A 19-year-old primigravida at 38 weeks gestation with intrauterine growth restriction, 4 cm cervical dilation, meconium‑stained amniotic fluid, and a non‑reassuring fetal heart‑rate pattern (baseline 130 bpm, no accelerations, poor variability, recurrent late decelerations) with regular strong uterine contractions 3–4 per 10 minutes—what is the most appropriate next step in management?

Emergency Cesarean Section is Immediately Indicated

This patient requires emergency cesarean section without delay due to the combination of severe fetal compromise (non-reassuring fetal heart rate pattern with recurrent late decelerations, absent accelerations, and poor variability), intrauterine growth restriction, and meconium-stained amniotic fluid at term gestation. 1, 2

Critical Clinical Features Mandating Immediate Delivery

The cardiotocography pattern demonstrates Category III fetal heart rate tracing characteristics that indicate severe fetal hypoxia and imminent risk of permanent neurologic injury or fetal demise:

• Recurrent late decelerations represent established placental insufficiency that worsens with each contraction, progressively compromising fetal oxygenation 1
• Absent accelerations and poor variability indicate loss of fetal central nervous system compensation mechanisms and advanced fetal compromise 1
• Meconium-stained amniotic fluid in the setting of IUGR suggests chronic fetal stress with acute decompensation 3

Why Other Options Are Contraindicated

Induction of Labor (Option A)

• Contraindicated because the patient is already in active labor at 4 cm dilation with adequate contractions (3-4 per 10 minutes) 2
• Attempting induction in a patient already laboring with established fetal compromise would only delay necessary intervention 1

Augmentation of Labor (Option B)

• Dangerous and contraindicated because uterine contractions are already adequate and regular 2
• Increasing uterine activity would further reduce placental perfusion during contractions, accelerating fetal deterioration in an already compromised fetus 1, 2
• Late decelerations represent placental insufficiency that will only worsen with continued or augmented contractions 1

Reassurance and Observation (Option D)

• Unacceptable given the Category III fetal heart rate pattern indicating severe, ongoing fetal hypoxia 1
• Expectant management when late decelerations are present represents established placental insufficiency and carries unacceptable risk of fetal death or permanent neurologic injury 1

Mode of Delivery Considerations

Cesarean delivery is strongly indicated rather than attempting vaginal delivery for several reasons:

• The Society for Maternal-Fetal Medicine recommends cesarean delivery be strongly considered for FGR complicated by absent/reversed end-diastolic velocity or signs of fetal compromise based on the entire clinical scenario 4, 5, 2
• At 38 weeks with established severe fetal compromise, there is no benefit to attempting vaginal delivery 2
• FGR fetuses with evidence of compromise have a 75-95% risk of requiring emergency cesarean for worsening intrapartum heart rate abnormalities if vaginal delivery is attempted 1, 2
• The growth-restricted fetus has severely limited ability to tolerate labor, and the risk for progressive acidosis is extremely high 3

Essential Pre-Delivery Coordination

• Neonatal team must be present at delivery given the evidence of intrapartum compromise requiring immediate neonatal assessment and potential resuscitation 1, 5
• Preparation for potential neonatal complications including respiratory distress, metabolic acidosis, and meconium aspiration syndrome is essential 5, 3

Common Pitfalls to Avoid

• Do not attempt fetal scalp sampling or operative vaginal delivery as these delay definitive intervention and carry unacceptable risk with pre-existing severe fetal compromise 1
• Do not wait for further deterioration such as prolonged bradycardia, as the current pattern already indicates severe compromise requiring immediate delivery 1, 6
• Do not rely on biophysical profile or additional testing to guide management when Category III fetal heart rate pattern is already present 2