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OG13.1-8 | Normal Labour — PBL Case

CLINICAL SETTING

Priya, a 24-year-old primigravida at 39+2 weeks gestation, presents to the labour room at 08:00 with regular painful contractions every 7 minutes for the past 4 hours. She is accompanied by her mother-in-law. On admission, vaginal examination shows the cervix to be 4 cm dilated, 60% effaced, vertex presentation with the head at station -1. Fetal heart rate is 144 bpm regular. Membranes are intact. Blood pressure is 118/76 mmHg, pulse 88/min, temperature 37.1°C. The midwife plots Priya's findings on the WHO partograph and reassures her that she is in active labour. Priya asks the midwife: 'How long will it take? Can my mother stay with me?' The midwife replies curtly, 'It depends. Family members are not allowed in the ward.'

Trigger 1: Two Hours Later — Alert Line Approached

At 10:00, the second vaginal examination shows the cervix is now 5 cm dilated. Contractions are 2–3 in 10 minutes, each lasting 30–35 seconds. The head remains at station -1. The partograph plot is now approaching the alert line. Fetal heart rate is 138 bpm. Membranes remain intact. Priya is distressed and asking for pain relief. Her mother-in-law is pacing in the corridor.

DISCUSSION POINTS

  • Plot the partograph: given her progress (4 cm at 08:00, 5 cm at 10:00), has she crossed the alert line? What does this mean clinically?
  • What are the possible causes of slow progress in active labour for a primigravida with 2–3 contractions in 10 minutes lasting 30–35 seconds?
  • What pain relief options are available for a primigravida at 5 cm dilatation in an Indian district hospital setting?
  • Reflecting on the midwife's response to Priya's request for her mother — how should this have been handled according to RMC principles? What evidence supports continuous labour support?
Click to reveal Trigger 2: Decision Point — Augmentation (discuss previous trigger first!)

Trigger 2: Decision Point — Augmentation

At 11:00, the registrar reviews Priya. Contractions remain 2 in 10 minutes lasting 30 seconds. Cervix is still 5 cm. The partograph plot has now crossed the alert line. The registrar decides to perform ARM followed by oxytocin augmentation. On ARM, clear liquor drains. Immediately after the ARM, the CTG shows a deceleration to 90 bpm lasting 60 seconds.

DISCUSSION POINTS

  • Was the decision to augment appropriate given the partograph findings? What are the criteria for augmentation versus caesarean section at this stage?
  • Walk through the safety checks required before ARM in this case — was it safe to perform ARM here?
  • The post-ARM bradycardia: what is the FIRST action? How do you distinguish cord prolapse from a vasovagal response to ARM?
  • If the deceleration resolves within 2 minutes and the subsequent CTG is normal, does management change? What is your plan for the next 2 hours?
Click to reveal Trigger 3: Full Dilatation — Second Stage Management (discuss previous trigger first!)

Trigger 3: Full Dilatation — Second Stage Management

At 14:30, Priya is fully dilated. The fetal head is at station +1, in the left occiput transverse (LOT) position. Contractions are now 4 in 10 minutes lasting 45 seconds with oxytocin. FHR baseline is 150 bpm with early decelerations. Priya is pushing effectively. The midwife asks the registrar: 'Should we do an episiotomy routinely?'

DISCUSSION POINTS

  • LOT at station +1 at full dilatation: what internal rotation is expected? Is an instrumental delivery indicated at this point?
  • The early decelerations on CTG — what do they indicate, and do they require intervention at this stage?
  • Episiotomy: what is the current evidence-based position on routine versus selective episiotomy? Under what specific circumstances is episiotomy indicated in a primigravida?
  • Describe the Ritgen manoeuvre and the steps you would take to deliver the head in a controlled manner.
Click to reveal Trigger 4: Delivery and Third Stage (discuss previous trigger first!)

Trigger 4: Delivery and Third Stage

At 15:45, Priya delivers a live female infant weighing 3.2 kg. Apgar score is 8 at 1 minute and 10 at 5 minutes. Active management of the third stage is initiated. At 16:10 (25 minutes after delivery), the placenta has not delivered. There is no active bleeding. The midwife prepares to perform manual removal of placenta in theatre.

DISCUSSION POINTS

  • Was active management of the third stage correctly initiated? Describe each of the three components — what should have been done and when?
  • At 25 minutes with no active bleeding — is the diagnosis of retained placenta established? What is the defined time limit for diagnosis of retained placenta and what are the management steps before going to theatre?
  • What are the signs of placental separation? Are they present here?
  • Consider the postpartum debrief with Priya: what information does she need, and how should the labour experience (including the RMC failures in trigger 1) be addressed?
Click to reveal Trigger 5: Preterm Labour — The Next Day's Case (discuss previous trigger first!)

Trigger 5: Preterm Labour — The Next Day's Case

The following morning, a 21-year-old G1 at 31 weeks presents with contractions every 5 minutes and cervical dilatation of 2 cm with 50% effacement. Her membranes are intact. She is anxious and asks: 'Will my baby survive?' The registrar plans to administer antenatal corticosteroids, tocolytics, and antibiotics.

DISCUSSION POINTS

  • Compare this case to Priya's — using the pathophysiology of preterm labour onset, what may be the initiating mechanism here that is different from term labour onset?
  • What is the 4-drug protocol for preterm labour at 28–32 weeks? What is the purpose of each drug?
  • Magnesium sulfate is sometimes given in preterm labour at <32 weeks — what is its specific indication here (not primarily tocolysis)?
  • How do you counsel this woman about prognosis and the goals of immediate management? Apply RMC principles to a frightened patient facing preterm delivery.

Group Task Assignments

  • Draw the completed WHO partograph for Priya's labour from 08:00 to 14:30 — plot cervical dilatation, head station, FHR, and contractions at each time point. Identify where the alert and action lines are crossed.
  • Role-play: one student is the midwife, one is Priya at the time of admission. Demonstrate the correct RMC-compliant admission conversation — introducing yourself, explaining findings, answering Priya's questions about her mother, and obtaining consent for vaginal examination.
  • Prepare a 5-minute presentation: 'Why does a primigravida take longer in labour than a multigravida?' — incorporate pelvic soft tissue resistance, uterine efficiency, and cervical factors.
  • List all clinical decisions in this case where informed consent should have been formally obtained. For each decision, state what information should be given and what alternatives should be discussed.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [OG13.3] What is the evidence base for the WHO partograph alert and action line thresholds, and what proportion of nulliparas labours actually progress at ≥1 cm/hour throughout the active phase?
  2. [OG13.2] What is the mechanism by which the LOT position at full dilatation rotates to OA, and what partograph or clinical findings predict failure of rotation?
  3. [OG13.4] What is the specific role of magnesium sulfate in preterm labour <32 weeks, and how does its mechanism differ from its use in eclampsia?
  4. [OG13.8] What is the quality of evidence supporting continuous labour support (a companion), and how is this operationalised in LaQshya guidelines?
  5. [OG13.3] What is the time limit for diagnosing retained placenta, what conservative measures should be attempted before manual removal, and what are the anaesthetic and haemorrhagic risks of manual removal?