Immediate Management: Stop Oxytocin
The immediate management for this primigravida with recurrent late decelerations and reduced variability on CTG after oxytocin administration is to stop the oxytocin infusion (Option D). This represents a Category III fetal heart rate tracing indicating uteroplacental insufficiency and potential fetal hypoxia, requiring discontinuation of oxytocin as the priority first intervention 1.
Rationale for Stopping Oxytocin First
- Discontinuing oxytocin addresses the root cause of uterine hyperstimulation leading to uteroplacental insufficiency and must be done before considering other measures or delivery 1.
- The American College of Obstetricians and Gynecologists and NICHD guidelines consistently prioritize stopping oxytocin as the first intervention for Category III tracings (recurrent late decelerations with reduced variability), supported by FDA labeling requirements 1.
- The FDA label explicitly states that "the oxytocin infusion should be discontinued immediately in the event of uterine hyperactivity or fetal distress" 2.
- When oxytocin is stopped abruptly, oxytocic stimulation of the uterine musculature will soon wane, allowing rapid reversal of the hyperstimulation 2.
Comprehensive Intrauterine Resuscitation Algorithm
After stopping oxytocin, implement these concurrent resuscitative measures:
- Change maternal position to left lateral to relieve potential cord compression and improve uteroplacental blood flow 1, 3.
- Administer oxygen at 6-10 L/min via face mask to improve fetal oxygenation 1, 3, 2.
- Give IV fluid bolus if not already administered to ensure adequate maternal hydration 3.
- Assess maternal vital signs and treat hypotension if present to ensure adequate uteroplacental perfusion 3.
- Perform vaginal examination to assess for rapid descent, cord prolapse, or signs of uterine rupture 4.
Monitoring Response and Decision for Delivery
- Continuous monitoring of the fetal heart rate tracing after stopping oxytocin is crucial to assess response to intervention 1.
- If the tracing improves, labor may continue with close monitoring 1.
- If the tracing remains abnormal despite intrauterine resuscitation, expedited delivery via operative vaginal delivery or cesarean section should be considered 1, 3.
- Consider tocolysis with terbutaline if fetal heart rate abnormalities persist despite stopping oxytocin and implementing other resuscitative measures 4, 5.
Critical Pitfall to Avoid
Do not proceed directly to cesarean section without first stopping oxytocin and attempting intrauterine resuscitation. The pattern may rapidly improve once the causative agent (oxytocin-induced hyperstimulation) is removed, potentially avoiding unnecessary operative delivery 1, 2. However, preparation for expedited delivery should occur simultaneously while assessing response to resuscitation 1.