What is the management plan for a 34-year-old woman, gravida 5 para 4, at 39 weeks gestation with a history of uncomplicated pregnancy, prepregnancy body mass index (BMI) of 33 kg/m2, and a weight gain of 18 kg, who presents with contractions and spontaneous rupture of membranes, and develops recurrent variable decelerations after receiving neuraxial anesthesia, which resolve with amnioinfusion?

From the Guidelines

The management of this patient with variable decelerations during labor was appropriate and followed standard obstetric protocols, as outlined in the NICHD guidelines for intrapartum fetal monitoring 1. The patient's presentation with variable decelerations after neuraxial anesthesia administration is consistent with umbilical cord compression, which can be caused by a variety of factors, including the patient's obesity (BMI 33 kg/m2) and significant weight gain during pregnancy (18 kg). According to the NICHD guidelines, variable decelerations without absent variability are typically managed with general measures, such as amnioinfusion, which was successfully performed in this case 1. Key points to consider in the management of this patient include:

• The use of an intrauterine catheter to monitor contractions and fetal heart rate patterns after neuraxial anesthesia administration, as the patient could no longer feel contractions.
• The resolution of variable decelerations with amnioinfusion, which suggests that the umbilical cord compression was effectively alleviated.
• The patient's history of four previous successful vaginal deliveries, which is reassuring for the current labor outcome. Overall, the management of this patient was consistent with current obstetric guidelines and prioritized the well-being of both the mother and the fetus, minimizing the risk of morbidity, mortality, and negatively impacting quality of life 1.

From the Research

Variable Decelerations and Amnioinfusion

• Variable decelerations in labor are a concern due to their association with fetal distress and potential adverse outcomes 2, 3.
• Amnioinfusion has been shown to be an effective technique in relieving variable decelerations caused by umbilical cord compression, with or without oligohydramnios 3, 4.
• The procedure involves the infusion of a normal saline solution into the uterine cavity to decrease the number and severity of variable decelerations 5.

Predicting the Success of Amnioinfusion

• The amniotic fluid index before amnioinfusion can be used to predict the success of the procedure in relieving variable decelerations 6.
• A lower amniotic fluid index is associated with a higher probability of success, while a higher index is associated with a lower probability of success 6.
• The presence of nuchal cords or true umbilical cord knots may increase with increasing amniotic fluid index, potentially explaining the decreased success of amnioinfusion at higher indices 6.

Types of Amnioinfusion

• Intermittent bolus amnioinfusion and continuous amnioinfusion have been compared, with both methods being effective in relieving variable decelerations 4.
• The choice between intermittent and continuous amnioinfusion may depend on individual patient factors and clinical judgment 4.

Clinical Implications

• Amnioinfusion may be a beneficial therapeutic intervention in women showing fetal distress in the first stage of labor, reducing the need for cesarean section and neonatal acidemia 2.
• The procedure may also reduce the duration of maternal postpartum hospital stay 2.
• Further research is necessary to determine the optimal technique and patient selection for amnioinfusion 4.