What is the management for a multigravida (multiparous woman) at 39 weeks gestation with a cervix 5 cm dilated, fully effaced, and strong regular contractions, after progressing from 4 cm dilation over 4 hours?

Management: Amniotomy with Oxytocin Augmentation

This patient has protracted active phase labor (1 cm dilation over 4 hours = 0.25 cm/hour, well below the 0.6 cm/hour threshold), and the evidence-based management is amniotomy combined with oxytocin augmentation after ruling out cephalopelvic disproportion. 1, 2, 3

Clinical Diagnosis

This multigravida presents with protracted active phase labor, defined by the American College of Obstetricians and Gynecologists as cervical dilation rate less than 0.6 cm/hour in the active phase. 1, 3 Her progression of 1 cm over 4 hours (0.25 cm/hour) is significantly below this threshold and represents a clear labor abnormality requiring intervention. 3

Critical Pre-Intervention Assessment

Before proceeding with augmentation, you must evaluate for cephalopelvic disproportion (CPD), which occurs in 25-30% of active phase abnormalities. 1, 2, 3 Assess for:

• Fetal position for malposition (occiput posterior/transverse) 3
• Excessive molding, deflexion, or asynclitism without descent 3
• Fetal macrosomia (maternal diabetes, obesity) 3
• Suprapubic palpation of the fetal skull base to differentiate true descent from molding 3

If CPD is confirmed or suspected, proceed directly to cesarean delivery—oxytocin is contraindicated in the presence of CPD. 1, 2, 3

Evidence-Based Management Algorithm

Step 1: Amniotomy

Perform amniotomy to:

• Assess for cord compression (if variable decelerations present) 2
• Facilitate labor progress and enable internal monitoring 2
• Visualize amniotic fluid volume 2

Amniotomy alone rarely produces adequate progress and must be combined with oxytocin. 3

Step 2: Oxytocin Augmentation

Initiate oxytocin immediately after amniotomy using the following protocol 1, 2, 4:

• Starting dose: 1-2 mU/min 1, 4
• Incremental increases: 1-2 mU/min every 15 minutes 1, 4
• Target: 7 contractions per 15 minutes (adequate contraction pattern) 3
• Maximum dose: 36 mU/min 3

Step 3: Monitoring Requirements

Continuous monitoring is essential 2:

• Serial cervical examinations every 2 hours to assess progress 1, 3
• Continuous fetal heart rate monitoring 2
• Contraction frequency, duration, and intensity 1
• Signs of uterine hyperstimulation (discontinue oxytocin immediately if present) 4

Step 4: Reassessment at 4 Hours

After 4 hours of adequate contractions 1, 2, 3:

• If adequate progress: Continue oxytocin titration
• If no progress: Reassess for CPD
  • Watch for increasingly marked molding, deflexion, or asynclitism without descent as signs of emerging CPD 3
  • If CPD confirmed or suspected: Proceed to cesarean delivery 1, 3
  • If CPD excluded: Continue oxytocin augmentation

Critical Pitfalls to Avoid

Do not simply reassess after 2 hours without intervention—this patient has already demonstrated 4 hours of inadequate progress and requires active management now. 1, 3 Recent evidence suggests that allowing 4 hours of arrest after 6 cm dilation may be too long, with 2 hours being safer. 3

Do not perform cesarean delivery without first attempting augmentation unless CPD is evident, as this increases unnecessary cesarean rates. 1

Do not use oxytocin if CPD cannot be excluded—this risks uterine rupture and fetal compromise. 1, 3

Answer to Question

The correct answer is C (amniotomy), immediately followed by B (oxytocin). The complete management requires both interventions sequentially, with amniotomy performed first, followed immediately by oxytocin augmentation if contractions remain inadequate. 1, 2, 3 Option D (reassess after 2 hours) is inappropriate as the patient has already demonstrated 4 hours of protracted labor requiring intervention. 3 Option A (cesarean section) is premature without first ruling out CPD and attempting augmentation. 1, 3