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 and priority action is to stop the oxytocin infusion (Option D), as this directly addresses the root cause of uterine hyperstimulation leading to uteroplacental insufficiency and fetal compromise. 1

Clinical Context and Rationale

This scenario describes a Category III fetal heart rate tracing characterized by recurrent late decelerations combined with reduced variability, which indicates uteroplacental insufficiency and potential fetal hypoxia or acidemia. 1 The oxytocin administration is causing uterine hyperstimulation, compromising placental blood flow to the fetus. 2

Evidence-Based Management Algorithm

First Priority: Discontinue Oxytocin

• Stopping oxytocin is the first and most critical intervention before considering other measures or delivery, as it addresses the underlying cause of the problem. 1
• The American College of Obstetricians and Gynecologists explicitly recommends discontinuing oxytocin infusion as the initial intervention for Category III tracings. 1
• FDA labeling for oxytocin states that "the oxytocin infusion should be discontinued immediately in the event of uterine hyperactivity or fetal distress." 3
• When oxytocin is stopped, the oxytocic stimulation of the uterine musculature will soon wane, allowing recovery of uteroplacental blood flow. 3

Simultaneous Resuscitative Measures (After Stopping Oxytocin)

While stopping oxytocin is the priority, these additional interventions should be implemented concurrently:

• Change maternal position to left lateral to relieve potential cord compression and improve uteroplacental blood flow. 1, 2
• Administer oxygen at 6-10 L/min via face mask to improve fetal oxygenation. 1, 2, 3
• IV fluid bolus if not already administered to ensure adequate maternal hydration. 2
• Assess maternal vital signs and treat hypotension if present. 2
• Perform vaginal examination to assess for rapid descent, cord prolapse, or other complications. 4

Continuous Monitoring and Reassessment

• Monitor the fetal heart rate tracing continuously after stopping oxytocin to assess response to intervention. 1
• If the tracing improves, labor may continue with close monitoring. 1
• If the tracing remains abnormal despite resuscitative measures, expedited delivery via operative vaginal delivery or cesarean section should be considered. 1, 2

Why Other Options Are Incorrect as First-Line

• Option A (Cesarean section): While this may ultimately be necessary if the tracing does not improve, it is not the immediate first step. You must first attempt intrauterine resuscitation by stopping the causative agent (oxytocin). 1
• Option B (Change maternal position): This is an important supportive measure but should be done simultaneously with—not instead of—stopping oxytocin. 1
• Option C (Oxygenation): Similarly, this is a supportive measure that should accompany, not replace, discontinuing oxytocin. 1

Critical Pitfall to Avoid

Do not continue oxytocin while implementing other resuscitative measures. The oxytocin is directly causing the problem through uterine hyperstimulation, and continuing it while trying other interventions is counterproductive and potentially dangerous. 1, 3 The FDA labeling explicitly requires immediate discontinuation in the presence of fetal distress. 3