Failure to generate regular contractions and cervical change after at least 24 hours of oxytocin, and with amniotomy if feasible.
Select the most appropriate diagnosis for the clinical situation described.
The diagnosis of arrest and protraction disorders is based on deviation from norms that have recently been reevaluated by the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the National Institute of Child Health and Human Development. For many years, Friedman curves were used to assess whether labor was progressing normally. However, more recent data indicates that labor in nulliparous women takes longer than expected based on Friedman curves, and that the active phase of labor does not start for most women until they are at least 6 cm dilated. This has changed how patients are managed in labor and has resulted in new definitions, which are the basis for these three questions.
Appears to lengthen the second stage of labor.
Match the description with the most appropriate type of obstetric anesthesia.
Parenteral narcotics are commonly used for labor pain. Meperidine is the most common opioid used for labor pain relief. It has a depressant effect on the fetus and can cause neonatal sedation. Pudendal block may provide adequate temporary pain relief for outlet operative vaginal deliveries in women not using regional analgesia. The success of a pudendal block depends on a clear understanding of the anatomy of the pudendal nerve and its surroundings. Complications (intravascular injection, hematoma, infection or abscess) are quite rare. Single-shot spinal analgesia provides prompt and adequate relief for procedures of limited duration such as cesarean delivery, rapidly progressing labor, or postpartum tubal ligation. The long-acting local anesthetic (with or without an opioid agonist) is injected at the level of the L4 to L5 interspace. Because of the inability to extend the duration of action, single-shot spinal analgesia is of limited use for management of labor. Epidural analgesia provides the most effective form of pain relief for the first and second stages of labor and for delivery. A catheter is placed in the epidural space, allowing for continuous infusion of local anesthetic agents or narcotics. The advantage of this method is that it can be titrated over time, and can be used for cesarean deliveries or postpartum tubal ligations. The most common side effect of regional analgesia is hypotension, which occurs in 25% to 67% of women undergoing spinal analgesia. Epidurals appear to lengthen the second stage of labor, and are associated with both an increased need for augmentation of labor with oxytocin and for instrument-assisted delivery.
Is associated with fetal sedation.
May be associated with increased need for augmentation of labor with oxytocin and for instrument-assisted delivery.
A 23-year-old G1 at 39 weeks’ gestation presents to triage with a chief complaint of uterine contractions. They began 2 hours ago, are painful, and occur every 4 to 8 minutes. She reports good fetal movement, and no bleeding or leaking fluid. The external tocometer shows contractions every 5 to 15 minutes. The fetal monitor shows a category 1 tracing. On examination, her cervix is 1-cm dilated, 60% effaced, and the fetal vertex is at -1 station. The patient had the same cervical examination in your office last week.
What is the most appropriate next step in management?
This patient is most likely experiencing false labor, or Braxton-Hicks contractions. False labor is characterized by contractions that are irregular in timing and duration, and do not result in any cervical dilation. The intensity of Braxton-Hicks contractions does not change, the discomfort is mainly felt in the lower abdomen, and the pain is usually relieved by sedation. In the case of true labor, the uterine contractions occur at regular intervals, tend to become increasingly more intense over time, and results in progressive dilation and effacement of the cervix. Sedation does not stop the discomfort. There are three stages of labor. The first stage of labor is the interval between the onset of labor and full cervical dilation. The first stage consists of a latent phase (with gradual cervical change), and an active phase (characterized by rapid cervical change). The second stage of labor begins with complete cervical dilation and ends with the delivery of the fetus. The third stage of labor is the time from delivery of the fetus to expulsion of the placenta. Since this patient is not in true labor, the best plan of management is to send her home and await spontaneous labor.
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