What is the most appropriate next step in management for a preterm patient at 34 weeks gestation, presenting with a 4 cm dilated cervix, intact membranes, and variable decelerations on cardiotocography (CTG), with strong and regular uterine contractions?

Management of Preterm Labor at 34 Weeks with Active Labor

The most appropriate next step is to proceed with delivery by allowing spontaneous vaginal delivery while administering corticosteroids, antibiotics for GBS prophylaxis, and magnesium sulfate for fetal neuroprotection, rather than attempting tocolysis. 1

Rationale Against Tocolysis (Option D)

• At 34 weeks gestation with 4 cm cervical dilation and strong regular contractions (4 in 10 minutes), this represents established active preterm labor where tocolysis is contraindicated. 1, 2
• Tocolytic agents are only advocated for 48-72 hours to allow time for corticosteroid administration and maternal transfer, not for labor this advanced. 2, 3
• Uterine contractions after 34 weeks' gestation are not an indication for tocolytic treatment, as neonatal outcomes at this gestational age are favorable with modern neonatal care. 2
• The cervix is already 4 cm dilated with regular strong contractions—attempting to stop labor at this stage is both futile and potentially harmful by delaying necessary interventions. 4

Rationale Against Cesarean Section (Option A)

• The fetal heart rate tracing shows a reassuring pattern: baseline 110 bpm (normal), present accelerations, good variability, and only variable decelerations. 5
• Variable decelerations alone without other concerning features (absent variability, late decelerations, prolonged decelerations, or bradycardia) do not constitute fetal compromise requiring cesarean delivery. 5
• Cesarean section should not be performed reflexively without clear obstetric indication based solely on preterm status or variable decelerations. 5
• The vertex is at -3 station with intact membranes, indicating the fetus is not yet engaged—this is not an indication for operative delivery. 5

Rationale Against Forceps Delivery (Option B)

• Forceps delivery requires the vertex to be at +2 station or lower; at -3 station, the fetal head is still high in the pelvis and forceps application would be dangerous and inappropriate. 5
• The cervix is only 4 cm dilated (not fully dilated at 10 cm), making instrumental delivery impossible. 5

Rationale Against Artificial Rupture of Membranes (Option C)

• While amniotomy may accelerate labor, the membranes are intact and this patient is already in active labor with strong regular contractions—rupturing membranes offers no therapeutic benefit and increases infection risk. 5, 6
• At 34 weeks, the priority is administering corticosteroids and GBS prophylaxis, not accelerating an already progressing labor. 1, 3

Correct Management Algorithm

Immediate Interventions (All Should Be Initiated Simultaneously):

• Administer a single course of antenatal corticosteroids (betamethasone 12 mg IM × 2 doses 24 hours apart or dexamethasone 6 mg IM × 4 doses 12 hours apart) between 24+0 and 34+0 weeks gestation to accelerate fetal lung maturity and reduce respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. 1, 3, 7

• Initiate GBS prophylaxis immediately with IV penicillin or ampicillin (or cefazolin if penicillin-allergic) for all preterm deliveries <37 weeks with labor, regardless of known GBS colonization status. 5, 1

• Administer magnesium sulfate for fetal neuroprotection when delivery is anticipated before 32 weeks; at 34 weeks, this may be considered based on institutional protocols but is less critical than at earlier gestational ages. 1, 3

Monitoring During Labor:

• Continue continuous fetal heart rate monitoring for signs of fetal compromise, particularly monitoring the variable decelerations for progression to more concerning patterns. 5

• Monitor for signs of chorioamnionitis: maternal fever ≥38°C, maternal tachycardia, uterine tenderness, fetal tachycardia, or purulent discharge. 1, 6

• Prepare for neonatal resuscitation team presence at delivery, as preterm infants at 34 weeks may require respiratory support despite favorable survival rates. 1

Critical Pitfalls to Avoid

• Do not delay antibiotic administration beyond what is necessary to establish IV access—infection risk increases with every hour of labor. 5, 1

• Do not administer multiple courses of corticosteroids, as this may be harmful; a single course is sufficient. 2, 3

• Do not perform cesarean section without clear obstetric indication (non-reassuring fetal heart rate pattern, cord prolapse, placental abruption, or failed progress in labor). 5

• Do not use amoxicillin-clavulanic acid (Augmentin) for antibiotic prophylaxis, as it increases the risk of neonatal necrotizing enterocolitis. 5, 1, 6

• Do not attempt tocolysis with advanced cervical dilation (≥4 cm) and established labor—this delays necessary interventions without benefit. 2, 4, 3