What is the management for a multigravida (multiparous woman) at 39 weeks gestation with a favorable Bishop score, 5 cm cervical dilation, and strong regular contractions after 4 hours of labor?

Management: Reassess After 2 Hours

For this multigravida at 39 weeks with a favorable Bishop score (5 cm dilation, fully effaced, strong regular contractions) who has progressed only 1 cm in 4 hours, the appropriate management is to reassess after 2 hours before intervening, as she is still within normal labor progression parameters for active labor.

Labor Progress Assessment

This patient is in active labor (≥4 cm dilation with regular contractions) but demonstrating slower than expected progress:

• Active labor typically progresses at ≥1 cm/hour for multiparous women, though individual variation exists 1
• Her progression of 1 cm over 4 hours (0.25 cm/hour) is slower than expected but does not yet meet criteria for labor arrest 1
• Labor arrest in active phase is defined as no cervical change for ≥4 hours with adequate contractions (or ≥6 hours with inadequate contractions) 1

Why Immediate Intervention Is Not Indicated

Against Cesarean Section (Option A):

• Cesarean delivery is not indicated without meeting arrest criteria, which requires documentation of no progress for at least 4 hours with adequate contractions 1
• She has demonstrated cervical change (4→5 cm), ruling out arrest disorder 1

Against Oxytocin (Option B):

• Her contractions are already described as "strong and regular," indicating adequate uterine activity 1
• Oxytocin augmentation is reserved for inadequate contraction patterns (frequency <3 in 10 minutes or inadequate intensity) 1
• Unnecessary oxytocin increases risks of tachysystole and fetal distress 2

Against Amniotomy (Option C):

• While amniotomy can augment labor with a favorable cervix, it commits the patient to delivery and increases infection risk with prolonged rupture 3
• With adequate contractions already present, amniotomy's benefit is limited 3
• Should be reserved for cases requiring augmentation after confirming inadequate progress 3

Recommended Management Algorithm

Reassess after 2 hours (Option D) with the following approach:

1. Continue monitoring: Assess cervical dilation, contraction pattern, and fetal heart rate 1

2. If progress continues (any cervical change): Continue expectant management with ongoing monitoring 1

3. If no change after total 4-6 hours from 5 cm: Consider interventions in this order:

   • First: Amniotomy if membranes intact (with favorable Bishop score) 3
   • Second: Oxytocin augmentation if contractions become inadequate 1
   • Last: Cesarean delivery only if arrest criteria met after adequate augmentation 1

Critical Pitfalls to Avoid

• Do not diagnose labor arrest prematurely - requires minimum 4 hours of adequate contractions without change 1
• Do not augment already adequate contractions - this increases maternal and fetal risks without benefit 2, 1
• Do not perform cesarean for slow but progressive labor - progression, even if slow, indicates labor is advancing 1

The favorable Bishop score (fully effaced, 5 cm dilated) predicts successful vaginal delivery, with significantly lower cesarean rates compared to unfavorable scores 4. This patient requires patience and continued observation rather than immediate intervention.