Managing A 31 Year Old G2P1 At 41 Weeks Gestation (Case Study)

Case Scenario: You are seeing a 31-year-old G2 P1 at 41 weeks gestation by definite last menstrual period and 16-week ultrasound. She continues to note fetal movement and her examination is normal: BP 120/68, urine dipstick negative for protein and glucose, fundal height 42 cm, vertex, FHR 156. Her cervix is soft, anterior, 2–3 cm dilated, 50% effaced, and +1 station. She was induced with her first pregnancy, and this time she wants to have a “natural labor.”

Q 1. You decide to check a Bishop score. The Bishop score helps to determine:
A) The health of the fetus.
B) The likely success with induction.
C) The maturity of the fetal lungs.
D) The results of a Catholic Intramural Baseball game.

Answer And Discussion
The correct answer is “B.” The likely success with induction
The Bishop score, which takes into account cervical dilation, cervical effacement, station of the infant, and cervical consistency, can be used to predict the likelihood of a successful induction.

Q 2. The Bishop score is favorable.
Which of the following are the most appropriate recommendations at this point?
A) She should be induced at once; there is a high chance of fetal mortality after 41 weeks gestation.
B) Since her antepartum course has been uncomplicated to date, it is safe for her to await spontaneous labor until 43 weeks gestation.
C) She should undergo a nonstress test and ultrasound for amniotic fluid index.
D) She should plan for a cesarean section.

Answer And Discussion

The correct answer is “C.” She should undergo a nonstress test and ultrasound for amniotic fluid index.

By definition, a term gestation is one completed in 38–42 weeks. There is no significant increase in fetal mortality in uncomplicated pregnancy at term. Virtually all reports suggest an increase in perinatal morbidity and mortality when pregnancy goes beyond 42 weeks gestation.
Antenatal surveillance of post mterm pregnancies should be initiated at 41 weeks gestation.

Accurate determination of conception is important in reducing the false diagnosis of post term pregnancy. The estimated date of delivery is most reliably and accurately determined early in pregnancy.

Q 3. Which of the following non pharmacologic methods of augmenting or inducing labor is LEAST
likely to be effective?
A) Stripping the amniotic membranes.
B) Prolonged walking.
C) Amniotomy.
D) Nipple stimulation.

Answer And Discussion
The correct answer is “B.”  Prolonged walking

Stripping membranes appears to be effective in initiating spontaneous labor within 72 hours. Amniotomy may be used for labor induction, especially if the Bishop score is favorable, but oxytocin is more effective.
Nipple stimulation causes release of oxytocin and may be utilized for labor induction, but its marginal benefit is only seen in patients with a favorable Bishop score.
Walking does not result in labor induction or augmentation, but it’s not harmful either.
Sexual intercourse is sometimes recommended to induce labor. Studies are of low quality and use various endpoints . . . also, it is difficult to standardize the intervention.

Q 4. If induction becomes necessary, which of the following pharmacologic interventions would be the best approach to your patient who has a cervix that is soft, anterior, 2–3 cm dilated, 50% effaced, and +1 station?
A) IV oxytocin.
B) Intracervical PGE2 (dinoprostone).
C) Intravaginal PGE2 (dinoprostone).
D) Intravaginal PGE1 (misoprostol).
E) None of the above. All pharmacologic interventions are contraindicated.

Answer And Discussion
The correct answer is “A.” IV oxytocin.

This patient does not need further cervical ripening but is a candidate for induction of labor. PGE2 gel (dinoprostone, brand name Cervidil or Prepidil) is administered vaginally— not intracervically—and is used for cervical ripening when induction is indicated but the status of the cervix is unfavorable. PGE2 gel is not indicated for induction of labor.
PGE1 (misoprostol, option “D”) can be administered intravaginally or orally and has been found to be effective for both cervical ripening and labor induction. However, the Food and Drug Administration (FDA) has not approved it for use in pregnancy.
Because the cervix is favorable in this case, proceeding with oxytocin is the best option.

Q 5. Your patient’s husband had an emergency business trip and would be leaving next week.. She is now 41 2/7 weeks gestation and desires induction so he can be with her for the delivery. You admit her to labor and delivery the following morning. The initial FHR monitoring before any induction (also known as a nonstress test) shows Baseline = 150 beats per minute; reactive. 

You perform amniotomy and get a meconium-stained fluid. Her cervix is now 5 cm dilated, 80% effaced, with vertex at +1 station. You elect to continue monitoring progress.
Which of the following choices of labor analgesia is MOST appropriate at this point?
A) Epidural analgesia.
B) Local perineal anesthetic infiltration.
C) Bilateral pudendal nerve block.
D) All of the above are equally appropriate.

Answer And Discussion:
The correct answer is “A.” Epidural analgesia.

Epidural analgesia offers the most effective form of pain relief and generally may be utilized once the patient is determined to be in active labor. Various local anesthetic agents are available for local infiltration of the perineum and vagina to provide analgesia for episiotomy or laceration repair following delivery but not for labor.
Bilateral pudendal nerve blocks are useful during the second stage of labor, as a supplement to epidural analgesia for anesthesia of the sacral nerves, or as an option for operative vaginal delivery anesthesia (forceps, vacuum).
Opioid agonists and agonist–antagonists are also available and commonly employed. However, recent
reports suggest that the analgesic effect of opioids in labor is limited when using doses that won’t effect the fetus.

Q 6. The nurse notices some changes on the fetal heart monitor. It shows Baseline 160 beats per minutes; variable decelerations to the 90s.
Which of the following should be performed next?
A) Check the patient’s cervix.
B) Place a fetal scalp electrode.
C) Begin IV oxytocin infusion.
D) Place an intrauterine pressure catheter and begin an amnioinfusion.

Answer And Discussion
The correct answer is “A.” Check the patient’s cervix.

Variable decelerations are common in labor, and brief variable decelerations are benign. When variable decelerations become recurrent, progressively deeper, longer lasting, and with delayed return to baseline, they are non reassuring and may reflect hypoxia.
A pelvic examination should be performed to determine if the umbilical cord is prolapsed or if there has been rapid descent of the fetal head or rapid progression of labor.
Oxytocin should not be considered since she is having adequate contractions.
Replacement of the amniotic fluid with normal saline infused through a transcervical catheter has been reported to decrease both the frequency and severity of repetitive variable decelerations. However, it would first be helpful to assess the cervical status.
Amnioinfusion is no longer recommended as a prophylactic intervention for moderate or severe
meconium.

Q 7. Labor progresses without incident. Your patient is now completely dilated and effaced, with vertex at +3 station. She is comfortable with her epidural and able to  push with good effort. The FHR tracing is reassuring. Contractions are every 3 minutes. Appropriate management at this point is:
A) Continue pushing.
B) Vacuum-assisted delivery.
C) Forceps-assisted delivery.
D) Midline episiotomy.
E) Augment with oxytocin.

Answer And Discussion
The correct answer is “A.” Continue pushing.

At this point, labor is progressing and maternal–fetal status is reassuring. You should continue expectant management. No intervention is indicated.

Q 8. She pushes for 3 hours. She is now exhausted. The fetal head now separates the labia with contractions, and then recedes slightly. You consider offering assistance with delivery.
In counseling your patient and her husband about the maternal risks of operative vaginal delivery,
which of the following should you discuss?
A) Vaginal trauma.
B) Shoulder dystocia.
C) Fetal injury.
D) Perineal and rectal trauma.
E) All of the above.

Answer And Discussion
The correct answer is “E.”

Q 9. Maternal risks of operative vaginal delivery include injury to the lower genital tract and rectal sphincter involvement in the case of a third- or fourth-degree laceration. In addition, fetal complications need to be discussed as well.

Each of the following is a fetal risk of operative vaginal delivery EXCEPT:
A) Cephalohematoma.
B) Skull fracture.
C) Brachial plexus injury.
D) Respiratory distress syndrome.
E) Facial nerve palsy.

Answer And Discussion
The correct answer is “D.” Respiratory distress syndrome.

Respiratory distress syndrome is not increased by assisted delivery. Neonatal cephalohematoma, retinal hemorrhage, and jaundice (secondary to breakdown and reabsorption of the cephalohematoma) are more common with vacuumassisted delivery than with forceps-assisted delivery. Skull fracture and facial nerve injury is more common with forceps-assisted delivery than with vacuum assisted delivery. Shoulder dystocia with resultant brachial plexus injury is more common with vacuum assisted delivery, prolonged time required for delivery,
and increasing birth weight. Note that injury can occur before operative delivery as a result of abnormal labor forces.

Q 10. Delivery of an 8-pound baby is accomplished without operative vaginal assistance.Following spontaneous delivery of the intact placenta 15 minutes later, you note a large gush of blood.
Which of the following is the most likely source of the bleeding?
A) Uterine atony.
B) Vaginal laceration.
C) Cervical laceration.
D) Retained placenta.

Answer And Discussion
The correct answer is “A.” Uterine atony

Postpartum hemorrhage is most commonly associated with uterine atony. Risk factors include prolonged labor, over-distended uterus (such as from 2 . . . or 8 . . . gestations), very rapid labor, high parity, chorioamnionitis, retained placental tissue, poorly perfused myometrium, halogenated
hydrocarbon anesthesia, and previous atony. Maternal trauma to the genital tract may result
in postpartum hemorrhage and should be routinely investigated following assisted delivery. A retained placenta cotyledon is another common source for postpartum hemorrhage. The placenta should be inspected, and if there is any question of retained products of conception, the uterus should be manually explored.

Q 11.Which of the following should be undertaken next?
A) Obtain IV access and initiate hydration.
B) Begin bimanual uterine compression.
C) Inspect vagina and cervix for lacerations.
D) Obtain blood for type and screen for possible
blood transfusion.
E) All of the above.

Answer And Discussion
The correct answer is “E.” Postpartum hemorrhage is an obstetrical emergency and must be addressed immediately. The gravid uterus receives 500 mL of blood per minute, which can lead to massive hemorrhage if not addressed quickly. Additional personnel should be notified to help with obtaining IV access and blood draws, while you quickly try to identify the source of bleeding.

Q 12. After thorough exploration of the vagina and uterus, you suspect uterine atony is the cause of bleeding. While continuing uterine massage, you think about your options. Which of the following is/are options in treating this patient’s bleeding?
A) Dilute oxytocin IV.
B) Methylergonovine (Methergine) IM.
C) Carboprost tromethamine (Hemabate) IM.
D) Misoprostol PR.
E) All of the above.

Discussion
The correct answer is “E.” Oxytocin can be given as a dilute IV solution or IM. It should never
be administered as an undiluted IV bolus, due to the risk of hypotension and cardiac arrhythmia.
Methergine (methylergonovine) may be administered orally or intramuscularly (not intravenously). Caution should be used in women with hypertension, as Methergine can cause hypertension. Hemabate (carboprost tromethamine) is an F-2 prostaglandin analog that is administered IM or directly into the uterine myometrium. Caution should be used in women with asthma, as Hemabate can cause bronchoconstriction. Misoprostol is a prostaglandin E1 analog that can be administered to women with asthma or hypertension. Rectal or oral administration can be used, but rectal administration is preferred in a patient with potential hemodynamic instability. This can be a life saver especially in the third world countries where other options may not exist.

Conclusion of The Case: She requires IV crystalloid and 4 units of packed red cells for symptomatic anemia following delivery. Both mother and infant are now doing well.