What is the next step in managing a 38-39 week pregnant primigravida (first-time mother) with hypertension (blood pressure 160/100 mmHg), who is in labor with a cervical dilation of 5 cm after 4 hours, and has a normal cardiotocography (CTG) and maternal condition?

Management of Severe Hypertension During Active Labor

This patient requires immediate antihypertensive treatment and urgent laboratory workup to assess for preeclampsia, NOT simple reassessment in 2 hours—the correct answer is B (Amniotomy) to expedite delivery, though this must be combined with immediate blood pressure control and preeclampsia evaluation.

Immediate Blood Pressure Management is Critical

• Blood pressure of 160/100 mmHg meets criteria for severe hypertension (≥160/110 mmHg) and requires urgent treatment within 15 minutes, regardless of symptoms. 1, 2
• The patient being asymptomatic does NOT eliminate risk—systolic BP >160 mmHg is independently associated with stroke and pulmonary edema. 1, 2
• First-line treatment options include:
  • Oral nifedipine 10-20 mg, repeat in 30 minutes if needed 2
  • IV labetalol 20 mg bolus, escalating doses 1
• Target BP should be maintained <160/110 mmHg throughout labor. 1, 2

Urgent Preeclampsia Assessment Required

Before making any labor management decisions, you must rule out preeclampsia with severe features:

• Obtain immediate laboratory testing: complete blood count (platelets), liver transaminases, creatinine, and uric acid. 2
• Urine protein quantification is mandatory—either 24-hour collection or protein/creatinine ratio (≥30 mg/mmol is abnormal). 2
• The absence of proteinuria information in this case is a critical gap that must be addressed immediately. 2

Labor Management Strategy

Regarding the specific question options:

Why NOT Option A (Reassess after 2 hours):

• Reassessment alone is insufficient given severe hypertension requiring expedited delivery at term gestation. 2
• Delaying treatment of severe hypertension increases maternal risk for stroke and eclampsia. 2
• At 38-39 weeks with severe hypertension, delivery should be considered rather than expectant management. 3

Why Option B (Amniotomy) is Most Appropriate:

• Amniotomy combined with oxytocin augmentation is recommended for prevention and treatment of slow labor progression. 4
• The patient has progressed only 1 cm in 4 hours (from 4 to 5 cm), indicating slow progress that warrants intervention. 4
• Early intervention with amniotomy and oxytocin is recommended to expedite delivery, which is the definitive treatment for hypertensive disorders. 5, 4
• At term gestation (38-39 weeks) with severe hypertension, expediting vaginal delivery is preferred over cesarean section unless standard obstetric indications exist. 3

Why NOT Option C (Cesarean Section):

• Cesarean delivery should not be performed for arrest of labor unless labor has arrested for minimum 4 hours with adequate contractions or 6 hours with inadequate contractions in a woman ≥6 cm dilated. 4
• This patient is only at 5 cm and has not met arrest criteria. 4
• Vaginal delivery should be considered for women with hypertensive disorders unless cesarean is required for standard obstetric indications. 3

Why NOT Option D (Discharge):

• Never discharge a patient with severe hypertension in active labor—this poses immediate maternal risk for stroke and eclampsia. 2
• The patient is in active labor at term with severe hypertension requiring hospitalization and close monitoring. 1

Additional Critical Management Steps

Magnesium sulfate prophylaxis:

• Should be strongly considered if preeclampsia is confirmed, especially with proteinuria and severe hypertension. 2
• Loading dose: 4-5g IV over 3-4 minutes, maintenance 1-2g/hour. 2

Monitoring requirements:

• Continue CTG monitoring throughout labor. 2
• Blood pressure monitoring every 15-30 minutes during active management. 2
• Fluid restriction to 60-80 mL/hour to prevent pulmonary edema. 2

Common Pitfalls to Avoid

• Do not delay antihypertensive treatment while waiting for proteinuria results—severe hypertension requires urgent treatment regardless. 2
• Do not assume the patient is safe because she is asymptomatic—24% of normotensive pregnant women develop hypertension during labor, and severe hypertension can rapidly progress to eclampsia. 6
• Do not use methyldopa for urgent BP reduction—it should not be used primarily for acute management. 1
• Avoid concurrent use of magnesium sulfate with calcium channel blockers due to risk of precipitous hypotension. 1

Clinical Algorithm

1. Immediately initiate antihypertensive therapy (nifedipine or labetalol) 1, 2
2. Obtain urgent labs and urine protein 2
3. Perform amniotomy and augment with oxytocin to expedite delivery 4
4. Administer magnesium sulfate if preeclampsia confirmed 2
5. Prepare for delivery at term gestation with severe hypertension 3