Shardul Rajeshirke 3-20

Case history of Labor

I. General information

1. Patient: Maria Ivanova

2. Age: 27 years old

3. Parity: Third pregnancy, second birth

4. Time of admission: January 15, 2024 at 9:30 am

5. Complaints on admission: Regular uterine contractions every 7-8 minutes since 5 am. Rupture of
amniotic membranes at 8:45 am with clear amniotic fluid.

II. ANAMNESIS OF LIFE

1. No significant childhood or adult diseases.

2. No history of injuries, fractures or operations.

3. No high degree myopia or eye surgeries.

4. No prior surgeries or allergies to medications.

5. No hormonal drug use.

6. No blood transfusions.

7. Does not smoke or use alcohol or drugs.

8. Husband is 32 years old, healthy, no bad habits.

III. Gynecological history

Menstrual function:

1. First menstruation at age 13, regular 28-30 day cycles, 5 days duration, moderate blood loss, no
pain.

2. Last menstrual period started May 3, 2023.

Sexual function:

First sexual activity at age 19. Married. Uses condoms for contraception.

No history of gynecological diseases, infections or surgeries.

IV. Generative function

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First pregnancy in 2018 at age 24, spontaneous vaginal delivery at 40 weeks, male infant 3500g, no
complications.

Second pregnancy in 2020 at age 26, spontaneous vaginal delivery at 39 weeks, female infant 3200g,
no complications.

V. This pregnancy

First antenatal visit at 8 weeks gestation. Normal prenatal course with regular visits. No
complications. Hospitalized at 37 weeks for false labor, discharged after 48 hours.

Current estimated gestational age 39 weeks based on last menstrual period and early ultrasounds.
Total weight gain of 12 kg.

VI. Objective examination

General:

- Height: 165 cm

- Weight: 72 kg, BMI: 26 kg/m2

- Skin normal color

- Temp: 36.5C

- No edema

- No abdominal scars

- No varicose veins

- BP 120/80, Pulse 72, RR 16

- Lungs clear, heart sounds normal

- Normal urinary and bowel function

Obstetric:

1) Abdomen:

- Fundal height 35 cm

- Estimated fetal weight 3100 g by fundal height

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2) Leopold's maneuvers:

- Cephalic presentation, head is 3/5 palpable, engaged

- Fetal back on left side

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- Head ballottable

- Pelvis adequate

3) FHR: 142 bpm, moderate variability, accelerations present

4) Vaginal exam:

- Vulva/vagina normal

- Cervix dilated 6 cm, effaced 80%, soft

- Vertex presentation at -2 station

- Amniotic fluid clear

VII. Clinical diagnosis:

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Pregnancy 39 weeks. Occipital presentation. True labor.

VIII. Labor management plan:

Continue monitoring labor progress. Supportive care. Spontaneous vaginal delivery anticipated.

IX. Labor course:

I stage: Began at 5 am with contractions every 7-8 min. At 6 cm dilated, received epidural anesthesia
with good pain relief. FHR reactive. Duration 8 hours.

II stage: Began pushing at 9:30 am with vertex at +2 station. Baby boy delivered spontaneously at
10:15 am. Apgars 8 and 9. Weight 3400 g, length 51 cm. Delayed cord clamping.

III stage: Placenta delivered spontaneously at 10:25 am. Uterus firm. Estimated blood loss 350 mL.

Total labor duration: 10 hours

X. Postpartum course:

1 day postpartum: Mother doing well, afebrile. Breasts full, colostrum expressed. Uterus firm, lochia
rubra normal. Perineal laceration sutured. Ambulating, voided, passed flatus. Baby breastfeeding
well.

2 days postpartum: Mother and baby stable. Lochia serosa now. Breastfeeding 8-10 times per day.
Baby having 6-8 wet diapers per day.

3 days postpartum: Mother and baby discharged in good condition. Breastfeeding going well. Lochia
changing to lochia alba. Uterus continuing to involute normally. Follow up appointment made for 2
weeks.