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The Case of Frieda Patterson











Frieda is a 34 year-old pregnant woman who is admitted to the labour and delivery unit in a rural hospital. She has been having contractions for the past eight hours, and she thinks her 'water broke' two hours ago. She has not been to a doctor during this pregnancy, and you have no chart for her.

What is labour?

Labour is a series of organized uterine contractions leading to progressive cervical effacement and dilation, bearing down efforts, and normally the delivery of the infant.


How would you assess whether she is in labour?

Time the contractions and assess their quality - the duration, frequency, and intensity of each.

Assess cervical dilation/effacement and descent of fetal head, and monitor for change every 2-4 hours. Normally a partogram is used to document change.

Ask about rupture of membranes.

If there is no change within 4 hours, labour is unlikely at this point.

What questions would you like to ask Frieda?

As she has had no prenatal care, a full history is required:

History of pregnancy:

  • last menstrual period
  • any results of pregnancy tests
  • bleeding
  • contractions (onset, duration, etc)
  • fetal activity
  • loss of fluid (colour, consistency

Past obstetric history

  • complications
  • GBS status

Past medical history

  • diabetes
  • hypertesion

Medications, allergies


Risk factors

  • smoking
  • drug use
  • blood type
  • infection status: HIV, Heb B, syphilis, etc




Part II

You confirm that Mary is indeed in labour, as her contractions are occurring every 3 minutes, and that her cervix is 9 cm dilated.


You prepare the room for a delivery.



What supplies are required for delivery?

The minimum supplies for delivery include:

sterile gloves

surgical drapes

effective lighting

clamps/sterile string

scalpel for the umbilical cord


suture material and local anaesthetic


IV supplies

newborn supplies: suction, bag-valve mask, oxygen

Mary develops the urge to push, and soon the head is visible in the birth canal.

What are the cardinal movements of delivery? Demonstrate these with a model, if available.

descent, flexion, internal rotation, extension, external rotation/restitution, delivery/expulsion


What are the steps as the head crowns?

As the head crowns, there are a number of options until the delivery of the head.

  • do nothing
  • stretch the posterior vagina with two fingers
  • make an O with your two thumbs and index fingers, placing your hands vertically
  • Ritgen's maneuver: apply pressure to the chin through the perineum to assist with neck extension, keeping the other hand anteriorly to control descent

Once the head delivers, as the mother to stop pushing. Feel for a cord around the neck and loop it forwards over the head, towards the face.

Ask the mother to give small pushes, pulling inferiorly to deliver the anterior shoulder and then lifting skyward to deliver the posterior shoulder. Place the infant on the mother's abdomen (using a clean sheet) and clamp and cut the cord.


Mary delivers a baby boy. He immediately starts to cry and flail his arms. His chest and abdomen are pink, but his hands and feet are bluish. His heart rate is 155.


What is his APGAR score?


9 - HR 2, resp 2, irritability 2, tone 2, colour 1