A 21-year-old primigravida at 39 weeks gestation presents to the hospital complaining of labor. Membranes are intact. The cervix is dilated to 2 cm, 90% effaced and the vertex at 0 station. Contractions occur every 5-15 minutes and last about 15-25 seconds each. Two hours later, both her cervical exam and her contraction pattern remain unchanged. The fetal heart tracing is reassuring.
What is the most appropriate next step in management?
Correct Answer D:
This is a patient in the latent phase of the 1st stage of labor. For a primigravid, this can last up to 20 hours before it is considered prolonged. At this point in time, there is no need for any intervention, since everything is normal. Often, these patients are even sent home and told to return when more active labor occurs.
A. The patient is in the latent phase of labor and the fetal condition is fine. No indication for cesarean exists at this point in time.
B. The patient is in the latent phase of labor and the fetal condition is fine. No indication for augmentation exists at this point in time.
C. The patient is in the latent phase of labor and fetal condition is fine. There is no concern about the adequacy of the maternal pelvis.
E. The patient is in the latent phase of labor and the fetal condition is fine. No indication for amniotomy nor intervention exists at this point in time.
A 19-year-old primigravid at 40 weeks’ gestation has been in labor for the last 8 hours. Fetal heart tones have a baseline for 135/min with normal variability, multiple accelerations and no decelerations. She has been completely dilated for the last hour, and with pushing, has descended from a +1 station to a +3 station at present. The vertex is direct occiput anterior.
Your next course of action is to recommend:
Correct Answer C:
This patient is progressing in normal fashion. She is allowed up to 2 hours in the second stage and even longer if the heart tones are reassuring. There is no need to intervene, and one would anticipate that the patient will be having a normal spontaneous vaginal delivery within the next hour.
A. The patient has made adequate descent in the last hour. She can push for at least another hour and maybe more if the fetal condition remains reassuring. No indication for instrumental vaginal delivery is present.
B. The patient has made adequate descent in the last hour. She can push for at least another hour and maybe more if the fetal condition remains reassuring. No indication for instrumental vaginal delivery is present.
D. The patient has made adequate descent in the last hour. She can push for at least another hour and maybe more if the fetal condition remains reassuring. Since progress has been made, there is no need to augment the labor with pitocin.
E. The patient has made adequate descent in the last hour. She can push for at least another hour and maybe more if the fetal condition remains reassuring. No indication for cesarean delivery is present.
A 29-year-old G3P2 woman is in labour and is now at full cervical dilation.
How much time should it normally take from this point to the delivery of her baby?
Stages of Labour:
Stage 1: Onset of labour to complete cervical dilation.
i. Latent Phase: infrequent contractions; slow cervical dilation to ~ 4cm and effacement.
ii. Active Phase: frequent, painful contractions (~q2min, lasting 50-60sec); rapid dilation to full cervical dilation.
Stage 2: Complete cervical dilation to delivery of the baby.
Stage 3: Delivery of the placenta; can last up to 30mins before intervention indicated.
Stage 4: 1st postpartum hour.
This is a two-part question: you must first identify which stage of labour the woman is in (Stage 2 in this case); second, you must recognize that she is a multipara (G3P2) who should normally take less time to transition between stages of labour when compared to a nullipara. It should take 5 to 30 minutes for a multipara to transition through this 2nd stage (as opposed to 30 minutes to 3 hours for a nullipara).
Course of Normal Labour:
PEARL: Multiparous women will normally transition through labour stages faster than nulliparous women.
An expectant mother in labour was brought to hospital. Four hours after admission, her labour is progressing normally and the cervix is dilated to 10 cm.
Which of the following signs is the best for monitoring progress of labour at this stage?
Correct Answer A:
This mother is in the second stage of labour (cervix is 10 cm or fully dilated) and progress of labour should be monitored by assessing descent of the fetus or fetal station (choice A). This is evaluated by determination of the position of the presenting part of the fetus relative to the mother’s ischial spines. The station is zero when the presenting part is exactly at the level of the ischial spines. Above the spines the station is designated as negative (-5 to -1 cm) and it is designated as positive below the spines (+1 to +5 cm).
→ Bishop score (choice B) is used to assess the likelihood of success of induction of labour and has no role in monitoring progress of labour. The score is calculated using five parameters including, position of the presenting part relative to the mother’s pelvis, consistency of the cervix, effacement of cervix, dilatation of cervix, and station of fetal head. Each of these is given a score from 0 to 3. Labour can be safely induced with score of 9 or more.
→ Frequency and rhythm of uterine contraction (choice C) are not used for monitoring the second stage of labour. However, during the active phase of the first stage of labour, uterine contractions get more frequent (every 2 to 3 minutes) and regular. Infrequent irregular contractions occur in the latent phase of the first stage of labour.
→ Rate of dilatation of the cervix (choice D) is used to monitor progress of the first stage of labour. This mother already passed this stage and her cervix is already fully dilated (10 cm).
→ Fetal heart rate (choice E) is evaluated in anticipation of any fetal distress and is not used to monitor progress of labour. During the second stage of labour, the fetal heart rate should be monitored every 15 minutes. Monitoring of the heart rate should be done more frequently or continuously with high risk delivery.
A 28-year-old woman is currently 10 weeks pregnant. She is HBsAg positive and is concerned about the risk of transmission to the baby.
Which one of the following is the most appropriate course to follow?
Correct Answer E:
Newborns who are exposed to hepatitis B have more than a 90% chance of becoming chronically infected. This means the virus stays in their blood and liver for possibly a lifetime. They can pass the virus on to others. They will also live with a greater chance of developing liver failure or liver cancer later in life.
It is most important that the newborn receive the first dose of the hepatitis B vaccine in the delivery room. If possible, also give the hepatitis B immune globulin (HBIG), which is another medication that helps the vaccine to work even more successfully.
According to the Center for Disease Control and Prevention (CDC) and the World Health Organization (WHO), it is safe for an infected woman to breastfeed her child.
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