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?

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From the Guidelines

This patient is at high risk for cephalopelvic disproportion (CPD) and should be considered for cesarean delivery due to the lack of cervical change despite adequate contractions over 4 hours and an estimated fetal weight of 3.6 kg. The patient's labor pattern, with strong contractions (240 Montevideo units) and no cervical change, suggests a possible mechanical obstruction, which is a strong indicator of CPD 1. The estimated fetal weight of 3.6 kg also increases the risk of CPD and complications during vaginal delivery.

Key Considerations

  • The patient has had an uncomplicated prenatal course, but the current labor pattern and fetal size suggest a high risk for complications
  • The lack of cervical change despite adequate contractions over 4 hours meets the criteria for active phase arrest, which is strongly associated with CPD 1
  • The patient's strong contractions and category 1 fetal heart rate tracing are reassuring, but do not rule out the possibility of CPD or other complications
  • Oxytocin augmentation may be considered, but if no progress occurs after 2-4 hours, cesarean delivery should be strongly considered due to the high risk of complications

Management

  • Cesarean delivery should be considered due to the high risk of CPD and complications, especially given the estimated fetal weight and lack of cervical change despite adequate contractions
  • If oxytocin augmentation is attempted, it should be done with careful monitoring and a low dose of 1-2 mU/min intravenously, increasing by 1-2 mU/min every 30-60 minutes until adequate contractions are achieved, typically not exceeding 20-40 mU/min 1
  • Continued fetal monitoring is essential during augmentation, and any signs of fetal distress or complications should prompt immediate consideration of cesarean delivery.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Dosage of oxytocin is determined by uterine response. The following dosage information is based upon the various regimens and indications in general use. Induction or Stimulation of Labor Intravenous infusion (drip method) is the only acceptable method of administration for the induction or stimulation of labor. Accurate control of the rate of infusion flow is essential An infusion pump or other such device and frequent monitoring of strength of contractions and fetal heart rate are necessary for the safe administration of oxytocin for the induction or stimulation of labor.

The patient is already experiencing painful contractions and the cervix is 8 cm dilated, so oxytocin may not be necessary for induction of labor. However, if oxytocin is considered, the initial dose should be no more than 1 to 2 mU/min and gradually increased until a contraction pattern similar to normal labor is established, while closely monitoring the fetal heart rate and uterine contractions 2.

  • The patient's current contraction pattern and fetal heart rate tracing should be evaluated to determine if oxytocin is necessary.
  • The decision to administer oxytocin should be made by the responsible physician, taking into account the patient's individual situation and medical indications 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. The estimated fetal weight is 3.6 kg (8 lb), and the cervix is 8 cm dilated and 90% effaced with the fetal vertex at 0 station.

Labor Progress

The patient has been admitted and epidural analgesia has been administered. Despite increasing rectal pressure, repeat cervical examination shows no change in cervical dilation or effacement. An intrauterine pressure catheter has been placed, showing contractions every 2-3 minutes with a sum of contraction strength of 240 Montevideo units over 10 minutes. This contraction pattern continues, and 4 hours later, the cervix remains unchanged.

Potential Complications

  • The patient's labor progress may be affected by potential complications such as:
    • Shoulder dystocia, which is an unpredictable obstetric complication with an incidence of 0.15% to 2% 3
    • Arrest of labor, which can be caused by uterine inactivity, obesity, cephalopelvic disproportion, and fetal malposition 4
    • Fetal macrosomia, which is a risk factor for shoulder dystocia and can lead to complications such as clavicular fracture, brachial plexus lesions, and peripartal asphyxia 3, 5

Management Options

  • The management of labor disorders consists of oxytocin administration, amniotomy, intrauterine pressure catheter use, and shared decision-making regarding proceeding with expectant management, operative vaginal delivery, or cesarean delivery 4
  • The decision to extend the duration of labor is personalized for each mother-baby dyad and should be agreed upon depending on individual maternal and fetal circumstances 4
  • Guidelines have been published for the management of shoulder dystocia, with the primary goal of educating the obstetrician and midwife on the importance of a preplanned sequence of maneuvers, thereby reducing maternal and neonatal morbidity and mortality 6

Fetal Monitoring

  • Fetal heart rate tracing is category 1, indicating a normal fetal heart rate pattern
  • Continuous fetal monitoring is essential to assess fetal well-being and detect any potential complications 4, 6

Risk Factors

  • The patient's risk factors for potential complications include:
    • Fetal macrosomia, with an estimated fetal weight of 3.6 kg (8 lb) 3, 5
    • Prolonged labor, with no change in cervical dilation or effacement after 4 hours 4, 7

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

3
Research

Fetal shoulder dystocia.

Acta medica Croatica : casopis Hravatske akademije medicinskih znanosti, 2002

4
Research

Defining arrest in the first and second stages of labor.

Minerva obstetrics and gynecology, 2021

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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