Obstetrics & Gynecology>>>>>Normal and Abnormal Labor and Delivery
Question 32#

A 16-year-old G1P0 at 38 weeks’ gestation presents to labor and delivery for the second time during the same weekend that you are on call. She initially presented at 2:00 pm Saturday afternoon complaining of regular uterine contractions. Her cervix was 1-cm dilated, 50% effaced with the vertex at −1 station, and she was sent home after walking for 2 hours in the hospital without any cervical change. It is now Sunday night at 8:00 pm, and the patient returns to labor and delivery with increasing pain. She is exhausted because she did not sleep the night before because her contractions kept waking her up. The patient is placed on the external fetal monitor. Her contractions are occurring every 2 to 3 minutes. You reexamine the patient and determine that her cervix is unchanged.

Which of the following is the best next step in the management of this patient?

A. Perform artificial rupture of membranes to initiate labor
B. Administer an epidural
C. Administer Pitocin to augment labor
D. Achieve cervical ripening with prostaglandin gel
E. Administer 10 mg intramuscular morphine

Correct Answer is E


This patient is either experiencing prolonged latent labor or is in false labor. Friedman criteria for the normal progress in labor were established in the 1950s, and until recently, were used for assessment and management of labor. Friedman data indicated that the transition from the latent to the active phase of labor occurred around 4 cm of cervical dilation, and that active phase dilation should proceed at 1.2 cm per hour for nulliparous women, and 1.5 cm per hour for multiparous women. However, contemporary data suggests that changes in obstetric and anesthesia practices have resulted in changes in typical labor, and therefore, criteria for labor progress have been reviewed and revised based on data from the Consortium for Safe Labor (CSL). This data showed that cervical change between 3 cm and 6 cm is much slower than originally thought, and that the active phase of labor is more likely to start around 6 cm dilation. Women who dilate at a rate less than 1 cm per hour before 6 cm are still likely to proceed to spontaneous vaginal delivery. Data needed to establish the normal range for the duration of labor in the latent phase are not readily available because the onset of the latent phase in most women occurs outside the hospital and therefore cannot be accurately determined. One way to manage a protracted latent labor is to administer a strong sedative such as morphine along with intravenous fluids. This is sometimes referred to as “hydration and sedation.” This is preferred over augmentation with Pitocin or performing an amniotomy, because 10% of patients will actually have been in false labor. Patients who are not truly in labor will usually stop contracting after administration of morphine and hydration with rest. If a patient truly is in labor, then, after the sedative wears off, she will have undergone cervical change and will have benefited from the rest in terms of having additional energy to proceed with labor. An epidural would not be recommended because the patient may not truly be in labor. There is no role for cervical ripening in this patient, because if she is not in labor, she can go home and wait for natural cervical ripening and spontaneous labor.