A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management?

Plan for oxytocin administration

Perform weekly pelvic ultrasound

A 24-year-old woman, gravida 1, at 35 weeks gestation is admitted to the hospital with regular contractions and pelvic pressure for the last 5 hours. Her pregnancy has been uncomplicated and she has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. She has had no history of fluid leakage or bleeding. At the hospital, her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 16/min. Cervical examination shows 60% effacement and 5 cm dilation with intact membranes. Cardiotocography shows a contraction amplitude of 220 MVU in 10 minutes. Which of the following is the most appropriate pharmacotherapy at this time?

No pharmacotherapy at this time

A 30-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the hospital for regular, painful contractions that have been increasing in frequency. Her pregnancy has been complicated by gestational diabetes treated with insulin. Pelvic examination shows the cervix is 50% effaced and 4 cm dilated; the vertex is at -1 station. Ultrasonography shows no abnormalities. A tocometer and Doppler fetal heart monitor are placed on the patient's abdomen. The fetal heart rate monitoring strip shows a baseline heart rate of 145/min with a variability of ≥ 15/min. Within a 20-minute recording, there are 7 uterine contractions, 4 accelerations, and 3 decelerations that have a nadir occurring within half a minute. The decelerations occur at differing intervals relative to the contractions. Which of the following is the most appropriate next step in the management of this patient?

Placement of fetal scalp electrode

A 26-year-old gravida 1 at 36 weeks gestation is brought to the emergency department by her husband complaining of contractions lasting up to 2 minutes. The contractions are mostly in the front of her abdomen and do not radiate. The frequency and intensity of contractions have not changed since the onset. The patient worries that she is in labor. The blood pressure is 125/80 mm Hg, the heart rate is 96/min, the respiratory rate is 15/min, and the temperature 36.8°C (98.2℉). The physical examination is unremarkable. The estimated fetal weight is 3200 g (6.6 lb). The fetal heart rate is 146/min. The cervix is not dilated. The vertex is at the -4 station. Which of the following would be proper short-term management of this woman?

Reassurance, hydration, and ambulation

Admit to the Obstetrics Department for observation

Admit to the Obstetrics Department in preparation for labor induction

Perform an ultrasound examination

A 28-year-old woman, gravida 2, para 1, at 14 weeks' gestation, comes to the physician with a 3-day history of abnormal vaginal discharge. She has not had fever, chills, or abdominal pain. One week ago, her 2-year-old daughter had a urinary tract infection that quickly resolved after antibiotic therapy. The patient reports that she is sexually active with one male partner and they do not use condoms. Vital signs are within normal limits. Pelvic examination shows an inflamed and friable cervix. There is mucopurulent, foul-smelling discharge from the cervical os. There is no uterine or cervical motion tenderness. Vaginal pH measurement shows a pH of 3.5. Which of the following is the most appropriate initial step in management?

Nucleic acid amplification test

Potassium hydroxide preparation

A 3-year-old girl is brought to the physician by her mother two days after the sudden onset of a rash. The mother says that the rash developed an hour after she bathed the child in hot water. Two weeks ago, the patient was diagnosed with a skin infection and was treated with penicillin V. She has been otherwise healthy but has missed several well-child examinations. She lives with her single mother, who recently lost her job and is now dependent on social assistance. The patient's mother has major depressive disorder and her maternal aunt has systemic lupus erythematosus. The girl's temperature is 36.8°C (98.2°F), pulse is 112/min, and blood pressure is 108/62 mm Hg. She has poor eye contact. Physical examination shows sharply delineated erythema on the lower extremities up to the umbilicus with sparing of the knees and flexor surfaces. Further evaluation is most likely to reveal which of the following?

Multiple injuries in different stages of healing

Malar rash with sparing of the nasolabial folds

First stage of labor | Stages of labor

First Stage of Labor - The Grand Opening

Definition: Onset of regular uterine contractions to full cervical dilation (10 cm).
Phases: Divided into Latent and Active phases based on the rate of cervical change.

Latent Phase: Gradual, slow cervical change.
- Dilation: 0 to <6 cm.
- Contractions: Mild, often irregular.
Active Phase: Rapid, predictable cervical dilation.
- Dilation: ≥6 cm to 10 cm.
- Dilation Rate: Nulliparous ≥1.2 cm/hr; Multiparous ≥1.5 cm/hr.
- Contractions: Strong, regular (e.g., every 2-3 min).

📌 3 P's of Labor: Power (contractions), Passenger (fetus), Passage (pelvis).

⭐ Active phase protraction (slower-than-expected dilation) is a common indication for intervention, often with oxytocin, to prevent arrest of labor.

Cervical Effacement and Dilation (0-10 cm)

Labor Dystocia - When Things Slow Down

Definition: Abnormally slow progression of labor, also known as "failure to progress."
Etiology 📌 (The 3 Ps):
- Power: Inadequate uterine contractions (< 200 Montevideo units).
- Passenger: Fetal factors like macrosomia, malpresentation (e.g., occiput posterior), or malposition.
- Passage: Pelvic anatomy limitations (cephalopelvic disproportion - CPD).
Diagnosis (Active Phase >6 cm):
- Protraction: Slower than expected dilation.
  - Nullipara: < 1.2 cm/hr
  - Multipara: < 1.5 cm/hr
- Arrest: No cervical change despite:
  - ≥ 4 hours of adequate contractions.
  - ≥ 6 hours of inadequate contractions (requires oxytocin).

⭐ Before diagnosing arrest and proceeding to C-section, ensure at least 4-6 hours of observation with augmented labor (if needed). This avoids premature surgical intervention.

Management:

Labor curve: Latent and active phases of cervical dilation

Management - The Watchful Wait

Maternal Monitoring:
- Vitals & pain assessment: q 1-4 hrs.
- Contractions: Palpation or tocometry for frequency, duration, strength.
- Cervical exam: q 2-4 hrs in active phase to assess dilation, effacement, station. Avoid excessive exams to ↓ infection risk.
Fetal Monitoring:
- Intermittent auscultation or continuous electronic fetal monitoring (EFM).
- Assess baseline FHR, variability, accelerations, and decelerations.
Patient Support:
- Encourage ambulation & position changes.
- Maintain hydration (oral or IV).
- Offer pain relief options (e.g., epidural).

⭐ Active Phase Progression: Expect cervical dilation of ≥ 1-2 cm/hr. Slower progression may indicate arrest of labor, requiring intervention like oxytocin.

High‑Yield Points - ⚡ Biggest Takeaways

First stage of labor spans from the onset of regular contractions to full cervical dilation (10 cm).

It comprises a latent phase (0-6 cm) and an active phase (6-10 cm).

Prolonged latent phase is >20 hours (nulliparous) or >14 hours (multiparous); management is often rest.

Active phase arrest-no cervical change for ≥4 hours with adequate contractions or ≥6 hours without-is a common reason for C-section.

Always evaluate the 3 Ps (Power, Passenger, Passage) to diagnose labor abnormalities.