Normal labour

Question 1

Define the three stages of labour.

Answer 1

1st - Onset of regular contractions to full cervical dilatation

2nd- full dilatation to delivery of baby

3rd - delivery of baby to delivery of placenta + membranes

Question 2

What are the phases of the first stage of labour?

Answer 2

Latent phase: 0 → 4cm dilatation. Irregular contractions. Can last hours to days. Managed at home if possible.

Active phase: 4cm → 10cm. Regular painful contractions (3-4 in 10 minutes). Expected progress ~0.5cm/hour

Question 3

What defines delay in the first stage of labour?

Answer 3

Progress <0.5cm/hour dilatation in active labour (over 4 hours)
Or no change in 2 hours despite good contractions
Actions: ARM (if membranes intact), then oxytocin augmentation

Question 4

What defines delay in the second stage of labour?

Answer 4

Nulliparous: Total second stage >3 hours (with epidural) or >2 hours (without)
Multiparous: Total second stage >2 hours (with epidural) or >1 hour (without)
If delay: assess, augment if possible, consider instrumental delivery or CS

Question 5

What are the options for birth setting?

Answer 5

For low-risk women:

Home birth
Freestanding midwifery unit (FMU)
Alongside midwifery unit (AMU)
Obstetric unit (OU)
Recommendations:

Multiparous low-risk: All 4 settings equally safe — offer all options
Nulliparous low-risk: AMU recommended (marginally better neonatal outcomes than home); home birth has slightly higher risk for nullips
Women with risk factors should be advised to deliver in OU

Question 6

What are the pain relief options in labour?

Answer 6

Breathing/relaxation techniques
TENS
Water immersion
Entonox
IM opioids (pethidine, diamorphine)
Epidural
Remifentanil PCA
Spinal anaesthesia (CS)

Question 7

What are the indications for continuous electronic fetal monitoring (CEFM/CTG) in labour?

Answer 7

Previous CS
Pre-eclampsia/hypertension
Diabetes
Post-dates (>42 weeks)
Induced/augmented labour
Oxytocin infusion
Epidural
Intrauterine growth restriction
Prematurity (<37 weeks)
Oligohydramnios
Breech presentation
Multiple pregnancy
Antepartum haemorrhage
Meconium-stained liquor (significant)
Maternal pyrexia (≥38°C)
Prolonged rupture of membranes (>24 hours)
Abnormal intermittent auscultation
Fresh vaginal bleeding in labour
Maternal medical conditions

Question 8

How is intermittent auscultation performed?

Answer 8

Used for low-risk women in established labour
Use Pinard stethoscope or handheld Doppler
First stage: Auscultate FHR after a contraction for at least 60 seconds, every 15 minutes
Second stage: Auscultate after a contraction for at least 60 seconds, every 5 minutes
Record: baseline rate, presence/absence of decelerations, accelerations

Question 9

What is active management of the third stage?

Answer 9

IM oxytocin 10 IU with delivery of anterior shoulder or immediately after
Alternative: Syntometrine (oxytocin 5 IU + ergometrine 500mcg) — more effective but more side effects (N&V, hypertension). Contraindicated in hypertension, cardiac disease.
Controlled cord traction (Brandt-Andrews method) after signs of separation
Delayed cord clamping (at least 1-3 minutes) — recommended even with active management
Expected duration: within 30 minutes
Benefits: Reduces PPH risk, reduces need for blood transfusion

Question 10

What are the signs of placental separation?

Answer 10

Gush of blood
Cord lengthening
Uterus becomes firm and globular
Uterus rises in abdomen (fundus elevates)

Question 11

When is the third stage considered prolonged?

Answer 11

Active management: >30 minutes
Physiological management: >60 minutes
If prolonged → attempt active management (if not already), then consider manual removal of placenta under regional/general anaesthesia