A 28-year-old null-gravid has been in active labor for the last 4 hours. Her labor was induced with an oxytocin intravenous infusion. Her cervix is dilated to 6 cm, and the fetal vertex is at plus 1 station. You estimate the fetus to weigh approximately 7 pounds, and by clinical exam you have determined that the maternal pelvis is adequate. Membranes have ruptured and the amniotic fluid is clear. The patient is afebrile and normotensive. She has not required any medication for pain control. Her nurse has notified you of a recent change in the character of the fetal heart tracing.
On arrival at the patient’s bedside, you note early decelerations on fetal heart tracing. Of the following, which is the most appropriate next step?
Correct Answer E:
These are examples of early decelerations and are felt to be due to head compression. Increased intracranial pressure causes local changes in cerebral artery blood flow, leading to a reflexive bradycardia mediated by the vagal nerve. Although not all authors agree that this class of decelerations is distinct from variable decelerations, there is good evidence to suggest that early decelerations are not associated with fetal asphyxia. Early decelerations are most often seen around 4-6 cm of cervical dilation and should not have any associated tachycardia, loss of variability, or other heart rate changes.
→ Instrumented vaginal delivery (choice A) is never indicated before the cervix is completely dilated.
→ Cesarean delivery (choice B) would be indicated if evidence of uncorrectable fetal hypoxia should develop.
→ Amnioinfusion (choice C) is appropriate for repetitive variable decelerations due to oligohydramnios. Its use for diluting thick meconium to decrease the incidence of meconium aspiration syndrome is controversial.
→ There is no evidence of uteroplacental insufficiency. Thus, no intervention (choice D) is required.
Late decelerations on fetal monitoring are thought to indicate which one of the following?
Late decelerations are thought to be associated with uteroplacental insufficiency and fetal hypoxia due to decreased blood flow in the placenta. This pattern is a warning sign and is associated with increasing fetal compromise, worsening fetal acidosis, fetal central nervous system depression, and/or direct myocardial hypoxia. Early decelerations are thought to result from vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity. Variable decelerations are thought to be due to acute, intermittent compression of the umbilical cord between fetal parts and the contracting uterus.
A pregnant woman at 20 weeks gestation has a uterine size of 25 cm.
All of the following are possibilities, except:
Correct Answer D:
Bilateral renal agenesis is associated with oligohydramnios, as the fetus cannot produce urine and contribute to the volume of the amniotic fluid. Therefore uterine size would be small for dates. The other answer choices could have a large uterine size on physical exam.
The most appropriate place to obtain a smear for the diagnosis of gonorrhea in a woman who presents with vaginal discharge is:
Correct Answer C:
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae. It typically infects epithelia of the urethra, cervix, rectum, pharynx, or eyes, causing irritation and purulent discharge. Dissemination to skin and joints occurs infrequently. Diagnosis is by culture or genetic methods.
Diagnosis is by Gram stain and culture. Endocervical swabs should be inserted at least 2 cm and rotated for 10 sec to obtain a proper specimen.
A patient with gonorrhea was treated with ceftriaxone. Afterwards there is recurrence of symptoms.
What is the most likely reason and what is the appropriate management?
Correct Answer A:
Uncomplicated gonococcal infection of the urethra, cervix, rectum, and pharynx is treated with a single dose of ceftriaxone. Patients are also empirically treated for chlamydia infection, which is often asymptomatic or masked by symptoms of gonorrhea.
Concomitant infection with Chlamydia occurs in 15 to 25% of heterosexual men and 35 to 50% of women.
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