What to do next for a young primigravida at 38-39 weeks gestation, 6 cm dilated, with irregular uterine (contractions) and type 2 decelerations on cardiotocography (CTG)?

Immediate Cesarean Section is Indicated

Given the presence of type 2 (late) decelerations on CTG in active labor, immediate cesarean section (Option C) is the most appropriate next step, as late decelerations indicate uteroplacental insufficiency and fetal hypoxemia that requires urgent intervention. 1

Understanding the Clinical Picture

This primigravida presents with several concerning features:

• 6 cm dilation with irregular contractions suggests inadequate labor progress, but the critical finding is the CTG pattern 1
• Type 2 (late) decelerations are the key pathological finding that drives management 1

Why Late Decelerations Demand Urgent Action

Late decelerations have specific characteristics that distinguish them from benign patterns:

• Delayed onset after contraction begins, with the nadir occurring after the peak of the contraction 1
• Physiologic basis is uteroplacental insufficiency, indicating the fetus is not receiving adequate oxygenation 1
• Associated with fetal acidosis when accompanied by loss of variability, which increases the risk of adverse neonatal outcomes 1

The presence of late decelerations is not benign like early decelerations, which mirror contractions and rarely indicate fetal compromise 1.

Why Other Options Are Inappropriate

Observation (Option A) is Contraindicated

• Late decelerations indicate active fetal compromise requiring intervention, not continued monitoring 1
• Waiting risks progression to severe fetal acidosis and permanent neurological damage 2

Amniotomy (Option B) is Dangerous

• Artificial rupture of membranes in the presence of late decelerations could worsen uteroplacental insufficiency 1
• This intervention is appropriate for augmenting normal labor, not managing fetal distress 1

Oxytocin (Option D) is Contraindicated

• Oxytocin increases uterine contractility, which would further compromise an already insufficient uteroplacental blood flow 3
• The FDA label explicitly states that oxytocin infusion should be discontinued immediately in the event of fetal distress 3
• Uterine hyperstimulation from oxytocin can lead to uteroplacental hypoperfusion and variable deceleration of fetal heart, fetal hypoxia, or death 3

Clinical Decision Algorithm

When encountering late decelerations in labor:

1. Recognize the pattern: Late decelerations = uteroplacental insufficiency 1
2. Assess severity: Recurrent late decelerations (>50% of contractions) indicate significant compromise 1
3. Immediate intervention: Prepare for cesarean delivery 1
4. Supportive measures while preparing: Administer oxygen to mother, position on left side, discontinue any oxytocin 3

Evidence Quality Considerations

The American Family Physician guideline 1 provides clear, evidence-based criteria for interpreting CTG patterns and emphasizes that late decelerations represent uteroplacental insufficiency requiring intervention. Research confirms that pathological CTG traces (which include late decelerations) are associated with significantly higher rates of neonatal acidosis (28.6%) 2, validating the urgency of intervention.

Critical Pitfall to Avoid

Do not attempt to "improve" the labor pattern with oxytocin or amniotomy when late decelerations are present. These interventions will worsen fetal oxygenation and increase the risk of severe acidosis, emergency delivery under more compromised conditions, and poor neonatal outcomes 3, 1.