A 32-year-old primigravida at 39 weeks gestation presents to the labour ward with spontaneous rupture of membranes. On examination, the cervix is 2 cm dilated, 80% effaced, and the fetal head is at −2 station. Fetal heart rate is 140 bpm with normal variability. After 12 hours of expectant management, there is no progress in cervical dilation. What is the most appropriate next step in management?

Explanation

## Clinical Context This is a case of **prolonged latent phase** in a primigravida with spontaneous rupture of membranes (SROM). The patient has been in labour for 12 hours with minimal cervical progress (2 cm dilation). ## Management Algorithm ```mermaid flowchart TD A[SROM at term + labour]:::outcome --> B{Cervical progress?}:::decision B -->|Adequate progress| C[Continue labour support]:::action B -->|No progress after 12h| D{Fetal status?}:::decision D -->|Normal FHR + variability| E[Augment with oxytocin]:::action D -->|Abnormal FHR| F[Cesarean section]:::urgent E --> G{Progress achieved?}:::decision G -->|Yes| H[Vaginal delivery]:::outcome G -->|No progress after 4h| I[Cesarean for arrest disorder]:::action ``` ## Key Point **Oxytocin augmentation is the standard next step** in a patient with SROM, normal fetal status, and arrest of dilation in the latent phase. This follows the ACOG/WHO partograph principles for active management of labour. ## High-Yield Facts - **Latent phase arrest** in primigravida: defined as <2 cm/hour progress over ≥4 hours - **SROM management**: expectant management is acceptable for 12–24 hours if maternal and fetal status remain reassuring - **Augmentation criteria**: normal FHR pattern + no contraindications to vaginal delivery - **Reassessment interval**: 4 hours after oxytocin initiation is standard before escalating to cesarean ## Clinical Pearl In a primigravida with SROM and normal fetal status, **immediate cesarean for arrest of dilation is premature**. Augmentation with oxytocin is the evidence-based intermediate step that respects the patient's wish for vaginal delivery while ensuring maternal and fetal safety. ## Timing Note Cesarean section for arrest disorder is indicated only after **adequate trial of augmentation** (typically ≥4 hours of oxytocin with adequate contractions) without progress.