Second stage, pushing
Room 3GA 39+0G3P235 yRuptured 06:00, clear
Fully dilated 40 minutes, head at plus 1, variable decelerations. Second stage.
39+0wksG3P2 · 35 y
- Triage
- Latent
- Active
- Second stage
- Delivery
- Postpartum
10:40: 10 cm, 100% effaced, station 1
Maternal
- BP
- 128/82
- HR
- 100
- Temp
- 37.2
- Labs
- no flags
- Running
- Penicillin G, Nitrous oxide
Fetal
- Monitor
- Variables, recovering
- Presentation
- Cephalic, occiput anterior, station plus 1 to plus 2
- Membranes
- Ruptured 06:00, clear
- Next
- Reassess 15 min
Summary
35-year-old G3P2 at 39+0, second stage, pushing. Fully dilated 40 minutes, head at plus 1, variable decelerations.
- Membranes
- Ruptured 06:00, clear
- Fetal presentation
- Cephalic, occiput anterior, station plus 1 to plus 2
- Board status
- Second stage
Notes
- Two prior uncomplicated vaginal births.
- Pushing well; the head is visible with contractions.
- Intermittent variable decelerations with shoulders and moderate variability between contractions.
Plan
- Continue pushing with maternal position changes
- Reassess the strip every 15 minutes in the second stage
- Prepare for delivery; paediatrics not required at this point
Medications
- Penicillin G: Intravenous, 4-hourly, for GBS
- Nitrous oxide: As needed
Maternal vitals
| Time | HR | BP | Temp |
|---|---|---|---|
| 09:00 | 92 | 124/80 | 37 |
| 11:20 | 100 | 128/82 | 37.2 |
Labs
- Haemoglobin121 g/L
- GBSPositive; penicillin given 06:30 and 10:30
What to watch
- Baseline rising or variability falling
- Decelerations deepening or slower to recover
- Descent with each contraction
OBGynSpace Tutor
It knows the chart and the monitor's context; it will not answer the pending decision or read the strip for you.