICHD Category III fetal heart rate pattern: recurrent late decelerations combined with reduced (minimal or absent) variability. 1 This combination indicates:

• Uteroplacental insufficiency as the underlying pathophysiology of late decelerations 1
• Potential fetal hypoxia or acidemia when combined with reduced variability 1
• Likely oxytocin-induced uterine hyperstimulation (tachysystole) causing the pattern 1, 2

Algorithmic Management Approach

Step 1: Discontinue Oxytocin Immediately

• Stop the oxytocin infusion as the first intervention 1
• The FDA label explicitly states: "The oxytocin infusion should be discontinued immediately in the event of uterine hyperactivity or fetal distress" 2
• Category III tracings require discontinuation of oxytocin and expedited delivery 1

Step 2: Implement General Resuscitative Measures (Simultaneously)

While stopping oxytocin is the priority, immediately initiate these concurrent interventions:

• Change maternal position (left lateral preferred) to relieve potential cord compression and improve uteroplacental blood flow 1, 3
• Administer oxygen at 6-10 L/min via face mask 1, 3, 2
• Assess maternal vital signs (blood pressure, pulse, temperature) 1
• Perform vaginal examination to assess cervical dilation and fetal station 1
• Administer IV fluids to optimize maternal intravascular volume 1, 3

Step 3: Assess Response and Prepare for Delivery

• Monitor the fetal heart rate tracing continuously after stopping oxytocin 1
• If the tracing improves (variability returns, late decelerations resolve), labor may continue with close monitoring 1
• If the tracing remains abnormal despite intrauterine resuscitation, expedite delivery via operative vaginal delivery or cesarean section 1, 3

Why Each Option Ranks as It Does

Why Stop Oxytocin First (Option D - Correct Answer)

• Oxytocin is the iatrogenic cause of uterine hyperstimulation leading to uteroplacental insufficiency 1, 2
• Stopping oxytocin allows uterine activity to decrease rapidly, as "oxytocic stimulation of the uterine musculature will soon wane" 2
• This is the most direct intervention to address the root cause 1

Why Not Immediate Cesarean Section (Option A)

• While Category III tracings may ultimately require expedited delivery, intrauterine resuscitation should be attempted first 1
• Many cases will improve after stopping oxytocin and implementing resuscitative measures, avoiding unnecessary cesarean delivery 1
• The guidelines specify "discontinue oxytocin; expedite delivery" - meaning stop oxytocin first, then assess need for delivery 1

Why Position Change Alone Is Insufficient (Option B)

• Position changes are part of the resuscitation bundle but do not address oxytocin-induced hyperstimulation 1, 3
• Late decelerations from uterine hyperstimulation require stopping the causative agent 1

Why Oxygenation Alone Is Insufficient (Option C)

• Oxygen administration is supportive but does not stop the underlying uterine hyperstimulation 1, 3, 2
• The FDA label prioritizes discontinuing oxytocin over oxygen administration in this scenario 2

Critical Pitfalls to Avoid

• Do not delay stopping oxytocin while attempting other interventions first - this is the most time-sensitive action 1, 2
• Do not proceed directly to cesarean section without attempting intrauterine resuscitation, as many cases will improve 1
• Do not restart oxytocin if the tracing improves unless labor arrest occurs and the tracing has normalized 1, 4, 5
• Do not fail to prepare for expedited delivery if the tracing does not improve within minutes of stopping oxytocin 1

Evidence Quality Note

The American College of Obstetricians and Gynecologists (ACOG) and National Institute of Child Health and Human Development (NICHD) guidelines consistently prioritize discontinuing oxytocin as the first intervention for Category III tracings, supported by FDA labeling requirements. 1, 2 This represents the highest level of guideline evidence available.