Obgyn · Year 3 · from Obgyn
Case 1: Normal Spontaneous Vaginal Delivery
Patient Demographics
- Age: 26 years
- Sex: Female
- Occupation: Nurse
Chief Complaint
"I think I'm in labor. My contractions are coming every 5 minutes."
History of Present Illness
The patient is a G1P0 at 39 weeks 2 days gestation who presents with regular, painful contractions that began 6 hours ago. Contractions are now occurring every 4-5 minutes, lasting 50-60 seconds. She reports her "water broke" 2 hours ago with clear fluid. She has had good fetal movement. She denies vaginal bleeding beyond a small amount of bloody mucus (bloody show).
Past Medical History
- No significant medical conditions
- No prior surgeries
- Uncomplicated prenatal course
Obstetric History
- G1P0 at 39 weeks 2 days
- GBS positive at 36 weeks
- Estimated fetal weight 3,400 grams by recent ultrasound
Physical Examination Findings
- Vital Signs: BP 120/74 mmHg, HR 88 bpm, Temperature 98.6F
- Abdomen: Gravid, vertex presentation by Leopold maneuvers, fundal height 38 cm
- Cervical Examination: 5 cm dilated, 80% effaced, -1 station, vertex presentation, membranes ruptured with clear fluid
- Fetal Heart Rate Tracing: Baseline 140 bpm, moderate variability, accelerations present, no decelerations
Diagnosis
Active Labor at 39 weeks 2 days gestation
- First stage of labor, active phase
- Ruptured membranes with clear amniotic fluid
- GBS positive - requires antibiotic prophylaxis
Labor Course
Admission (1400):
- Cervix: 5 cm/80%/-1 station
- Started penicillin G 5 million units IV, then 2.5 million units every 4 hours for GBS prophylaxis
- Epidural placed at patient request
Progress (1800):
- Cervix: 8 cm/100%/0 station
- Fetal heart rate tracing remains Category I
Complete Dilation (2000):
- Cervix: 10 cm/100%/+1 station
- Began passive descent ("laboring down")
Active Pushing (2045):
- Began pushing with contractions
- +2 to +3 station with good descent
Delivery (2132):
- Spontaneous vaginal delivery of viable male infant
- Weight: 3,380 grams
- Apgar scores: 8 at 1 minute, 9 at 5 minutes
- Cord clamped after 60-second delayed clamping
- Active management of third stage with oxytocin 10 units IM
Third Stage (2138):
- Placenta delivered spontaneously, appeared complete
- Estimated blood loss: 350 mL
- Second-degree perineal laceration repaired with absorbable suture
Management Points
GBS Prophylaxis:
- Adequate prophylaxis achieved (received 2 doses of penicillin >4 hours before delivery)
Pain Management:
- Epidural analgesia provided effective pain control
- Did not impede pushing efforts
Delivery Technique:
- Controlled delivery of fetal head with perineal support
- Nuchal cord reduced over head (loose, single loop)
- Gentle downward traction for anterior shoulder, upward for posterior
- Delayed cord clamping for improved neonatal iron stores
Immediate Postpartum:
- Skin-to-skin contact initiated
- Breastfeeding attempted within first hour
- Uterus firm, fundus at umbilicus
- Lochia rubra, moderate flow
Clinical Image
Image Description: Diagram illustrating the stages of labor including the latent and active phases of the first stage, second stage (pushing and delivery), and third stage (placental delivery). The cervical dilation curve demonstrates the typical progression.
Attribution: Image from Wikimedia Commons. Public domain educational illustration.