What's the next step for a young primigravida (first-time mother) at 38-39 weeks gestation, admitted for labor with 6 cm cervical dilation, irregular contractions, and a cardiotocography (CTG) showing type 2 decelerations?

Immediate Management of Type 2 (Late) Decelerations in Active Labor

Implement immediate intrauterine resuscitation measures while preparing for urgent cesarean delivery, as type 2 (late) decelerations indicate uteroplacental insufficiency and fetal hypoxemia requiring intervention, not continued observation. 1

Understanding the Clinical Urgency

Late decelerations represent uteroplacental insufficiency with delayed onset after contraction begins, where the nadir occurs after the peak of the contraction. 2 This pattern indicates fetal hypoxemia and potential acidosis, particularly when accompanied by loss of variability, significantly increasing the risk of adverse neonatal outcomes. 1

The presence of late decelerations in a primigravida at 6 cm dilation with irregular contractions represents a Category II or potentially Category III fetal heart rate tracing depending on baseline variability, which requires urgent intervention to prevent progression to fetal acidemia. 2

Immediate Intrauterine Resuscitation (While Preparing for Delivery)

Implement these supportive measures immediately: 1

• Position the mother on her left side to improve uteroplacental blood flow 1
• Administer supplemental oxygen (8-10 L/min via face mask) to maximize maternal and fetal oxygenation 1
• Discontinue oxytocin immediately if it is being administered, as it increases uterine contractility and further compromises uteroplacental blood flow 2, 3
• Establish or increase IV fluid administration with physiologic electrolyte solutions to optimize maternal blood volume and uterine perfusion 2
• Perform vaginal examination to assess for cord prolapse or rapid cervical change 2
• Check maternal vital signs to identify maternal hypotension or other contributing factors 2

Definitive Management Decision

Proceed with urgent cesarean delivery as the definitive management for persistent late decelerations. 1 Late decelerations indicate active fetal compromise requiring intervention, not continued monitoring or expectant management. 1

Why Other Options Are Contraindicated:

• Observation alone is inappropriate because late decelerations represent active fetal compromise, not a benign finding that can be monitored 1
• Amniotomy is contraindicated as it could worsen uteroplacental insufficiency and increase the risk of cord compression 1
• Oxytocin augmentation is absolutely contraindicated because it increases uterine contractility, further compromising uteroplacental blood flow and worsening fetal hypoxemia 1, 3

Assessment of Fetal Heart Rate Variability

While preparing for delivery, assess baseline variability on the CTG: 2

• If absent baseline variability accompanies the late decelerations, this represents a Category III tracing requiring immediate expeditious delivery 2
• If moderate variability is present, this represents a Category II tracing requiring increased surveillance frequency and preparation for expedited delivery if abnormalities persist or worsen 2

Clinical Pitfalls to Avoid

• Do not delay delivery waiting for "improvement" in the tracing, as late decelerations indicate established uteroplacental insufficiency that will not spontaneously resolve 1
• Do not attempt fetal scalp stimulation or acoustic stimulation as a substitute for delivery when late decelerations are present, as these are temporizing measures for equivocal tracings, not established fetal compromise 2
• Do not continue labor expecting vaginal delivery in a primigravida at 6 cm with persistent late decelerations, as the risk of progressive fetal acidemia is high 1, 4

Neonatal Preparation

Alert the neonatal resuscitation team, as neonates born following late decelerations have increased risk of: 4

• Cord blood acidemia (pH < 7.20) 4
• Need for active resuscitation 4
• Neonatal seizures (though cesarean delivery before progression to severe acidemia reduces this risk) 5