Instructions
You are a medical student on placement in the birth suite. My Pham, 29, is in her first labour at 40 weeks and 3 days. It is now 14:00, and her midwife has asked you and the obstetric registrar to review her labour. Her antenatal summary, partogram and latest CTG are below.
Interpret the partogram and CTG provided
Outline to the examiner:
- Your findings
- Your most likely diagnosis
- You do not need to take a history or examine the patient
- The examiner will ask you questions at the end
Antenatal summary
G1 P0, dated by an 8-week scan. Uncomplicated pregnancy; normal 20-week morphology scan; group B streptococcus swab negative at 36 weeks. Height 162 cm, booking BMI 23. Fundal height 39 cm last week; cephalic. No medical problems, regular medicines or allergies.
Partogram: onset and analgesia
Regular painful contractions from 21:00 yesterday; admitted at 02:00. Nitrous oxide 02:00 to 07:00. Epidural sited 07:00, good block, infusion running. Hartmann's solution 125 mL/h since 07:00.
Partogram: membranes
Intact until spontaneous rupture at 08:00; clear liquor since.
Partogram: cervix (vaginal examination)
02:00 4 cm; 06:00 6 cm; 10:00 7 cm; 14:00 7 cm. Thin and well applied to the head at 02:00 and 06:00; thin but loosely applied at 10:00 and 14:00.
Partogram: head palpable abdominally
02:00 3/5; 06:00 3/5; 10:00 2/5; 14:00 2/5. Station -1 at 10:00 and at 14:00. No caput or moulding at 06:00 or 10:00; caput + and moulding + at 14:00.
Partogram: fontanelles (vaginal examination)
06:00 not clearly felt. 10:00 and 14:00: posterior fontanelle at 7 o'clock; anterior fontanelle easily felt at 1 o'clock.
Partogram: contractions (per 10 minutes)
02:00 to 10:00: 4 in 10, lasting 45 to 50 seconds, strong. 11:00: 3 in 10, 40 seconds. 12:00 to 14:00: 2 in 10, lasting 30 seconds, mild on palpation.
Partogram: abdomen at 14:00
Uterus soft and non-tender at rest; bladder palpable above the symphysis pubis.
Partogram: urine
09:00: voided 200 mL; protein, ketones and blood nil. Not voided since.
Partogram: maternal observations
Pulse 78 at 02:00, 82 at 06:00, 88 at 10:00, 92 at 14:00 per minute. BP 122/76 at 02:00, 112/70 at 08:00, 118/72 at 14:00 mmHg. Temperature 36.7, 36.9, 37.1 and 37.3 degrees C at 02:00, 06:00, 10:00 and 14:00.
Partogram: fetal heart
Intermittent auscultation 130 to 140 bpm until 07:00; continuous CTG since the epidural.
CTG (13:30 to 14:00)
Baseline 140 bpm; variability 10 to 15 bpm; accelerations 2 in 30 minutes, each 15 bpm for at least 15 seconds; no decelerations. Contractions 2 in 10 minutes, about 30 seconds each.
Partogram (02:00 to 14:00)
| Item | Value | Reference range |
|---|---|---|
| Onset | Regular painful tightenings from 21:00 yesterday; admitted at 02:00 | - |
| Cervical dilatation | 02:00 4 cm; 06:00 6 cm; 10:00 7 cm; 14:00 7 cm | - |
| Cervix | Thin and well applied to the head at 02:00 and 06:00; thin but loosely applied at 10:00 and 14:00 | - |
| Head palpable abdominally | 02:00 3/5; 06:00 3/5; 10:00 2/5; 14:00 2/5. Station -1 at 10:00 and at 14:00 | - |
| Fontanelles (vaginal examination) | 06:00 not clearly felt. 10:00 and 14:00: posterior fontanelle at 7 o'clock; anterior fontanelle easily felt at 1 o'clock | - |
| Caput and moulding | None at 06:00 or 10:00; caput + and moulding + at 14:00 | - |
| Membranes and liquor | Intact until spontaneous rupture at 08:00; clear liquor since | - |
| Contractions (per 10 minutes) | 02:00 to 10:00: 4 in 10, lasting 45 to 50 seconds, strong. 11:00: 3 in 10, 40 seconds. 12:00 to 14:00: 2 in 10, lasting 30 seconds, mild on palpation | - |
| Abdominal palpation at 14:00 | Uterus soft and non-tender at rest; bladder palpable above the symphysis pubis | - |
| Fetal heart | Intermittent auscultation 130 to 140 bpm until 07:00; continuous CTG since the epidural | - |
| Analgesia and fluids | Nitrous oxide 02:00 to 07:00. Epidural sited at 07:00, good block, infusion running. IV Hartmann's solution 125 mL/h since 07:00 | - |
| Maternal pulse | 02:00 78; 06:00 82; 10:00 88; 14:00 92 /min | - |
| Maternal blood pressure | 02:00 122/76; 08:00 112/70; 14:00 118/72 mmHg | - |
| Maternal temperature | 02:00 36.7; 06:00 36.9; 10:00 37.1; 14:00 37.3 degrees C | - |
| Urine | 09:00: voided 200 mL; protein, ketones and blood nil. Not voided since | - |
CTG (13:30 to 14:00)
| Item | Value | Reference range |
|---|---|---|
| Baseline rate | 140 bpm | 110-160 bpm |
| Variability | 10 to 15 bpm | 6-25 bpm |
| Accelerations | Present: 2 in 30 minutes, each 15 bpm for at least 15 seconds | - |
| Decelerations | None | - |
| Contractions | 2 in 10 minutes, each lasting about 30 seconds | - |