Case 89: Labour

 CASE 89: LABOUR

History

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.

Examination

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.

INVESTIGATIONS

Urinalysis: blood ++

Proteinuria: +

Leucocytes: negative

Nitrites: negative

Questions

• What is the diagnosis?

• What is the appropriate management?100 Cases in Obstetrics and Gynaecology

252

ANSWER 89

This woman is in normal labour.

! Definition of labour

The onset of regular painful contractions with progressive dilatation of the cervix and

descent of the presenting part.

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.

Management

The pregnancy and labour are low risk in that there is no evidence of any fetal or maternal

disorder that requires doctor-led care. The woman should therefore remain under midwifeled care and does not need continuous electronic fetal monitoring (cardiotocograph (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.

The progress of the labour should be recorded on a partogram, which should include maternal and fetal observations.

! Monitoring in low-risk labour

• Hourly blood pressure

• Hourly heart rate

• Four-hourly examinations for cervical dilatation

• Assessment for meconium

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.

KEY POINTS

• Normal labour is the onset of regular painful contractions with progressive dilatation of the cervix and descent of the presenting part.

• Continuous CTG is not required for low-risk women in normal labour, but intermittent auscultation is essential.