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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