A 43-year-old G1P0 who conceived via in vitro fertilization comes into the office for her routine OB visit at 38 weeks. She reports good fetal movement and reports no leakage of fluid, vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels crampy at the end of the day when she gets home from work, but this discomfort is alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured 37 cm the week before. Her cervical examination is 2 cm dilated and the fetal head is engaged.
Which of the following is the most appropriate next step in the management of this patient?
The decrease in fundal height between visits can be most easily explained by engagement of the fetal head, which is verified on vaginal examination with determination of the presenting part at 0 station. Engagement of the fetal head commonly occurs before labor in nulliparous patients. Therefore, it is appropriate for the patient to return for another scheduled visit in 1 week. IUGR is unlikely because there will usually be a greater discrepancy (> 3 cm) between fundal height and gestational age. Therefore, the patient does not need to be induced. Since the patient has been reporting good fetal movement and is not post-term, there is no indication to do antepartum testing such as an NST. A fern test is not indicated since the patient has not reported leakage of fluid. An assessment of amniotic fluid to detect oligohydramnios is not indicated since the fundal height is appropriate for the patient’s gestational age.
A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well-being of this pregnancy.
Which of the following modalities will allow you to best document fetal cardiac activity?
Vaginal ultrasound can detect fetal cardiac activity as early as 5 weeks after a missed period. With a traditional stethoscope, fetal heart tones can be heard starting between 17 and 19 weeks’ gestation. Doppler stethoscope can detect fetal heart tones by 10 weeks’ gestational age in nonobese women.
A 30-year-old G2P1001 presents to your office at 37 weeks for her routine OB visit. Her first pregnancy resulted in a vaginal delivery of a 9-lb 8-oz baby boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50% effaced and 2-cm dilated. The presenting breech is high out of the pelvis. The estimated fetal weight is about 7 lb. The patient reports no contractions. You send the patient for an ultrasound, which confirms a fetus with a double footling breech presentation. There is a normal amount of amniotic fluid present, and the head is hyperextended in the “stargazer” position.
Which of the following is the best next step in the management of this patient?
According to ACOG, breech presentation occurs in 3% to 4% of term pregnancies. The patient who has a fetus with a breech presentation has the option of scheduling an ECV, an elective cesarean delivery at or after 39 weeks, or a vaginal breech delivery if certain conditions are met. It is not appropriate to electively deliver any patient prior to 39 weeks without documentation of fetal lung maturity due to the risk of neonatal RDS. An elective cesarean should be scheduled at or after 39 weeks’ gestational age to avoid RDS. If a patient would like to avoid a cesarean, but does not want to undergo a vaginal breech delivery, or this is not an option in her medical community, then an ECV is an appropriate management plan. ECV is a procedure where the breech fetus is manipulated through the abdominal wall to change the presentation to vertex. The goal is to increase the proportion of vertex presentations among fetuses formerly in the breech presentation near term, which increases the chances for a successful vaginal delivery. Studies indicate that if an ECV is not performed, 80% of breech presentations will persist at term, versus only 30% if a successful version is performed. ECV has an average success rate of about 60%; it is most successful in parous women with an unengaged breech and a normal amount of amniotic fluid (all conditions that exist in the patient described). A trial of labor for a pregnant woman with a fetus in the breech presentation may be appropriate if the fetus is frank breech, has a flexed head, has a normal amount of amniotic fluid, has an estimated weight between 2500 and 3800 g, and if there are experienced personnel available to counsel the patient about risks and benefits and perform the delivery. In addition, the pelvis should be adequate, usually as assessed by noting a history of delivery of a previous baby of larger size. A fetus with a hyperextended, or “stargazer,” head has a higher risk of spinal cord injury during vaginal breech delivery; therefore, delivery should be by cesarean. The best course of management in this case is ECV.
A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40 weeks by a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement and no contractions. She has been doing kick counts for the past several days, and reports that the baby moves at least ten times in 2 hours. On physical examination, her cervix is firm, posterior, 50% effaced, and 1-cm dilated, and the vertex is at a-1 station.
As her obstetrician, which of the following should you recommend to the patient as the best next step in management?
According to ACOG, postterm pregnancy refers to a pregnancy that has reached beyond 42 0/7 weeks of gestation from the last menstrual period (LMP). Late-term pregnancy is defined as one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation. The overall incidence of postterm pregnancy is approximately 5%. Accurate determination of gestational age is essential, and this patient has appropriate dating criteria with an early ultrasound. This patient is currently 40 weeks’ gestation, which is considered term, and therefore does not necessarily require immediate plans for delivery. Her cervical examination is unfavorable as determined by Bishop score. If she had a favorable cervix, it would be reasonable to offer her induction at 40 weeks, because the chance of having a successful vaginal delivery is very high. In this situation, it is most appropriate to ask her to return in 1 week to reassess her situation.
The patient presents in 1 week for a follow-up visit. She is now 41 weeks’ gestation. She reports that the baby is still passing the fetal kick count assessment, and she has been having intermittent contractions for several days. On physical examination, her cervix is 3 cm dilated, 70% effaced, anterior, soft, and the vertex is at 0 station. Now
what is the next best step in management?
Late-term and post-term pregnancies are associated with an increased risk of maternal and neonatal morbidity. Due to these risks, at 41 weeks, one must undertake a careful assessment of the options for delivery versus continued pregnancy. Membrane stripping (or sweeping) involves digital separation of the membranes from the lower uterine segment, and has an approximately 50% chance of resulting in labor. If a patient has a favorable cervix at 41 weeks, it is reasonable to offer induction of labor, because the chance of a successful vaginal delivery is very high. Alternatively, a patient can be induced at 41 weeks with an unfavorable cervix if cervical ripening agents are used.
If a patient waits until 42 weeks and still has an unfavorable cervix, then admission with administration of cervical ripening agents prior to Pitocin induction is recommended to improve the likelihood of a successful vaginal delivery.
The Bishop score is a method to document the favorability of the cervix for induction. The elements of the Bishop score include effacement, dilation, station, consistency, and position of the cervix (Table). Points are assigned for each element, and then totaled to give the Bishop score. Induction to active labor is usually successful with a Bishop score of 8 or greater. In the scenario described here, the patient has a Bishop score of 10, which is favorable for induction. Therefore, it is reasonable to schedule induction of labor at this point. It is not recommended to perform an elective cesarean without a trial of labor because of the risks of major surgery, and the high likelihood of vaginal delivery with a favorable cervix.
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