What is the management for a 23-year-old primigravida (first pregnancy) at 38 weeks gestation with spontaneous rupture of membranes, painful contractions, and arrested labor despite adequate uterine contractions, with a fetal weight of 3.6 kg and Category 1 fetal heart rate tracing?

From the Guidelines

This patient requires immediate consideration for cesarean delivery due to labor arrest in the active phase of labor, as evidenced by no cervical change after 4 hours of observation and adequate contractions. The patient's labor arrest, characterized by no cervical change from 8 cm dilation after 4 hours of observation, despite adequate contractions (>200 Montevideo units), suggests a potential cephalopelvic disproportion (CPD) or other underlying issues 1. Given the estimated fetal weight of 3.6 kg and the patient's uncomplicated prenatal course, the risk of CPD or other complications must be carefully evaluated. The patient's favorable fetal heart rate tracing (category 1) is a positive indicator, but the lack of cervical progress despite adequate contractions is a concern. Key factors to consider in this patient's management include:

• The presence of adequate contractions, as measured by Montevideo units
• The estimated fetal weight and potential for CPD
• The patient's uncomplicated prenatal course and negative group B Streptococcus culture
• The favorable fetal heart rate tracing Considering these factors, cesarean delivery should be considered as a safer option to prevent potential harm to the mother and fetus, especially if there is any uncertainty about the potential for a safe vaginal delivery 1. The use of oxytocin augmentation may be considered, but given the patient's already adequate contractions, it is unlikely to result in significant cervical change. Regular cervical examinations and continuous fetal heart rate monitoring should be continued to assess the patient's progress and make informed decisions about her care. Ultimately, the decision to proceed with cesarean delivery should be based on a thorough evaluation of the patient's individual risk factors and the potential benefits and risks of each management option 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage of oxytocin is determined by uterine response. The initial dose should be no more than 1 to 2 mU/min The dose may be gradually increased in increments of no more than 1 to 2 mU/min, until a contraction pattern has been established which is similar to normal labor.

The patient is already experiencing contractions every 2-3 minutes, and the sum of contraction strength is 240 Montevideo units over 10 minutes. Oxytocin administration is not indicated in this case, as the patient is already experiencing a contraction pattern similar to normal labor. The use of oxytocin in this scenario may increase the risk of uterine hyperactivity or fetal distress. 2

From the Research

Patient's Condition

• The patient is a 23-year-old primigravida at 38 weeks gestation with spontaneous rupture of membranes and painful contractions.
• She has had an uncomplicated prenatal course and a negative group B Streptococcus culture last week.
• Leopold maneuvers show an estimated fetal weight of 3.6 kg (8 lb).
• Cervical examination shows the cervix to be 8 cm dilated and 90% effaced with the fetal vertex at 0 station.

Contraction Pattern and Fetal Heart Rate Tracing

• An intrauterine pressure catheter is placed and shows contractions every 2-3 minutes, and the sum of contraction strength is 240 Montevideo units over 10 minutes.
• This contraction pattern continues, and 4 hours later the cervix remains unchanged.
• Fetal heart rate tracing is category 1.

Management Options

• According to the study by 3, oxytocin augmentation for at least 4 hours is recommended for active-phase labor arrest.
• The study found that 92% of women delivered vaginally after oxytocin augmentation, and there were no severe maternal complications.
• Another study by 4 compared maternal and fetal effects of vacuum extraction with forceps or cesarean deliveries, and found that vacuum extraction had a lower incidence of birth canal trauma and anemia compared to forceps delivery.
• However, a more recent study by 5 found that forceps and vacuum delivery were associated with higher rates of perinatal morbidity and mortality compared to cesarean delivery among women with dystocia.

Considerations for Delivery

• The patient's estimated fetal weight is 3.6 kg, which may increase the risk of complications during delivery.
• The study by 6 found that manual rotation forceps extraction and vacuum extraction were safe methods of delivery in deep transverse arrest, but cesarean section was associated with a high incidence of birth asphyxia.
• The patient's cervical examination shows no progress after 4 hours, which may indicate a need for further intervention, such as oxytocin augmentation or instrumental delivery, as suggested by the study by 3.