CASE REPORT #2
VAGINAL DELIVERY
CLINICAL # 618
Name: N.H
Age: 24 years
Religion: Christain
In her first trimester, pregnatal tablets and folic acid were prescribed for her and afterwards, she
came monthly for prenatal visits. She experienced nausea and vomiting which occurred daily
accompanied by mild temporal headaches.
During her second trimester she said the nausea and vomiting stopped. In her third trimester, she
said she experienced lower abdominal pain which she rated 6/10 with 10 most severe. She
characterized the pain as “tearing” with radiation to the lower back. She said the pain is relieved
with rest and aggravated by exertion to the pelvic area and spine. The patient also reported lower
limb weakness and easy fatigability from walking about 50meters.
Obstetrics History:
Gravida 2 Para 1
1st Pregnancy -
Date of delivery: 6th February 2012
Sex: Male
Weight: 6.6lb
Length of gestation: 40 weeks
Place of delivery: St Kitts
Mode of delivery: Induced vaginal delivery due to membrane rupture.
No complications during pregnancy and after delivery.
Child is healthy with no medical condition.
Gynecological History
Menarche was at 14years of age.
Last menstrual period: 19th Nov 2014
Cycle length: Patient said she doesn’t keep records
Number of days of period: 5days of light flow
Experiences dysmenorrhea sometimes which she takes 2 tablets of advil to relieve the pain
Number of pads per day: 3 pads
Mammogram: never been done
Pap smear: last done in January 2013 results showed inflammatory cells which she was given
medications for .
No sexually transmitted disease
Has one male sexual partner.
No pain during sexual intercourse
Doesn’t use condoms or oral contraceptives
DRUG HISTORY:
Pregnatals, Folic acid
REVIEW OF SYSTEMS:
No known allergies.
Patient was conscious and alert, oriented to place and time
PHYSICAL EXAMINATION
INVESTIGATION:
Fetal heart rate 160 beats per minute
Temperature 99.2F
Pulse 80 beats per min
Respiratory rate 24 breaths per min
Blood pressure 109/60mmHg
Physical Findings:
Patient breathing spontaneously on room air, hair braided, scalp dry, mucous membrane pink and
moist. Nostril clear no drainage, ears no drainage, no lymph nodes palpated. Breast medium in
size, nipples flat but on stimulation colostrum present in both.
Abdominal Examination:
Abdomen round, sign of pregnancy noted, linea nigra and straie gravidaum noted, fundal height
36cm.
Pelvic and Perineal Examination: Vulva area healthy looking, shaving already done, no
hemorrhoids, enema withheld. Vagina warm and moist, cervix is posteriorly located, soft and
thick, it is about 30% effaced, presenting part cephalic -3 station. No cord felt, membrane flat,
whitish discharge on gloved finger.
Urine Test: Glucose negative, ketone negative .
MANAGEMENT:
Labor induction.
Brief summary of delivery: Spontaneous vaginal delivery of a live female infant at term, cried
shortly after. Suction was done once, the infant was dried and warmth applied. Baby weight is
3.07kg(6.77lb), length 49cm , occipital circumference 35cm.
DISCUSSION: LABOR
DEFINITION:
Labor is a series of events occurring in a pregnant woman that involves regular, rhythmic,
painful uterine contractions resulting in the progressive cervical dilatation and effacement,
descent of the presenting part of the fetus, with the goal of expulsion of the products of
conception per vagina.
STAGES OF LABOR
Obstetricians have divided labor into 3 stages that delineate milestones in a continuous process.
Begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm
Divided into a latent phase and an active phase
The latent phase begins with mild, irregular uterine contractions that soften and shorten the
cervix. Contractions become progressively more rhythmic and stronger, usually takes 6 – 12
hours for multiparous women, and 12 – 18 hours for the nulliparous women. It took about 5
hours in the case of the patient above.
The active phase usually begins at about 3-4 cm of cervical dilation and is characterized by rapid
cervical dilation and descent of the presenting fetal part
Active Phase starts from when the cervix is 4cm dilated to when the cervix is fully dilated at 9-
10cm and usually 30 minutes per cm for multiparous women, and takes at most 1 hour for each
rise in cm for nulliparous women. It was about 30 minutes in the case of the patient above.
Begins with complete cervical dilatation and ends with the delivery of the fetus
In nulliparous women, the second stage should be considered prolonged if it exceeds 3 hours if
regional anesthesia is administered or 2 hours in the absence of regional anesthesia
In multiparous women, the second stage should be considered prolonged if it exceeds 2 hours
with regional anesthesia or 1 hour without it.
The period between the delivery of the fetus and the delivery of the placenta and fetal
membranes
Delivery of the placenta often takes less than 10 minutes, but the third stage may last as long as
30 minutes. This took 13 minutes in the patient above.
The third stage of labor is considered prolonged after 30 minutes, and active intervention is
commonly considered
Mechanism of labor
The mechanisms of labor, also known as the cardinal movements, involve changes in the
position of the fetus’s head during its passage/navigation through maternal pelvis, in labor. These
are described in relation to a vertex presentation. Although labor and delivery occurs in a
continuous fashion, the cardinal movements are described as the following 7 discrete sequences:
1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. Restitution and external rotation
7. Expulsion
Intrapartum Management of Labor
For proper management of labor all the following parameters have to be closely observed the
physical examination should include documentation of the following:
On admission to the Labor and Delivery suite, a woman having normal labor should be
encouraged to assume the position that she finds most comfortable. Possibilities including the
following:
Walking
Lying supine
Sitting
Resting in a left lateral decubitus position
Management Includes The Following:
Periodic assessment of the frequency and strength of uterine contractions and changes in cervix
and in the fetus' station and position
Monitoring the fetal heart rate at least every 15 minutes, particularly during and immediately
after uterine contractions; in most obstetric units, the fetal heart rate is assessed continuously
Second Stage of Labor
With complete cervical dilatation, the fetal heart rate should be monitored or auscultated at least
every 5 minutes and after each contraction. Prolonged duration of the second stage alone does
not mandate operative delivery if progress is being made, but management options for second-
stage arrest include the following:
Continuing observation/expectant management
Operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean
delivery.
Delivery of the fetus
Supine with her knees bent (, dorsal lithotomy position; the usual choice)
Lateral (Sims) position
Partial sitting or squatting position
On her hands and knees
Episiotomy used to be routinely performed at this time, but current recommendations restrict its
use to maternal or fetal indications
The head is held in mid position until it is delivered, followed by suctioning of the oropharynx
and nares
Check the fetus's neck for a wrapped umbilical cord, and promptly reduce it if possible
If the cord is wrapped too tightly to be removed, the cord can be double clamped and cut
The fetus's anterior shoulder is delivered with gentle downward traction on its head and chin
Subsequent upward pressure in the opposite direction facilitates delivery of the posterior
shoulder
The rest of the fetus should now be easily delivered with gentle traction away from the mother
If not done previously, the cord is clamped and cut
The baby is vigorously stimulated and dried and then transferred to the care of the waiting
attendants or placed on the mother's abdomen
Third stage of labor
The following 3 classic signs indicate that the placenta has separated from the uterus :
REFERENCES:
• Dr. Rosina .C. Castaneda; Obstetrics and Gynecology, J.N. France hospital, St Kitts.
• Current Obstetric & Gynecologic Diagnosis & Treatment, 11th Edition – Lange.
• E medicine - medscape.com