A 32-year-old primigravida at 39 weeks of gestation presents to the labor ward with spontaneous rupture of membranes. On examination, the cervix is 2 cm dilated, 50% effaced, and the fetal head is at −2 station. Fetal heart rate is 140 bpm with normal variability. After 18 hours of expectant management, there is no progress in cervical dilation. The patient is afebrile with normal vital signs and normal amniotic fluid appearance. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has spontaneous rupture of membranes (SROM) at term with arrest of dilation after 18 hours of expectant management. The cervix remains at 2 cm with minimal progress, meeting criteria for arrest of dilation in the latent phase. ## Management Algorithm ```mermaid flowchart TD A[SROM at term]:::outcome --> B{Cervical dilation progress?}:::decision B -->|Progressing normally| C[Expectant management]:::action B -->|Arrest of dilation| D{Maternal/fetal status?}:::decision D -->|Stable| E[Augmentation with oxytocin]:::action D -->|Compromised| F[Cesarean section]:::action E --> G{Response to augmentation?}:::decision G -->|Progresses| H[Vaginal delivery]:::outcome G -->|No progress after 4-6 hrs| I[Cesarean section for arrest]:::urgent ``` ## Key Point: **Oxytocin augmentation is the first-line intervention for arrest of dilation in the latent phase when maternal and fetal status are reassuring.** Cesarean section is reserved for failure to progress despite adequate augmentation or signs of maternal/fetal compromise. ## Clinical Pearl: **The latent phase of labor extends from onset of labor to 3–4 cm dilation.** Arrest in the latent phase (no cervical change for ≥6–8 hours despite contractions) warrants augmentation with oxytocin before considering operative delivery. ## High-Yield: - **SROM at term:** Expectant management (awaiting spontaneous labor) is acceptable for up to 24 hours in the absence of maternal fever or fetal compromise. - **Arrest of dilation:** Defined as no cervical change for ≥6 hours in the latent phase or ≥4 hours in the active phase with adequate contractions. - **Augmentation:** Oxytocin infusion is indicated for arrest of dilation when maternal/fetal status is reassuring and membranes are already ruptured. ## Why Cesarean Section Is Premature Here: The patient is hemodynamically stable, afebrile, and the fetus is reassuring (normal FHR with variability). Arrest of dilation in the latent phase is managed medically first; cesarean section is indicated only if augmentation fails or complications arise. [cite:Williams Obstetrics 26e Ch 17]