Incorrect
You selected C — commence intravenous oxytocin augmentation. The correct answer is B.
Question 14 of 50
A 29-year-old woman, para 1, is in spontaneous labour at 40+3 weeks' gestation. Vaginal examination confirms 7 cm cervical dilatation with intact membranes and a cephalic presentation. Her blood pressure is 118/76 mmHg, pulse 88 beats per minute and temperature 36.8°C. The cardiotocograph trace shown below has been recorded continuously over the preceding 20 minutes.
What is the single most appropriate next step in management?
Clinical explanation
The trace shows a baseline of 140 bpm with moderate variability and repetitive variable decelerations that coincide with contractions but recover promptly to baseline, each lasting under 60 seconds with no associated tachycardia or reduction in variability. Applying the NICE NG235 framework, this pattern is best classified as non-reassuring rather than abnormal: a single non-reassuring feature in an otherwise low-risk labour does not, on its own, mandate immediate operative delivery or invasive testing.
Variable decelerations are typically vagally mediated and result from transient compression of the umbilical cord, often related to fetal position, reduced liquor volume or cord location relative to the presenting part. Their characteristic abrupt onset and offset, and variability in shape, duration and timing relative to contractions, distinguish them from late decelerations, which instead reflect uteroplacental insufficiency and carry a different risk profile.
For a non-reassoring trace of this kind, first-line management is conservative: reposition the mother — left lateral or all-fours — to relieve cord compression, correct any maternal hypotension, discontinue oxytocin if it is running, and consider amnioinfusion if decelerations recur despite repositioning. Oxytocin augmentation is not indicated here; increasing contraction frequency would shorten the intervals available for fetal recovery and risks converting a non-reassuring trace into an abnormal one.
The trace should be reassessed after simple measures, generally over the following 20–30 minutes. Escalation to fetal blood sampling or expedited delivery is reserved for traces that remain non-reassuring or evolve to abnormal despite conservative management — the stepwise approach the exam consistently rewards over jumping straight to an invasive or operative option.
Key learning points
- Variable decelerations are usually caused by transient umbilical cord compression and are vagally mediated.
- NICE NG235 classifies CTG features as reassuring, non-reassuring or abnormal; a single non-reassuring feature rarely mandates immediate delivery.
- Simple conservative measures — maternal repositioning, correcting hypotension, stopping oxytocin — are first-line for a non-reassuring trace.
- Fetal blood sampling is reserved for traces that remain non-reassuring or abnormal despite conservative measures, or are abnormal from the outset.
- Document the time, the CTG category assigned and the rationale for the chosen management step.
Why the other options are incorrect
Immediate category 1 caesarean section is not justified by a single non-reassuring feature with no other abnormal findings; it skips the conservative measures the exam expects to be tried first.
Oxytocin augmentation would increase contraction frequency, reducing the intervals for fetal recovery and risking further cord compression — the opposite of what a non-reassuring trace requires.
Fetal blood sampling is premature before conservative measures have been trialled and the trace reassessed; it is reserved for traces that persist or worsen.
A fluid bolus is not specifically indicated here — her blood pressure of 118/76 mmHg is normal, so there is no evidence of maternal hypotension to correct.
Guidelines and references
- NICE NICE NG235 — Intrapartum care for healthy women and babies, section on fetal monitoring and CTG classification.
- FIGO FIGO Consensus Guidelines on Intrapartum Fetal Monitoring: cardiotocography (2015).
- RCOG RCOG Each Baby Counts programme — recurring themes in intrapartum fetal monitoring and escalation.
- TEXTBOOK Fetal Monitoring in Practice, 4th edition — Chapter 9: Cardiotocograph Interpretation and Classification.