PURPOSE:
To share the clinical management and lessons learned from a rare case of spontaneous quadruplet pregnancy delivered vaginally, in which the fourth fetus was unexpectedly discovered during labor. This case illustrates the critical decision-making role of midwives and the value of multidisciplinary teamwork in unpredictable obstetric situations.

DISCUSSION:
Despite advances in antenatal care, multiple pregnancies in low- and middle-income countries may be underdiagnosed due to limited access to high-quality ultrasound. In this case, the pregnancy was monitored as a triplet pregnancy. The patient presented at 32 weeks and 6 days in full labor, and vaginal delivery was performed. The fourth fetus was discovered per-partum, requiring rapid adaptation from the care team. Technical management included internal podalic version for the third twin in transverse presentation, demonstrating mastery of advanced obstetric maneuvers. The presence of an experienced midwife, working collaboratively with obstetricians, enabled a safe outcome despite the unplanned nature of the event. This case underscores the importance of clinical vigilance, timely response, technical mastery of obstetric maneuvers, and trust in midwifery leadership.

EVIDENCE WHERE RELEVANT:
Spontaneous quadruplet pregnancies are extremely rare, with an estimated natural incidence of 1 in 512,000 births (Hellin-Zeleny rule). Most are delivered by cesarean section. Only a few cases of successful vaginal delivery of quadruplets have been documented, often in emergent or unanticipated situations. In this case, all four newborns had satisfactory Apgar scores and were admitted to neonatal care for moderate prematurity. The mother experienced postpartum hemorrhage due to uterine atony, which was managed promptly without surgical intervention.

KEY MESSAGE:
Even in well-equipped hospitals, unanticipated findings can occur during labor. Skilled midwives, supported by a multidisciplinary team, play a vital role in ensuring safe and respectful maternal and neonatal outcomes—even in complex and high-risk situations such as this spontaneous, unplanned quadruplet vaginal birth. Poster session 1 (Group A)