What is the most appropriate next step in management for a 34-year-old woman, gravida (number of times pregnant) 2, para (number of viable births) 1, at 39 weeks' gestation, with confirmed spontaneous rupture of membranes, 8 cm cervical dilation, 70% effacement, and a fetal heart rate of 130 beats per minute with moderate accelerations?

From the Guidelines

The most appropriate next step in management for this patient is oxytocin infusion (option D). This patient is experiencing arrest of labor in the active phase, as evidenced by minimal cervical change over 3 hours (from 7 cm to only 8 cm) with the fetal station remaining at -1 1. When labor progress stalls despite adequate contractions, augmentation with oxytocin is indicated to strengthen contractions and facilitate cervical dilation and fetal descent. The reassuring fetal heart rate pattern (130/min with moderate accelerations and no concerning decelerations) indicates the fetus is tolerating labor well, making augmentation a safe option.

Key considerations in this scenario include:

• The patient's labor progress has stalled, indicating a potential need for intervention to prevent complications such as cephalopelvic disproportion (CPD) or fetal distress 1.
• Oxytocin infusion is a standard intervention for arrest of active labor when maternal and fetal status are reassuring, as it can help strengthen contractions and facilitate cervical dilation and fetal descent 1.
• The decision to proceed with oxytocin infusion should be based on a thorough evaluation of the patient's labor progress, fetal status, and potential underlying causes of the arrest, such as CPD or uterine dysfunction 1.

Given the patient's clinical presentation and the absence of any contraindications to oxytocin infusion, oxytocin infusion is the most appropriate next step in management. This approach prioritizes the patient's morbidity, mortality, and quality of life outcomes by attempting to facilitate a safe and successful vaginal delivery while minimizing the risks associated with prolonged labor or cesarean delivery.

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 in labor, with contractions occurring every 4 minutes and lasting 40 seconds, and the cervix is 8 cm dilated.

• The fetal heart rate is 130/min, with moderate accelerations and no late or variable decelerations.
• The patient's labor is progressing, but the vertex is at -1 station, which may indicate a need for continued monitoring and potential intervention. Given the patient's labor progress and the absence of any indications for immediate intervention, such as fetal distress or uterine hyperactivity, the most appropriate next step in management is B. Reassurance and close follow up 2.

From the Research

Assessment of the Situation

• The patient is a 34-year-old woman, gravida 2, para 1, at 39 weeks' gestation, admitted to the hospital with leakage of fluid and increasing contractions.
• On admission, the cervix is 2 cm dilated and 50% effaced, with the vertex at -1 station.
• Two hours later, the cervical dilation is 7 cm and 70% effaced, with the vertex still at -1 station.
• An additional 3 hours later, the cervix is 8 cm dilated and 70% effaced, with the vertex at -1 station.
• Contractions occur every 4 minutes and last 40 seconds, with a fetal heart rate of 130/min and moderate accelerations, but no late or variable decelerations.

Management Options

• The patient's labor progress and fetal status need to be carefully evaluated to determine the most appropriate next step in management.
• Options include:
  • Cesarian delivery
  • Reassurance and close follow-up
  • Assisted vaginal delivery
  • Oxytocin infusion
  • Placement of intrauterine pressure catheter

Evidence-Based Considerations

• According to 3, oxytocin and breast stimulation are methods used for labor augmentation in women with a previous cesarean delivery.
• The study by 4 discusses the use of oxytocin for labor induction, highlighting the importance of understanding the trade-offs involved and the need for close patient monitoring.
• The study by 5 found that adjunctive oxytocin infusion during balloon cervical ripening improves labor induction, shortening the time to overall delivery and vaginal delivery.
• The studies by 6 and 7 compare the use of balloon catheter and oxytocin alone for induction of labor in women with a previous cesarean section and an unfavorable cervix, suggesting that balloon catheter may be more effective in increasing the rate of vaginal birth.

Next Steps

• Based on the patient's progress and the evidence available, the most appropriate next step in management would be to continue close monitoring of the patient's labor progress and fetal status.
• Considering the patient's cervical dilation and effacement, as well as the fetal heart rate and contractions, reassurance and close follow-up may be the most appropriate option at this time, as there are no indications of fetal distress or other complications that would require immediate intervention 3, 4.