# Clinical Cases: Labor and Delivery ## 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 ![Stages of Labor](case_01_image.jpg) **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. --- ## Case 2: Non-Reassuring Fetal Heart Rate Tracing and Intrauterine Resuscitation ### Patient Demographics - **Age:** 31 years - **Sex:** Female - **Occupation:** Marketing manager ### Chief Complaint "The nurse said the baby's heart rate is dropping." ### History of Present Illness The patient is a G2P1 at 40 weeks 1 day undergoing induction of labor for post-dates. She received misoprostol for cervical ripening followed by oxytocin augmentation. She has been in active labor for 4 hours and just received epidural analgesia. Shortly after the epidural was placed, the fetal heart rate monitor shows recurrent variable decelerations with slow return to baseline. ### Current Labor Status - Cervix: 6 cm dilated, 90% effaced, 0 station - Oxytocin running at 12 milliunits/minute - Recent epidural placement with patient supine - Amniotic fluid clear when membranes ruptured 3 hours ago ### Fetal Heart Rate Findings - **Baseline:** 150 bpm - **Variability:** Minimal (decreased from moderate prior to decelerations) - **Decelerations:** Recurrent variable decelerations to 80 bpm, lasting 60-90 seconds, with slow return to baseline - **Accelerations:** Absent ### Diagnosis **Category II Fetal Heart Rate Tracing** with: - Recurrent variable decelerations (suggesting cord compression) - Minimal variability (concerning in context of decelerations) ### Immediate Intrauterine Resuscitation **Step 1: Position Change** - Patient repositioned from supine to left lateral decubitus - If no improvement, try right lateral, then hands-and-knees position **Step 2: Discontinue Oxytocin** - Oxytocin infusion stopped immediately to reduce uterine activity **Step 3: IV Fluid Bolus** - 500 mL lactated Ringer's bolus administered to improve maternal perfusion **Step 4: Oxygen** - Supplemental oxygen 10 L/min by face mask (consider if hypoxic) **Step 5: Cervical Examination** - Performed to rule out cord prolapse - No cord palpable; cervix 6 cm, vertex at 0 station **Step 6: Assess for Tachysystole** - Contraction frequency: 3-4 in 10 minutes (not tachysystole) ### Response to Resuscitation **After 5 minutes:** - Variable decelerations persist but less severe (nadir 90 bpm) - Variability improved to moderate - Baseline stable at 145 bpm **After 15 minutes:** - Decelerations resolved - Category I tracing restored - Oxytocin restarted at lower rate (8 milliunits/minute) ### Subsequent Labor Course - Labor progressed without further significant decelerations - Complete dilation at 4 hours after resuscitation - Spontaneous vaginal delivery - Infant vigorous at birth, Apgar 8/9 ### Teaching Points **Variable Decelerations:** - Caused by umbilical cord compression - Characterized by abrupt onset and return - Mild variables are common and usually benign - Recurrent severe variables require intervention **When to Consider Emergent Delivery:** - Prolonged deceleration >10 minutes not responding to resuscitation - Category III tracing (absent variability with recurrent late or variable decelerations, bradycardia, or sinusoidal pattern) - Evidence of cord prolapse **Documentation:** - Time and nature of abnormality - Interventions performed and timing - Response to each intervention - Communication with team ### Clinical Image ![Fetal Heart Rate Tracing](case_02_image.jpg) **Image Description:** Electronic fetal heart rate monitoring strip demonstrating variable decelerations with abrupt onset and variable timing relative to contractions. The lower channel shows uterine contraction pattern. **Attribution:** Image from medical education resources. Used for educational purposes. --- ## Case 3: Shoulder Dystocia ### Patient Demographics - **Age:** 34 years - **Sex:** Female - **Occupation:** Pharmacist ### Chief Complaint The fetal head has delivered but the anterior shoulder is impacted behind the pubic symphysis. ### History of Present Illness The patient is a G3P2 at 39 weeks with gestational diabetes (diet-controlled) who presented in spontaneous labor. Her estimated fetal weight by ultrasound last week was 4,100 grams. She has been pushing for 45 minutes and the fetal head has just delivered with significant difficulty ("turtle sign" noted - retraction of chin against perineum). The anterior shoulder will not deliver with routine maneuvers. ### Risk Factors Present - Gestational diabetes (associated with macrosomia) - Estimated fetal weight >4,000 grams - Prior macrosomic infant (4,200 grams at birth) - Maternal obesity (BMI 32) - Prolonged second stage ### Clinical Recognition - **Turtle Sign:** Fetal head retracts against perineum after delivery - **Failure of external rotation:** Head does not rotate as expected - **Failed gentle downward traction:** Anterior shoulder does not deliver ### Emergency Management - HELPERR Mnemonic **H - Help** - Called for additional nurses, obstetricians, anesthesia, and pediatrics - Activated shoulder dystocia protocol **E - Evaluate for Episiotomy** - Mediolateral episiotomy performed to allow room for maneuvers - (Note: does not relieve bony obstruction but provides access) **L - Legs (McRoberts Maneuver)** - Maternal thighs hyperflexed against abdomen - Flattens lumbar lordosis and rotates pelvis - First-line maneuver, resolves ~50% of cases - **Result:** Shoulder remains impacted **P - Pressure (Suprapubic)** - Assistant applied continuous suprapubic pressure in downward and lateral direction - Attempts to dislodge anterior shoulder from behind symphysis - **Result:** Partial descent but not delivered **E - Enter Maneuvers (Rotational)** - **Rubin II Maneuver:** Fingers behind anterior shoulder, pushed toward fetal chest to adduct and rotate - **Woods Corkscrew:** Pressure on posterior shoulder in opposite direction to rotate fetus 180 degrees - **Result:** Successful rotation and delivery of anterior shoulder **R - Remove Posterior Arm** - Not required in this case (reserved if rotation fails) **R - Roll Patient** - Not required (Gaskin maneuver - hands and knees position) ### Delivery Outcome - Time from head delivery to body delivery: 90 seconds - Male infant, weight 4,350 grams - Apgar scores: 6 at 1 minute (decreased due to initial cyanosis), 8 at 5 minutes - Right arm limp at delivery - suspected brachial plexus injury ### Neonatal Examination - Right upper extremity weakness - Absent Moro reflex on right - Grasp reflex present bilaterally - No clavicle fracture palpated - **Diagnosis:** Right Erb palsy (C5-C6 brachial plexus injury) ### Postpartum Management **Maternal:** - Careful examination for cervical and vaginal lacerations - Estimated blood loss 500 mL - Postpartum hemorrhage protocol on standby **Neonatal:** - Pediatric neurology consultation - Physical therapy referral - Counseling that >90% of Erb palsy cases resolve within 12 months **Documentation:** - Detailed documentation of maneuvers used and timing - Risk factors identified - Team members present - Neonatal condition and disposition ### Counseling Points - Shoulder dystocia occurs in approximately 1% of vaginal deliveries - Despite risk factors, it cannot be reliably predicted or prevented - Future pregnancy counseling: increased recurrence risk (10-15%) - Consider elective cesarean if estimated fetal weight >4,500 grams in diabetic patient ### Clinical Image ![Shoulder Dystocia Management](case_03_image.jpg) **Image Description:** Illustration demonstrating the McRoberts maneuver with hyperflexion of maternal thighs and simultaneous suprapubic pressure applied to dislodge the impacted anterior shoulder from behind the pubic symphysis. **Attribution:** Image from Wikimedia Commons. Educational illustration of shoulder dystocia management. Public domain.