A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestati

A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient?

A. Administer antibiotics to the mother after vaginal delivery
B. Administer antibiotics to the mother now and allow vaginal delivery
C. Perform cesarean delivery
D. Perform cesarean delivery and then administer antibiotics to the mother
E. Perform intra-amniotic injection of antibiotics

The answer is B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor.