Abnormal Obstetrics 3

Front 1

A 29-year-old G1P0 woman at 28 weeks gestation who is the wife of basketball player is diagnosed with gestational diabetes. Her mother had a delivery complicated by shoulder dystocia and she is concerned about her own risk. Which of the following is her biggest risk factor for shoulder dystocia?
A. Family history
B. Tall husband
C. Age
D. Gestational diabetes
E. Parity

Back 1

Gestational diabetes
Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy, a prior delivery complicated by a shoulder dystocia, and a prolonged second stage of labor are all associated with an increased incidence of shoulder dystocia.

Front 2

A 30-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with contractions every 2-3 minutes. Her membranes are intact. Her cervical examination is 5 centimeters dilated, 100% effaced, and -1 station. The fetal heart rate tracing is category I. Two hours later, she progresses to 7 cm and 0 station and receives an epidural for pain. Four hours after that, her exam is unchanged (7/100/0). Fetal heart rate tracing remains category I. Which of the following is the most appropriate next step in the management of this patient?
A. Allow her to ambulate and return when she is ready to push
B. Perform a contraction stress test
C. Perform an amniotomy
D. Perform a Cesarean delivery
E. Place an internal fetal scalp electrode

Back 2

Perform an amniotomy.
This patient has secondary arrest of dilation, as she has not had any further cervical change in the active phase for over four hours. Amniotomy is often recommended in this situation. After it is performed, if the patient is still not in an adequate contraction pattern, augmentation with oxytocin can be attempted after careful evaluation. Although the patient requires close monitoring, it is too early to proceed with a Cesarean delivery. An internal scalp electrode is not necessary, since the fetal heart monitoring is reassuring.

Front 3

A 25-year-old G1 woman at term presents in active labor. Her cervix rapidly changes from 7 centimeters to complete dilation in 1 hour. She has been pushing for two hours. The fetal station has changed from -1 to +1. Fetal heart tracing is category I. The patient is feeling strong contractions every three minutes. Which of the following is the most appropriate next step in the management of this patient?
A. Cesarean delivery
B. Forceps delivery
C. Continued monitoring of labor
D. Augmentation with oxytocin
E. Ultrasound for estimated fetal weight

Back 3

Continued monitoring of labor. Continued monitoring of labor is appropriate if clinical evaluation indicates that the fetus is not macrosomic or there is no obvious fetopelvic disproportion. If either were the case, then a Cesarean delivery would be indicated. At this time, there is no fetal or maternal indication to perform a forceps delivery because the station is +1. Augmentation would be indicated if the contractions were inadequate in intensity or frequency. An ultrasound at this stage of labor is inaccurate and one relies on clinical estimates of weight.

Front 4

A 35-year-old G3P2 woman is at 18 weeks gestation. Her obstetrical history is significant for two previous low transverse Cesarean deliveries. Her first one was performed secondary to arrest of dilation in the active phase at 7cm. She delivered a healthy 3500-gram infant. Her second Cesarean delivery was an elective repeat. She delivered a healthy 3400-gram infant. The patient strongly desires to attempt a VBAC (vaginal birth after cesarean). Which of the following statements is correct?

Back 4

. The likelihood of a successful VBAC is lower in patients with two previous Cesarean deliveries than in women with one prior Cesarean delivery

Front 5

A 25-year-old G1 woman at 41 weeks gestation presents to labor and delivery with painful contractions every four minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical exam, you are able to feel a fetal body part but it is not the head. Which of the following is the most likely body part you were palplating?
A. Foot
B. Hand
C. Buttocks
D. Back
E. Shoulder

Back 5

Buttocks. Breech presentation occurs in approximately 3-4% of women in labor overall, and occurs more frequently in preterm deliveries. Frank breech is the most common type, occurring in 48-73% of cases and the buttocks are the presenting part.

Front 6

A 19-year-old G1P0 woman presents to the hospital at 25 weeks gestation with vaginal bleeding for the past hour. She had intercourse earlier without discomfort. Currently she denies cramping or pain and feels the baby moving. Her prenatal course has been uncomplicated. She takes no medication besides prenatal vitamins and denies smoking, alcohol or drug use. Her vital signs are: blood pressure 110/70; pulse 68; and she is afebrile. Her abdomen and uterus are soft and non-tender. Fetal heart tones are in the 150s. Which of the following is the most appropriate next step in the management of this patient?
A. Digital cervical examination
B. Biophysical profile
C. Pelvic ultrasound
D. Blood transfusion
E. Bed rest

Back 6

Pelvic ultrasound. n ultrasound should be performed to check for abnormal placentation. A biophysical profile is not appropriate in this patient. Placenta previa must be ruled out before proceeding with digital cervical examination because of the risk of injury to the placenta and hemorrhage. Bleeding from placenta previa often is without warning or pain.

Front 7

A 23-year-old G2P1 woman at 36 weeks gestation presents with her third episode of heavy vaginal bleeding. She has normal prenatal labs and a known placenta previa. She denies uterine contractions or abdominal pain and reports good fetal movement. Her vital signs are: blood pressure 100/60; pulse 110; and she is afebrile. Her abdomen and uterus are nontender. Fundal height measures 35 centimeters and fetal heart tones reveal a baseline of 140 and are reassuring. Pelvic ultrasound confirms a placenta previa and the fetus is in the cephalic presentation. Hematocrit is 29%. Which of the following is the most appropriate next step in the management of this patient?
A. Tocolysis
B. Induction of labor
C. Cesarean delivery
D. Amniocentesis
E. Administer steroids

Back 7

Cesarean delivery.. This patient is near term with a third episode of active bleeding from a placenta previa. The appropriate next step would be to move towards delivery via Cesarean section. The patient is not experiencing contractions, so tocolysis is not necessary and would not be used with heavy vaginal bleeding. Catastrophic bleeding could occur due to disruption of blood vessels as the cervix dilates if a vaginal delivery is pursued, and induction of labor would therefore be contraindicated

Front 8

A 38-year-old G5P4 woman with a history of four Cesarean deliveries is at 36 weeks gestation with a singleton pregnancy. She presents to labor and delivery with complaints of vaginal bleeding for the last hour. Prenatal care has been unremarkable except for a second trimester ultrasound discovering an anterior placenta, which partially covers the cervical os. Follow up ultrasound exams have confirmed these findings. The patient denies uterine contractions and abdominal pain. She feels the baby moving. Her blood pressure is 110/60, pulse 110, and she is afebrile. Her abdomen and uterus are non-tender and soft. Fetal heart tones have a baseline of 140 and are reassuring. This patient is at greatest risk for which of the following complications?
A. Vasa previa
B. Placenta accreta
C. Placental abruption
D. Uterine rupture
E. Preterm labor

Back 8

Placenta accreta. Placenta accreta occurs when the placenta grows into the myometrium. This patient is at risk for this condition due to her history of four previous Cesarean deliveries, and the low anterior placenta. The scar tissue from the previous surgery prevents proper implantation of the placenta and it subsequently grows into the muscle. Vasa previa is a rare condition where the umbilical cord inserts into the membranes.

Front 9

Question 4 of 10Point value 0 - 1
A 24-year-old G2P1 woman is undergoing a Cesarean section for placental abruption. She presented to labor and delivery with severe abdominal pain and heavy vaginal bleeding. The fetus was delivered uneventfully. The placenta delivered with a significant clot attached to the maternal surface. The patient continues to bleed from the placental bed. Estimated blood loss is 1500 ml. The operative team decides to give her fresh frozen plasma (FFP) to replace which of the following components?
A. Platelets
B. Von Willebrand’s factor
C. Red blood cells
D. Fibrinogen
E. Factor X

Back 9

Correcting coagulation deficiencies requires replacing all necessary blood components. Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand’s factor. Neither of these preparations contains red blood cells or platelets, which must be given separately.

Front 10

An 18-year-old G1 woman at 32 weeks gestation presents with severe abdominal pain and a small amount of bleeding. She has received routine prenatal care, smokes one pack of cigarettes per day and admits to using crack cocaine. On exam, her blood pressure is 140/80, pulse 100 and she is afebrile. Her uterus is tense and very tender. Pelvic ultrasound reveals a fundal placenta, cephalic presentation of the fetus and no other abnormalities. Cervical examination reveals blood coming through the os and is one centimeter dilated. Fetal heart tones have a baseline of 160s, with a category III tracing. Which of the following is the most likely diagnosis?

A. Placenta previa
B. Premature rupture of the membranes
C. Preterm labor
D. Placental abruption
E. Chorioamnionitis

Back 10

Placental abruption
This patient has a placental abruption. Common presenting signs of an abruption include abdominal pain, bleeding, uterine hypertonus and fetal distress. Risk factors include smoking, cocaine use, chronic hypertension, trauma, prolonged premature rupture of membranes, and history of prior abruption

Front 11

A 21-year-old G1 woman at 36 weeks gestation presents with sudden onset of abdominal pain and bleeding. She smokes a pack of cigarettes a day, but otherwise her pregnancy has been uncomplicated. She takes no medications other than prenatal vitamins. Her blood pressure is 150/90, pulse 90 and she is afebrile. Her uterus is tense and very tender. Pelvic ultrasound shows the placenta to be posterior and fundal, with a cephalic presentation of the fetus. Cervical examination reveals no lesions, blood coming through the os and is one centimeter dilated. Fetal heart tones have a baseline of 150, with a category III fetal heart rate tracing. Tocometer reveals contractions every 30-45 seconds. Which of the following is the most appropriate next step in the management of this patient?
A. Amniotomy
B. Cesarean delivery
C. Induction of labor
D. Tocolysis
E. A double set-up examinatio

Back 11

Cesarean delivery. This patient is undergoing a placental abruption, with a deteriorating fetal condition. An emergent Cesarean delivery is necessary

Front 12

A 25-year-old G0 woman presents to her doctor for preconception counseling. She is healthy without significant medical problems. She takes no medications. She smokes one pack of cigarettes per day since age 16 and drinks occasionally. She weighs 140 pounds and her vital signs and examination are normal. The patient is at increased risk of which of the following during her pregnancy?

Back 12

Placental abruption
Smoking increases the risk of several serious complications of pregnancy, including placental abruption, placenta previa, fetal growth restriction, preeclampsia and infection

Front 13

A 32-year-old G3P2 woman presents at 40 1/7 weeks gestation because of regular uterine contractions every five minutes for the last two hours. Her prenatal course was unremarkable. She states the baby is moving, but she has had a bright red, bloody discharge for the last 30 minutes. She does not think she has ruptured her membranes. Her blood pressure is 120/70, pulse 80 and she is afebrile. Her abdomen is soft and she has regular contractions of moderate intensity. Fetal heart tones have a baseline of 130 with a category I fetal heart rate tracing. Pelvic ultrasound reveals a fundal placenta and cephalic presentation of the fetus. Cervical examination reveals a friable cervix that bleeds easily and is 5 centimeters dilated and completely effaced. Membranes are confirmed to be intact. Which of the following is the most likely source of bleeding?
A. Placental abruption
B. Placenta previa
C. Bloody show
D. Cervical cancer
E. Cervicitis

Back 13

Bloody show
During pregnancy the cervix is extremely vascular, and with dilation a small amount of bleeding may occur. This bloody show is not of clinical significance and often occurs with normal labor. Serious causes of bleeding, such as placental abruption and placenta previa, need to be ruled out in order to make the proper delivery plans. Cervical cancer and cervicitis are very unlikely causes for the bleeding in this situation.

Front 14

A 17-year-old G1 woman at 24 weeks gestation presents with vaginal bleeding. She denies any pain, cramping or dysuria. She reports last having intercourse three weeks ago. Prenatal care and labs have been unremarkable. Her vital signs are normal and she is afebrile. Pelvic ultrasound reveals a fundal placenta and viable fetus. Abdominal examination is unremarkable. Vaginal examination reveals a uniformly friable cervix with a small amount of blood in the vault. Digital examination reveals a firm, closed cervix. What is the most likely diagnosis that explains the bleeding?
A. Trauma
B. Cervical cancer
C. Cervicitis
D. Bloody show
E. Threatened abortion

Back 14

Cervicitis. Cervicitis caused by chlamydia, gonorrhea, trichomonas or other infections can present with vaginal bleeding.

Front 15

A 45-year-old G4P3 woman presents with vaginal bleeding. Last week, she performed a home pregnancy test that was positive. She thinks her last menstrual period was four months ago. The last time she saw her doctor was eight years ago, with the birth of her last child. She has no serious medical problems, has smoked a pack of cigarettes a day since the age of 20, occasionally has a beer and does not exercise. Abdominal examination reveals a soft abdomen and the fundus palpable just below the umbilicus. Pelvic ultrasound reveals a fundal placenta and a fetus measuring 18 weeks with normal cardiac activity. Vaginal examination reveals a 3-centimeter lesion arising off the posterior lip of the cervix. It easily bleeds with palpation and is hard in consistency. Which of the following is the most likely cause of the bleeding?
A. Cervicitis
B. Cervical polyp
C. Endometrial polyp
D. Cervical cancer
E. Nabothian cyst

Back 15

Cervical cancer. Cervical cancer can unfortunately complicate pregnancies and presents with bleeding. She is at risk due to lack of screening

Front 16

A 19-year-old G1 woman at 28 weeks gestation comes to labor and delivery because of the onset of contractions. The patient describes the contractions as progressively becoming more painful, each lasting 40 seconds and now occurring every five minutes. She reports good fetal movement and does not have any bleeding or leakage of fluid. On evaluation in triage, it is noted that she is having regular contractions, approximately every five minutes, has intact membranes and her cervical exam is 3 cm dilated and 50% effaced. What is the most frequent cause of this condition?
A. Dehydration
B. Fetal anomalies
C. Idiopathic
D. Uterine fibroids
E. Cervical incompetence

Back 16

Idiopathic

Front 17

A 20-year-old G1P0 woman at 28 weeks gestation presents to triage with uterine contractions every four minutes. On exam, her cervix is long, closed and posterior. Her urinalysis is normal. Fetal fibronectin is negative. In addition to hydration, which of the following is the most appropriate next step in the management of this patient?
A. Expectant management
B. Bedrest
C. Tocolysis
D. Cerclage
E. Administer betamethasone

Back 17

Expectant management. Approximately 50% of patients with preterm contractions have spontaneous resolution of abnormal uterine activity. The patient should be observed until a correct diagnosis is made. If there is evidence the patient is dehydrated and she is unable to tolerate PO fluids, then IV hydration would be indicated. Preterm labor, which is defined as the presence of regular uterine contractions leading to cervical change, needs to be promptly treated. Tocolysis is not necessary in this case because a diagnosis of preterm labor has not been made (no cervical change).

Front 18

A 20-year-old G2P1 woman at 28 weeks gestation presents to labor and delivery with contractions every four minutes. On physical examination, her vital signs are: temperature 100.5°F (38.0°C); heart rate 120; respiratory rate 18, and blood pressure 110/65. Her uterine fundus is tender and the rest of the physical exam is normal. Her cervix is dilated 1 cm and is 50% effaced. Baby is in vertex presentation. Fetal heart tones are in the 150s with a category I tracing. Her white blood cell count (WBC) is 18,000/mcL. Which of the following is the most appropriate next step in the management of this patient?
A. Observation
B. Tocolysis
C. Contraction stress test
D. Labor induction
E. Cesarean section

Back 18

Labor induction
This patient has a fever, a tender fundus, and elevated white blood cell count, which are concerning for an intra-amniotic infection. Delivery is warranted and in the case of reassuring heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time. Tocolytics should not be used in the case of an intra-amniotic infection

Front 19

A 26-year-old G2P1 woman at 33 weeks gestation presents in preterm labor. She has a history of a prior preterm birth at 32 weeks gestation. She has insulin dependent diabetes and has a history of myasthenia gravis. She has regular contractions every three minutes and fetal heart tones are reassuring. Cervix is 3 cm dilated and 0 station. Her blood pressure is 140/90. Which of the following is the most appropriate tocolytic agent to use in this patient?
A. Nifedipine
B. Terbutaline
C. Magnesium sulfate
D. Indomethacin
E. Ritodrine

Back 19

Incorrect! Correct answer is A. Nifedipine, a calcium channel blocker is the best option for her as she has contraindications to the other agents listed. Terbutaline and ritodrine are contraindicated in diabetic patients and the FDA made a formal announcement in 2011 warning against using terbutaline to stop preterm labor stating that terbutaline is both ineffective and dangerous if used for longer than 48 hours; magnesium sulfate is contraindicated in myasthenia gravis; and indomethacin is contraindicated at 33 weeks due to risk of premature ductus arteriosus closure.

Front 20

A 19-year-old G2P1 woman at 28 weeks gestation has been diagnosed with preterm labor. Her physician has chosen to treat her with magnesium sulfate. By what mechanism of action does magnesium sulfate work as a tocolytic?
A. Decreases prostaglandin (PG) production
B. Competes with calcium for entry into cells
C. Increases cAMP in the cell
D. Blocks calcium entry into muscle cells
E. Inhibits calcium transport

Back 20

Competes with calcium for entry into cells

Front 21

A 35-year-old G1 woman at 30-weeks gestation is transferred from an outside hospital in preterm labor. Her cervix is 3 cm dilated, 50% effaced and the vertex is at 0 station. She is having contractions every five minutes and has no signs consistent with an intra-amniotic infection (chorioamnionitis). She was initially treated with terbutaline prior to her transfer. Which of the following side effects would you expect?
A. Premature constriction of the ductus arteriosus
B. Respiratory depression
C. Tachycardia
D. Tachypnea
E. Headache

Back 21

. Tachycardia

Front 22

A 38-year-old G2P0 woman at 28 weeks gestation has been diagnosed with preterm labor and is currently stable on nifedipine. Her cervical exam has remained unchanged at 2 cm dilated, 75% effaced and -2 station. Her vital signs are stable and fetal heart tracing is category I. You recommend treatment with betamethasone (a steroid). Which of the following is associated with betamethasone therapy in the newborn?
A. Enhancement of fetal growth
B. Increased risk of infection
C. Increased incidence of necrotizing enterocolitis
D. Increased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage

Back 22

Decreased incidence of intracerebral hemorrhage. reatment with betamethasone from 24 to 34 weeks gestation has been shown to increase pulmonary maturity and reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn. It is also associated with decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn

Front 23

A 29-year-old G1 woman at 31 weeks gestation presents with watery discharge from the vagina commencing several hours ago. Her prenatal course has been uncomplicated and she takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. On examination, her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Which of the following is the most appropriate next step in the management of this patient?
A. Nitrazine testing of mucus swabbed from cervix
B. Examination of vaginal fluid for ferning
C. Digital examination of cervix
D. Determination of amniotic fluid index (AFI)
E. Non-stress test

Back 23

. Examination of vaginal fluid for ferning
Methods to confirm rupture of membranes include testing the vaginal fluid for ferning and nitrazine testing. It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns. A digital exam should be avoided in a patient you suspect might have preterm rupture of membranes because of the risk of introducing bacteria into the uterine cavity and increasing risk for chorioamnionitis. Determination of AFI with ultrasound may reveal oligohydramnios and support the diagnosis of rupture of membranes, but does not confirm this diagnosis. Similarly, a non-stress test may reveal variable decelerations, which may be present in the setting of rupture of membranes.

Front 24

Question 3 of 10Point value 0 - 1
A 19-year-old G2P1 African American woman at 30 weeks gestation presents with preterm rupture of membranes six hours ago. Her prenatal course has been complicated by two episodes of bacterial vaginosis for which she was treated. She takes prenatal vitamins and iron. She denies substance abuse or alcohol use, but admits to smoking five cigarettes each day. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Pertinent sonographic findings reveal oligohydramnios and a cervical length of 30 mm. Which of the following is the most likely cause of preterm premature rupture of membranes in this patient?
A. Ethnicity
B. Smoking
C. Previous premature rupture of membranes
D. Cervical length
E. Genital tract infections

Back 24

Genital tract infections. The primary risk factor for preterm rupture of membranes is genital tract infection, especially associated with bacterial vaginosis. All of the other listed options are risk factors.

Front 25

A 33-year-old G2P1 woman at 29 weeks gestation presents with confirmed preterm premature rupture of membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Which of the following is the best medication to delay the onset of labor?
A. Antibiotics
B. Betamethasone
C. Calcium channel blocker
D. Beta mimetics
E. Magnesium sulfate

Back 25

Antibiotics. Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis. Corticosteroids (betamethasone) and tocolytics may also prolong the pregnancy for various lengths of time, but generally not seven days.

Front 26

A 24-year-old G1 woman at 32 weeks gestation presents with leaking watery fluid from the vagina. On evaluation, preterm premature rupture of membranes is confirmed. She has occasional Braxton Hicks contractions associated with fetal heart rate accelerations. She does not have vaginal bleeding and vaginal fluid phosphatidylglycerol is absent. Her blood pressure is 110/70; pulse 90; temperature 98.6°F (37.0°C). Fundal height is 30 cm and her fundus is tender. Amniotic fluid index (AFI) is 4. Which of the following findings is an indication for delivery in this patient?
A. Tender uterine fundus
B. Size less than dates
C. Fetal heart rate accelerations
D. Amniotic fluid index of less than 5
E. Absence of vaginal fluid phosphatidylglycerol

Back 26

Tender uterine fundus. . Maternal signs of chorioamnionitis or other evidence of intra-amniotic infection are indications for delivery. This patient has ruptured membranes and a tender fundus, which indicate chorioamnionitis. Labor at 32 weeks would be allowed to progress and prolonged non-reassuring fetal testing would prompt delivery. There are no criteria for amniotic fluid index or degree of oligohydramnios as an indication for delivery. Most authors agree that the achievement of fetal lung maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational age) is the threshold at which the risk of morbidity and mortality of maintaining the pregnancy in utero outweighs the benefits of prolonging the pregnancy.

Front 27

A 28-year-old G1 woman at 31 weeks gestation presents with complaints of fluid leaking from the vagina. Preterm premature rupture of membranes is diagnosed. The patient has mild uterine tenderness concerning for early chorioamnionitis. An amniocentesis is performed. Which of the following amniotic fluid results is indicative of an intra-amniotic infection?
A. Presence of leukocytes
B. Low Interleukin-6
C. Amniotic glucose less than 20 mg/dl
D. Elevated level of bilirubin
E. Lecithin/sphingomyelin (L/S) ratio <

Back 27

Amniotic glucose less than 20 mg/dl. In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. The presence of amniotic leukocytes has the lowest predictive value for the diagnosis of chorioamnionitis. Interleukin-6 would be increased in the setting of chorioamnionitis. A low amniotic fluid glucose is an indication of intra-amniotic infection

Front 28

rupture of the membranes at 28 weeks gestation. Which of the following interventions could reduce the risk of preterm premature rupture of the membranes during this pregnancy?
A. Bedrest
B. Placement of a cerclage
C. Placement of a Tertbutaline pump
D. 17 alpha-hydroxyprogesterone
E. Nifedipine

Back 28

Bedrest and tocolytics have not been shown to reduce the risk for PPROM, and may have detrimental effects to the mother. A cerclage may be indicated for patients with a history of an incompetent cervix. 17 alpha-hydroxyprogesterone has been shown to reduce the risk of premature labor.

Front 29

A 32-year-old G2P1 woman at 36 weeks gestation presents with preterm premature rupture of the membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy delivered vaginally at 34 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). The estimated fetal weight is 2700 grams. She is having one contraction per hour and fetal heart tracing is category I. Which of the following is the most appropriate next step in the management of this patient?
A. Observation until spontaneous onset of labor
B. Augmentation of labor
C. Magnesium sulfate
D. Nifedipine
E. Corticosteroids

Back 29

Augmentation of labor. In this patient, the benefits for delivery outweigh the risk of expectant management, so the patient should undergo augmentation of labor. Expectant management at 36 weeks poses a large risk to the development of chorioamnionitis. The role of tocolytics in the setting of preterm premature rupture of membranes is controversial and is contraindicated at 36 weeks gestation. Steroid administration after 32 weeks is controversial.