A 32-year-old primigravida at 32 weeks of gestation presents to the labour ward with complaints of vaginal spotting and lower abdominal cramps for the past 6 hours. On examination, her cervix is 2 cm dilated, 80% effaced, and contractions are occurring every 5 minutes. Fetal heart rate is 140 bpm and reactive. She has no fever, and rupture of membranes has been ruled out. What is the most appropriate immediate next step in management?

Explanation

## Clinical Scenario Analysis This patient presents with **preterm labour at 32 weeks** (viable gestation with good neonatal outcomes) with: - Regular uterine contractions (every 5 minutes) - Progressive cervical dilation (2 cm) and effacement (80%) - Intact membranes - Reassuring fetal heart rate ## Management Principles for Preterm Labour **Key Point:** The twin pillars of preterm labour management at 28–34 weeks are: 1. **Fetal neuroprotection** with antenatal corticosteroids 2. **Prolongation of pregnancy** with tocolytic agents ### Antenatal Corticosteroids **High-Yield:** Betamethasone (12 mg IM × 2 doses, 24 hours apart) or dexamethasone reduces: - Neonatal respiratory distress syndrome (RDS) by ~30% - Intraventricular haemorrhage (IVH) by ~50% - Neonatal mortality by ~30% Indicated from **24 to 34 weeks** of gestation. At 32 weeks, this patient is well within the window. ### Tocolytic Agents | Agent | Mechanism | Efficacy | First-Line? | |-------|-----------|----------|-------------| | **Nifedipine** | L-type calcium channel blocker | Delays delivery by 48 hrs–7 days | Yes (safest) | | **Atosiban** | Oxytocin antagonist | Similar to nifedipine | Yes (if available) | | **Indomethacin** | NSAID, ↓ prostaglandins | Effective but ↑ fetal complications | No (avoid >32 weeks) | | **Terbutaline** | β~2~-agonist | Effective but ↑ maternal side effects | Rarely used now | **Clinical Pearl:** Nifedipine is the preferred first-line tocolytic in India and most guidelines (RCOG, ACOG) because it has: - No maternal cardiovascular collapse risk - No pulmonary oedema risk - Better neonatal outcomes vs. β-agonists **Key Point:** The goal of tocolysis is NOT to stop labour indefinitely, but to **gain 48 hours** for corticosteroid action and allow in-utero transfer to a tertiary centre if needed. ## Why This Answer Is Correct Combined **betamethasone + nifedipine** addresses both: - Immediate fetal lung maturation (corticosteroid) - Delay of delivery to allow steroid effect (tocolytic) This is the standard of care at 32 weeks in a woman with preterm labour and intact membranes. [cite:RCOG Green-top Guideline 1b, ACOG Practice Bulletin 159]