Spontaneous labour, active phase
Room 1GA 39+2G1P029 yIntact
6 cm, epidural, contractions every 3 minutes. Active labour.
39+2wksG1P0 · 29 y
- Triage
- Latent
- Active
- Second stage
- Delivery
- Postpartum
12:00: 6 cm, 100% effaced, station 0
Maternal
- BP
- 108/66
- HR
- 90
- Temp
- 37.1
- Labs
- no flags
- Running
- Epidural
Fetal
- Monitor
- Reassuring
- Presentation
- Cephalic, occiput anterior, station 0
- Membranes
- Intact
- Next
- Reassess 16:00
Summary
29-year-old G1P0 at 39+2, spontaneous labour, active phase. 6 cm, epidural, contractions every 3 minutes.
- Membranes
- Intact
- Fetal presentation
- Cephalic, occiput anterior, station 0
- Board status
- Active labour
Notes
- Uncomplicated pregnancy, all screening normal, anatomy scan normal, placenta fundal.
- Progressing from 4 to 6 cm over 5.5 hours with an epidural in place, now entering the active phase by contemporary definition.
- Category I tracing on continuous monitoring since the epidural.
Plan
- Reassess at 16:00 or sooner if the membranes rupture
- Continue continuous monitoring while the epidural runs
- Encourage position changes; empty the bladder (catheter with the epidural)
Medications
- Epidural: Bupivacaine and fentanyl, continuous, sited 09:15
Maternal vitals
| Time | HR | BP | Temp |
|---|---|---|---|
| 08:00 | 84 | 118/72 | 36.9 |
| 10:00 | 88 | 112/68 | 37 |
| 12:00 | 90 | 108/66 | 37.1 |
Labs
- Haemoglobin118 g/L(110 to 150)
- Platelets210(150 to 400)
- Blood groupO positive, antibody screen negative
- GBSNegative (36+4)
What to watch
- Progress at 16:00 (expect 8 cm or more)
- Maternal temperature with the epidural
- The tracing if membranes rupture
OBGynSpace Tutor
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