The patient is a 36-year-old G3 P0020 at 39 gestational weeks who presented in labor to the hospital where she planned to give birth. She attended prenatal care visits regularly, had a healthy pregnancy, and desired a natural birth without intervention. On admission, her initial cervical examination was 2 to 3 cm, 100% effacement, — 1 station, and membranes intact. She reported regular contractions for 2 hours prior to coming to the hospital. An abdominal examination indicated a longitudinal lie, cephalic presentation, and right occiput posterior position of the fetus. The fetal heart rate pattern was reassuring. Contractions occurred every 3 to 5 minutes via external tocometer. The patient coped well with her husband's support and was encouraged to return home to labor through latent phase. Feeling uncomfortable about the possibility of staying home too long, the patient chose to be admitted and placed on intermittent monitoring. The patient was examined 4 hours later and her cervix was 5 cm, 100% effaced, — 1 station. Her contraction pattern was unchanged. The fetal heart rate pattern was consistently reassuring. Four hours later, 8 hours after her admission, the patient reported increased discomfort and wanted to know how much progress she had made. Her cervix was 7 cm, 100% effaced, — 1 station; her infant remained in occiput posterior position. At this time, the midwife diagnosed a protracted active labor pattern.
The midwife encouraged the patient to use positions such as hands and knees and side lunge to encourage rotation of the fetal head, yet her cervical examination remained unchanged over the next 4 hours. At 12 hours after admission, the midwife suggested nipple stimulation in an effort to enhance uterine forces and promote progressive cervical change. The patient's husband stimulated her nipples bilaterally for 15 minutes, followed by a 15-minute rest period. The midwife remained in the room during nipple stimulation to ensure consistent use of the technique. She noted no uterine tachysystole, which she defined as five contractions in 10 minutes, and the fetal heart rate pattern remained reassuring.
The cycle was repeated four times over the next 2 hours, at which point the patient's cervix was 8 cm, 100% effaced, 0 station, with contractions every 5 to 10 minutes. Despite cervical change, the contraction strength and frequency pattern were thought to be insufficient for active progress expected at this point in first-stage labor. Fourteen hours after hospital admission, the collaborative decision was made to simultaneously perform amniotomy and initiate oxytocin augmentation at a rate of 1 mU/min. Nipple stimulation was discontinued at this time. Continuous external fetal monitoring was initiated.
Oxytocin was progressively increased by 2 mU/min every 30 minutes for the next 6 hours. After more than 20 hours of laboring in the hospital, the patient felt the urge to push and her cervix was completely dilated. She pushed for a full hour and gave birth to a healthy infant girl in direct OP position, with Apgar scores 9 and 9 at 1 and 5 minutes, respectively.