LABOUR
A
32-year-old woman presents
to the labour ward with abdominal pain. This is her
first baby after two miscarriages. She was trying
to conceive for 18 months
prior to this pregnancy.
Her estimated delivery date was
corrected after her 11–14-week scan
to make her now 40 weeks
and 6 days. All pregnancy blood tests and ultrasound scans
have been normal. The baby was breech
at 34 weeks but cephalic
at 37 weeks.
This morning she had a mucus-like dark-red discharge followed
by the onset of irregular period-type pains.
Two hours ago she felt a gush of clear
fluid from the vagina and since
then pains have become much more severe
now occurring every
4 min, lasting
for 45 s.
The baby has moved normally during
the day.
She
had a bath at home and took paracetamol but is now distressed and has come to
hospital for assessment. Her partner
and sister who
are both very
anxious accompany her.
On
examination she is comfortable between
pains. Her blood
pressure is 129/76
mmHg and pulse 101/min. Symphysiofundal height is 37 cm and
the fetus is cephalic with
2/5 palpable.
Speculum examination shows clear
fluid pooled in the posterior vaginal fornix.
Vaginal examination reveals
the cervix to be fully
effaced and 4 cm dilated.
The position is right
occipitoposterior and the head is 2 cm above the ischial spines.
There is no fetal
caput or moulding.
·
What is the diagnosis?
·
What is the appropriate management?
This woman is in normal labour.
Spontaneous rupture of membranes has occurred but is not necessary for the diagnosis of labour.
The woman’s observations and
examination findings are normal for labour:
·
the
dark mucus discharge is a ‘show’
and is not a cause
for concern unless
the bleeding is fresh or ongoing
·
the
pulse is almost certainly raised secondarily to the pain
·
the
haematuria and proteinuria are secondary to contamination by the show and liquor
·
the
symphysiofundal height is low because
the head has
descended into the
pelvis and because the liquor has been released from the uterus.
The
pregnancy and labour
are low risk in that there is no evidence
of any fetal or mater- nal disorder that requires
doctor-led care. The woman should therefore remain under midwife-led care and does not need continuous electronic fetal monitoring (cardiotoco- graph, CTG). The fetus does need assessment for
wellbeing with intermittent auscultation for
a full minute after a contraction at least every
15 min in the first
stage of labour
and for a full
minute after a contraction every
5 min in the second
stage of labour.
Once labour is established, expected dilatation is approximately 1 cm/h. If this does not
occur or if signs suggest
that fetal or maternal wellbeing
might be compromised, then medical assessment and possible intervention may be indicated.
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