What is the recommended intrapartum monitoring for a pregnant patient at 38 weeks with controlled hypertension and a baby below the average percentile?

Recommended Intrapartum Monitoring for Controlled Hypertension at 38 Weeks with Below-Average Fetal Growth

This patient requires continuous fetal cardiotocography (CTG) throughout labor due to the combined high-risk factors of controlled hypertension and fetal growth restriction below the 10th percentile. 1

Rationale for Continuous Electronic Fetal Monitoring

Continuous CTG monitoring is mandatory in this clinical scenario because:

• Controlled hypertension on medication places this patient at substantial risk for superimposed preeclampsia, placental insufficiency, and acute hypertensive crises during labor 1
• Fetal growth restriction below the 10th percentile indicates uteroplacental insufficiency with significantly increased risk of intrapartum hypoxia and acute fetal decompensation 2, 1
• The combination of maternal hypertension and fetal growth restriction creates compounded risk requiring continuous surveillance rather than intermittent monitoring 1
• While continuous CTG does not reduce overall perinatal mortality compared to intermittent auscultation, it significantly reduces neonatal seizures (RR 0.50) in high-risk populations 3

Essential Maternal Monitoring Components

Continuous blood pressure monitoring is required throughout labor with the following specific parameters 2, 1:

• Maintain target BP at 110-140/85 mmHg to prevent maternal stroke 1
• Blood pressure ≥160/110 mmHg lasting >15 minutes constitutes a hypertensive emergency requiring immediate treatment 2
• First-line urgent treatment options include oral nifedipine or intravenous labetalol/hydralazine 2, 1
• Magnesium sulfate for seizure prophylaxis must be administered if severe hypertension develops or any neurological symptoms appear 2, 1

Critical caveat: Methyldopa should NOT be used for urgent BP reduction during labor 2

Comprehensive Intrapartum Surveillance Protocol

The following monitoring must occur simultaneously 2, 1:

• Continuous electronic fetal heart rate monitoring (CTG) - not intermittent auscultation
• Continuous or very frequent maternal blood pressure assessment
• Clinical assessment for signs of preeclampsia progression including proteinuria, neurological symptoms (headache, visual changes), and epigastric pain 2, 1
• Monitoring for oliguria as an early maternal warning sign 2

Laboratory Surveillance During Labor

Baseline and serial laboratory monitoring should include 2, 1:

• Complete blood count (hemoglobin and platelet count) to detect HELLP syndrome
• Liver transaminases (AST, ALT) for hepatic involvement
• Serum creatinine and uric acid for renal function
• Urinalysis for proteinuria assessment 2, 1

Common Pitfalls to Avoid

At least 25% of gestational hypertension cases progress to preeclampsia, and this progression can occur rapidly during labor 1. Key mistakes include:

• Relying on intermittent monitoring in this high-risk scenario - the combination of hypertension and growth restriction mandates continuous surveillance 1
• Assuming controlled hypertension means low risk - blood pressure alone is not a reliable indicator of disease severity, and serious organ dysfunction can develop at relatively mild BP elevations 1
• Delaying treatment of severe hypertension - BP ≥160/110 mmHg requires treatment within minutes, not hours 2, 1
• Administering calcium channel blockers (nifedipine) concomitantly with magnesium sulfate due to risk of severe hypotension from synergism 2

Mode of Delivery Considerations

Vaginal delivery should be attempted unless obstetric indications require cesarean section 2. However:

• Antihypertensive treatment must be continued during labor and delivery to keep SBP <160 mmHg and DBP <110 mmHg 2
• All women with severe preeclampsia should be delivered promptly regardless of gestational age 2
• Cesarean section rates are higher with continuous CTG monitoring (RR 1.63), but this must be balanced against the reduction in neonatal seizures in high-risk populations 3

Postpartum Monitoring

Enhanced surveillance continues after delivery because 10% of maternal deaths from hypertensive disorders occur postpartum 2:

• BP and urine should be checked at 6 weeks postpartum 2
• Persistent hypertension should be confirmed by 24-hour ambulatory monitoring 2
• Women with persisting hypertension or proteinuria at 6 weeks require specialist referral 2

Answer to the specific question options: All four options (A, B, C, D) are necessary, but Option C (continuous fetal cardiotocography) is the most critical distinguishing feature that defines appropriate care for this high-risk pregnancy, as opposed to low-risk pregnancies where intermittent monitoring would be acceptable 1, 3.