A 32-year-old multipara (G3P2) at term presents to the labour ward with strong, regular uterine contractions. On cervical examination, the cervix is 8 cm dilated, 90% effaced, and the fetal head is at 0 station. Contractions occur every 2 minutes, lasting 60 seconds, with moderate-to-strong intensity. The patient reports severe pain and requests epidural analgesia. Fetal heart rate is 138 bpm with good variability. What is the appropriate management at this stage of labour?

Explanation

## Management During Active Phase of Labour **Key Point:** This patient is in the **active phase** (or late active/deceleration phase) of the first stage of labour. Management focuses on pain relief, maternal comfort, and close fetal-maternal monitoring—not acceleration or intervention. ### Clinical Assessment | Parameter | This Patient | Active Phase Range | Deceleration Phase Range | |-----------|--------------|-------------------|-------------------------| | Cervical dilation | 8 cm | 3–7 cm | 7–10 cm | | Effacement | 90% | 40–80% | 80–100% | | Contraction frequency | Every 2 min | Every 2–3 min | Every 1–2 min | | Contraction duration | 60 sec | 40–60 sec | 60–90 sec | | Contraction intensity | Moderate–strong | Moderate–strong | Strong | | Fetal station | 0 | −2 to 0 | −1 to +2 | **High-Yield:** This patient is actually in the **deceleration phase** (7–10 cm dilation), which is the final phase of the first stage. Progress is appropriate, and labour is advancing normally. ### Appropriate Management 1. **Analgesia:** Epidural analgesia is the gold standard for pain relief in active labour. It is safe, effective, and does not impede labour progression when properly managed. 2. **Partograph:** Continuous monitoring using a partograph ensures that labour is progressing along the expected curve and identifies prolonged labour early. 3. **Fetal Monitoring:** Continuous cardiotocography (CTG) or intermittent auscultation to ensure fetal well-being. 4. **Hydration & Support:** IV fluids, maternal ambulation (if epidural permits), and continuous labour support. 5. **No Acceleration Needed:** This patient is progressing normally. Oxytocin or ARM are not indicated in normal labour progression. **Clinical Pearl:** In a multipara, labour typically progresses faster than in a primigravida. This patient's dilation rate (8 cm in what appears to be active labour) is consistent with expected multipara progression (≥1.5 cm/hr in active phase). **Mnemonic - Pain Management in Labour:** **SAFE** = **S**upport (continuous labour companion), **A**nalgesia (epidural/spinal/nitrous), **F**luids (IV hydration), **E**ncouragement (positive reinforcement). ### Why NOT Oxytocin or ARM? - **Oxytocin augmentation** is reserved for **prolonged labour** (labour arrest or slow progress beyond the partograph action line). This patient is progressing normally. - **Artificial rupture of membranes (ARM)** is sometimes used to augment labour, but it is not routinely indicated in normal labour and carries risks (cord prolapse, infection, increased pain). It is not the first-line intervention.