DAY 5
📅 Nov 14 (Thu)
🔴 First Stage of Labour
DME 111: Physiology & Management
- Physiology: Contractions, Cervical dilatation, Descent
- Management: Assessment, Vaginal Examination, Partograph
- Maternal & Fetal Monitoring
⏱️ REMEMBER: Latent phase = 0-4cm, Active phase = 4-10cm. 1cm/hr expected!
🚨 KEY POINT: VE = Vaginal Examination. Use 5 fingers, assess 5Ps! (Passage, Passenger, Power, Position, Psyche)
"First stage is a marathon. Your patience and skill guide the mother!"
"Weeping may endure for a night, but joy comes in the morning." - Psalm 30:5
1. FIRST STAGE PHYSIOLOGY - THE FOUNDATION
📚 Definition:
First stage of labour is the period from the onset of true labour until the cervix reaches full dilatation (10cm).
Duration: Primipara 8-12 hours, Multipara 6-8 hours (but highly variable!)
🎯 Two Phases - "Latent to Active":
🧠 MNEMONIC: "LATENT LEADS TO ACTIVE LABOUR"
Latent Phase (0-4cm):
• Long, variable duration
• Able to talk/walk
• Thin cervix effacing
• Early, irregular contractions
• Normal to last 8 hours
• Teach patience - don't rush!
Active Phase (4-10cm):
• Alert line starts here!
• Cervix dilates 1cm/hour (primip)
• Transfer if slow progress
• Increased contraction intensity
• Vaginal exam every 4 hours
• Epidural often requested
• Labour pains stronger
• Baby's head descends
• Oxytocin receptors peak
• Uterus contracts regularly
• Rupture of membranes often occurs
Latent Phase (0-4cm):
• Long, variable duration
• Able to talk/walk
• Thin cervix effacing
• Early, irregular contractions
• Normal to last 8 hours
• Teach patience - don't rush!
Active Phase (4-10cm):
• Alert line starts here!
• Cervix dilates 1cm/hour (primip)
• Transfer if slow progress
• Increased contraction intensity
• Vaginal exam every 4 hours
• Epidural often requested
• Labour pains stronger
• Baby's head descends
• Oxytocin receptors peak
• Uterus contracts regularly
• Rupture of membranes often occurs
⚡ Uterine Contractions - The "POWER":
- Frequency: Every 2-3 minutes in active phase
- Duration: 45-60 seconds each
- Intensity: Strong enough to cause cervical change
- Resting tone: <10 mmHg between contractions
- Peak pressure: 50-80 mmHg in active phase
⚠️ EXAM CRITICAL: Contractions assessed by PALPATION: Place hand on fundus - should feel hard, lasting 45-60s, with complete relaxation between. Hypertonus = resting tone >20 mmHg = FETAL DISTRESS!
🔄 Cervical Changes - The "5 Changes":
🎯 MNEMONIC: "DIRECTION"
Dilatation: Opening from 0cm → 10cm
Ineffacement: Shortening from 2cm length → paper-thin
Reconsistency: Softening (firm → soft → stretchy)
Elevation: Moves from posterior → anterior → mid-position
Channel formation: Cervical canal opens completely
Timing: Follows predictable pattern in active phase
Integration: Coordinated with contractions
Opening: End result = 10cm (full dilation)
Normal progress = 1cm/hour for primip, 1.5cm/hour for multip
Dilatation: Opening from 0cm → 10cm
Ineffacement: Shortening from 2cm length → paper-thin
Reconsistency: Softening (firm → soft → stretchy)
Elevation: Moves from posterior → anterior → mid-position
Channel formation: Cervical canal opens completely
Timing: Follows predictable pattern in active phase
Integration: Coordinated with contractions
Opening: End result = 10cm (full dilation)
Normal progress = 1cm/hour for primip, 1.5cm/hour for multip
📉 Stations of Descent - "The -3 to +3 Journey":
| Station | Definition | Active Labour? | Management |
|---|---|---|---|
| -3 | Head floating, above inlet | No/Early latent | Observe, ambulate |
| -2 | Head at inlet | Latent phase | Encourage movement |
| -1 | Head in pelvis | Early active | Monitor progress |
| 0 | Head at ischial spines | Active phase | Start partograph! |
| +1 | Head below spines | Active phase | Good descent |
| +2 | Head at perineum | Late active | Prepare for 2nd stage |
| +3 | Head visible at introitus | Second stage imminent | Get delivery set ready! |
💡 EXAM STRATEGY: When asked "What station indicates engagement?" Answer: 0 station (at ischial spines) in primigravida. Engagement may not occur until late in multipara.
2. MANAGEMENT OF FIRST STAGE - THE "ABCs"
🎯 Initial Assessment on Admission - The "6 Checks":
🩺 MNEMONIC: "ADMIT EVERY LABOURING MOTHER"
Assess contractions: Frequency, duration, intensity
Determine stage: VE to confirm cervical dilation
Measure vitals: BP, pulse, temperature, respiration
Inspect abdomen: Fundal height, lie, presentation, engagement
Test FHR: Baseline rate, variability, decelerations
Evaluate danger signs: Bleeding, fever, fetal distress
Vulva check for show, ruptured membranes
Encourage to pass urine
Review ANC card & birth plan
Yield to problems - address any concerns
Make comfortable (ambulate if early labor)
Offer fluids & light food (if allowed)
Teach about labor process
Hydration: Start IV if needed
Explain all procedures
Record findings on partograph (if ≥4cm)
Assess contractions: Frequency, duration, intensity
Determine stage: VE to confirm cervical dilation
Measure vitals: BP, pulse, temperature, respiration
Inspect abdomen: Fundal height, lie, presentation, engagement
Test FHR: Baseline rate, variability, decelerations
Evaluate danger signs: Bleeding, fever, fetal distress
Vulva check for show, ruptured membranes
Encourage to pass urine
Review ANC card & birth plan
Yield to problems - address any concerns
Make comfortable (ambulate if early labor)
Offer fluids & light food (if allowed)
Teach about labor process
Hydration: Start IV if needed
Explain all procedures
Record findings on partograph (if ≥4cm)
🩺 Vaginal Examination (VE) - The Procedure:
Indications: Confirm onset, assess progress, detect problems
Frequency:
- Latent phase: Every 4 hours
- Active phase: Every 4 hours (or more if concern)
- Before interventions (oxytocin, ARM)
⚠️ EXAM CRITICAL: AVOID frequent VE! Each VE increases infection risk. NEVER do VE if placenta previa suspected!
🔍 The "5Ps" Assessment - What to Evaluate:
🖐️ MNEMONIC: "5 FINGERS FOR 5 Ps"
PASSAGE: Pelvis adequacy (diagonal conjugate, ischial spines)
• Is pelvis adequate for baby's head? (clinical pelvimetry)
• Assess mid-pelvis (spines prominence), outlet
PASSENGER: Fetal presentation, position, size
• Presentation: Cephalic (vertex, face), Breech, Shoulder
• Position: OA, OP, OT (for vertex)
• Size: Estimated fetal weight, moulding present?
POWER: Contractions quality, uterine tone
• Palpate fundus during VE - strength, duration, resting tone
POSITION: Cervical position & station
• Cervix: Posterior/Anterior/Mid-position
• Station: -3 to +3
PSYCHE: Mother's condition & cooperation
• Pain level, anxiety, fatigue, hydration status
PASSAGE: Pelvis adequacy (diagonal conjugate, ischial spines)
• Is pelvis adequate for baby's head? (clinical pelvimetry)
• Assess mid-pelvis (spines prominence), outlet
PASSENGER: Fetal presentation, position, size
• Presentation: Cephalic (vertex, face), Breech, Shoulder
• Position: OA, OP, OT (for vertex)
• Size: Estimated fetal weight, moulding present?
POWER: Contractions quality, uterine tone
• Palpate fundus during VE - strength, duration, resting tone
POSITION: Cervical position & station
• Cervix: Posterior/Anterior/Mid-position
• Station: -3 to +3
PSYCHE: Mother's condition & cooperation
• Pain level, anxiety, fatigue, hydration status
📊 Using the Partograph in First Stage:
- Start: When cervix reaches 4cm (active phase)
- Plot: Cervical dilation every 4 hours (or after VE)
- Plot: Descent (stations) every 4 hours
- Record: FHR every 30 minutes, BP every 4 hours
- Record: Contractions frequency every 30 minutes
💡 EXAM ALERT: Partograph is WHO MANDATORY TOOL for monitoring labour. In exam, always state: "I will plot partograph and monitor progress!"
🚨 Prolonged Labour - The "3 Ps Problem":
⚠️ MNEMONIC: "FIND THE CAUSE IN 3 Ps"
POWER inadequate: Poor contractions (inefficient uterine action)
→ Check: Frequency <3/10min, intensity weak, resting tone high
→ Management: Oxytocin augmentation (hospital only!)
PASSENGER too big: Large baby, malposition, hydrocephalus
→ Check: Moulding 2-3+, caput formation, poor descent
→ Management: CS if CPD diagnosed
PASSAGE too small: Contracted pelvis, soft tissue obstruction
→ Check: Prominent ischial spines, narrow subpubic angle
→ Management: CS for cephalopelvic disproportion (CPD)
POWER inadequate: Poor contractions (inefficient uterine action)
→ Check: Frequency <3/10min, intensity weak, resting tone high
→ Management: Oxytocin augmentation (hospital only!)
PASSENGER too big: Large baby, malposition, hydrocephalus
→ Check: Moulding 2-3+, caput formation, poor descent
→ Management: CS if CPD diagnosed
PASSAGE too small: Contracted pelvis, soft tissue obstruction
→ Check: Prominent ischial spines, narrow subpubic angle
→ Management: CS for cephalopelvic disproportion (CPD)
3. MATERNAL & FETAL MONITORING - THE "MOTHER FETUS" PROTOCOL
🤰 Maternal Monitoring - Frequency & Actions:
| Parameter | Frequency | Normal Range | Abnormal Action |
|---|---|---|---|
| Blood Pressure | Every 4 hours | <140/90 mmHg | ≥140/90 = PIH protocol |
| Pulse | Every 4 hours | 80-100 bpm | >100 = dehydration/sepsis |
| Temperature | Every 4 hours | <37.5°C | ≥38°C = infection screen |
| Urine Output | Every 4 hours | >30ml/hour | <30ml/hour = dehydration |
| Pain Level | Continuous | Tolerable | Severe = assess for obstruction |
| Emotional State | Continuous | Coping | Anxious = provide support |
👶 Fetal Monitoring - "Heart Tones Matter":
- Frequency: Every 30 minutes in active phase
- Method: Pinard stethoscope or Doppler ultrasound
- Normal: 120-160 beats/minute
- Assess: Baseline rate, variability, decelerations
🚨 CERTIFICATE EXAM CRITICAL: FHR <120 or >160 = IMMEDIATE ACTION!
- Change maternal position (left lateral)
- Give oxygen 6L/min via mask
- Stop oxytocin if running
- Call for help/transfer!
💧 Amniotic Fluid (Liquor) Assessment:
🌊 MNEMONIC: "CLEAR MEANS CLEAN"
Clear = Normal
Light yellow = Acceptable
Early meconium = Greenish tinge
Accumulation = Check for obstruction
Release = Time of ROM matters
Meconium-stained = Fetal distress (especially thick)
Early in labour = Worrisome
Associated with = Hypoxia, infection
Notify senior midwife
Suction baby at birth (prepare for MAS)
Clear = Normal
Light yellow = Acceptable
Early meconium = Greenish tinge
Accumulation = Check for obstruction
Release = Time of ROM matters
Meconium-stained = Fetal distress (especially thick)
Early in labour = Worrisome
Associated with = Hypoxia, infection
Notify senior midwife
Suction baby at birth (prepare for MAS)
4. COMPLICATIONS OF FIRST STAGE - "THE DEADLY DELAYS"
🚨 Prolonged Latent Phase:
- Definition: >20 hours (primip) or >14 hours (multip)
- Causes: False labor, inefficient contractions, anxiety
- Management: Rest (morphine sleep), hydrate, reassess
🚨 Prolonged Active Phase:
- Definition: <1cm/hour dilation in active phase
- Diagnosis: Plot on partograph crosses action line
- Management: REFER TO HOSPITAL! (Augmentation or CS)
⚠️ EXAM ALERT: Prolonged labor = MAJOR CAUSE OF MATERNAL DEATH! Leads to:
- Maternal exhaustion
- Postpartum hemorrhage
- Sepsis (especially if ROM >18 hours)
- Uterine rupture
- Stillbirth
🚨 Obstructed Labour - The "CATASTROPHE":
🆘 MNEMONIC: "OBSTRUCTED LABOUR KILLS BOTH"
Oedema of vulva (from pressure)
Bandl's ring (retraction ring)
Severe pain & exhaustion
Thick meconium
Ruptured membranes usually >18 hours
Uterus very tender
Cervix fully dilated but no descent
Transverse lie or malpresentation
Engorged bladder (can't void)
Dead fetus (late sign)
Life-threatening emergency!
Abdominal distension (from urine)
Blood-stained urine (bladder injury)
Ominous signs = REFER IMMEDIATELY!
Urgent CS needed!
Rapid transfer critical!
Oedema of vulva (from pressure)
Bandl's ring (retraction ring)
Severe pain & exhaustion
Thick meconium
Ruptured membranes usually >18 hours
Uterus very tender
Cervix fully dilated but no descent
Transverse lie or malpresentation
Engorged bladder (can't void)
Dead fetus (late sign)
Life-threatening emergency!
Abdominal distension (from urine)
Blood-stained urine (bladder injury)
Ominous signs = REFER IMMEDIATELY!
Urgent CS needed!
Rapid transfer critical!
🌍 UGANDA CONTEXT: Obstructed labour is common in rural areas due to delayed referral. HC IIIs must transfer early - don't wait for full dilation if progress poor!
DAY 6
📅 Nov 15 (Fri)
💪 Second & Third Stage
DME 111: Delivery & Placenta
- 2nd Stage: Physiology, Management, Episiotomy, Mechanism
- 3rd Stage: Physiology, Active Management, Placenta examination
👶 REMEMBER: Second stage = Full dilatation to birth. Bear down with contractions!
🩸 KEY POINT: Active management = Oxytocin + Controlled cord traction + Uterine massage!
"Birth is a miracle. You are the guardian of that miracle!"
"I will praise You, for I am fearfully and wonderfully made." - Psalm 139:14
5. SECOND STAGE OF LABOUR - "PUSH TO PRIZE"
📚 Definition & Diagnosis:
Second stage is from FULL CERVICAL DILATATION (10cm) until the BABY IS BORN.
Diagnosis: VE confirms 10cm + strong urge to push + visible descent
⏱️ Duration Limits - The "DON'T EXCEED" Times:
| Mother | Maximum Duration | Action if Exceeded |
|---|---|---|
| Primipara (no epidural) | 2 hours | Assess for cause, consider assisted delivery |
| Primipara (with epidural) | 3 hours | Same assessment |
| Multipara (no epidural) | 1 hour | URGENT review! |
| Multipara (with epidural) | 2 hours | Assess |
🚨 EXAM CRITICAL: Multipara >1 hour in 2nd stage = ABNORMAL! Think obstruction, CPD, or poor contractions. Multips deliver fast - delay is suspicious!
🎯 Physiology - The "Pushing Reflex":
- Ferguson's reflex: Descending head stimulates stretch receptors → mother feels urge to push
- Contractions: Every 2-3 minutes, lasting 60-90 seconds
- Bearing down: Mother pushes WITH contractions (not in between!)
- Descent: Head rotates from OT → OA as it passes through levator ani
🩺 Management Principles - The "SUPPORT" Approach:
🤱 MNEMONIC: "SUPPORT THE PUSHING MOTHER"
Stay with her (never leave alone!)
Upright positions encouraged (squatting, kneeling)
Privacy & dignity maintained
Praise her efforts (encouragement!)
Observe descent: Watch perineum bulging
Rest between contractions (conserve energy)
Teach breathing: Exhale while pushing
Timing: Push with contractions (3 pushes per contraction)
Hydration: Offer sips of water
Encourage to empty bladder
Perineal support (warm compresses)
Use of lithotomy if needed for delivery
Stop pushing when head crowns (controlled delivery)
Hands ready for baby (delivery set open!)
Stay with her (never leave alone!)
Upright positions encouraged (squatting, kneeling)
Privacy & dignity maintained
Praise her efforts (encouragement!)
Observe descent: Watch perineum bulging
Rest between contractions (conserve energy)
Teach breathing: Exhale while pushing
Timing: Push with contractions (3 pushes per contraction)
Hydration: Offer sips of water
Encourage to empty bladder
Perineal support (warm compresses)
Use of lithotomy if needed for delivery
Stop pushing when head crowns (controlled delivery)
Hands ready for baby (delivery set open!)
🪑 Maternal Positions for 2nd Stage:
- Squatting: Uses gravity, widens pelvic outlet by 1-2cm
- Kneeling/on all fours: Good for back pain, OP positions
- Left lateral/Sims: Less strenuous, good for tired mother
- Lithotomy: For assisted deliveries, episiotomy, primip perineal support
- Semi-recumbent: Common but less efficient than upright
🌍 UGANDA CONTEXT: Traditional birthing positions (squatting, kneeling) are culturally preferred. Use them! Only use lithotomy if needed for episiotomy or assisted delivery. Respect cultural practices while ensuring safety.
✂️ Episiotomy - The Controversial Cut:
Definition: Surgical incision of perineum to enlarge vaginal outlet
Indications (WHO restrictive approach):
- Fetal distress requiring quick delivery
- Assisted delivery (vacuum, forceps)
- Very tight perineum preventing descent
- Previous FGM with rigid scar tissue
✂️ MNEMONIC: "EPISIOTOMY ONLY WHEN ESSENTIAL"
Emergency fetal distress
Previous FGM scar
Instrumental delivery planned
Severe perineal rigidity
Impending severe tear
Obstructed delivery imminent
Tight perineum blocking descent
Otherwise AVOID - it's not routine!
Midline (median) or Mediolateral
Yield better healing if restricted
Emergency fetal distress
Previous FGM scar
Instrumental delivery planned
Severe perineal rigidity
Impending severe tear
Obstructed delivery imminent
Tight perineum blocking descent
Otherwise AVOID - it's not routine!
Midline (median) or Mediolateral
Yield better healing if restricted
📐 Types of Episiotomy:
| Type | Incision | Advantages | Disadvantages | Use in Uganda |
|---|---|---|---|---|
| Median | Midline towards anus | Easy repair, less bleeding | Risk of 3rd/4th degree tear | Not recommended (anal sphincter risk) |
| Mediolateral | 45° angle to midline | Safer, less sphincter damage | More blood loss, harder repair | Standard of care |
⚠️ EXAM RULE: In Uganda, MEDIOLATERAL EPISIOTOMY is the ONLY recommended type! Median episiotomy is contraindicated due to high risk of anal sphincter injury and fistula.
6. MECHANISM OF NORMAL DELIVERY - VERTEX
🔄 The 7 Cardinal Movements - "EDIEPEE":
🎯 MNEMONIC: "EVERY DOCTOR MUST ENTER PERFORMING DELIVERY EXPERTLY"
Engagement: Biparietal diameter passes pelvic inlet (0 station)
Descent: Head moves down with contractions (-3 → +3)
Mflexion: Chin to chest → smallest diameter (suboccipitobregmatic)
EInternal Rotation: Head rotates from OT → OA at spines
PExtension: Head extends under symphysis → crowning
DExternal Rotation (Restitution): Head aligns with shoulders
Expulsion: Shoulders & body deliver (largest diameter)
WATCH FOR: Moulding (overlapping skull bones) - normal if mild (0-1+)
Engagement: Biparietal diameter passes pelvic inlet (0 station)
Descent: Head moves down with contractions (-3 → +3)
Mflexion: Chin to chest → smallest diameter (suboccipitobregmatic)
EInternal Rotation: Head rotates from OT → OA at spines
PExtension: Head extends under symphysis → crowning
DExternal Rotation (Restitution): Head aligns with shoulders
Expulsion: Shoulders & body deliver (largest diameter)
WATCH FOR: Moulding (overlapping skull bones) - normal if mild (0-1+)
👑 Crowning - The Critical Moment:
- Definition: Largest diameter of fetal head visible at introitus
- Action: CONTROLLED DELIVERY to prevent perineal trauma
- Technique:
- Support perineum with warm compress
- Encourage small pushes or "blow" (pant) instead of pushing
- Allow head to emerge slowly between contractions
- Check for nuchal cord (cord around neck)
- Deliver shoulders one at a time (gentle traction)
- Support baby's head, guide downwards then upwards
7. THIRD STAGE OF LABOUR - "PLAS TO PLACENTA"
📚 Definition & Duration:
Third stage is from BABY'S BIRTH until PLACENTA DELIVERY
Duration: 5-30 minutes maximum (ideally <15 minutes)
Normal blood loss: <500ml (vaginal delivery)
🚨 EXAM CRITICAL: Retained placenta = NO separation after 30 minutes = Active management required!
🩸 Placental Separation Signs - "4 Signs of Separation":
🎯 MNEMONIC: "CRED SIGNS"
Chord lengthening: Umbilical cord lengthens at vulva
Retracted uterus: Fundus rises up, becomes firm & globular
Expulsion of clots: Small gush of blood with clots
Disc not felt: Uterus rises into abdomen (no palpable placenta)
Sudden trickle of blood
Increased fundal height
Gush from vagina
No more cord lengthening
Separation complete!
Chord lengthening: Umbilical cord lengthens at vulva
Retracted uterus: Fundus rises up, becomes firm & globular
Expulsion of clots: Small gush of blood with clots
Disc not felt: Uterus rises into abdomen (no palpable placenta)
Sudden trickle of blood
Increased fundal height
Gush from vagina
No more cord lengthening
Separation complete!
🎯 Active Management of Third Stage (AMTSL) - THE GOLD STANDARD:
AMTSL reduces PPH by 60%! 3 components:
🩸 MNEMONIC: "OCT - THE PPH PREVENTER"
Oxytocin: 10 IU IM within 1 minute of baby's birth
→ Causes uterine contraction → placenta separates → vessels constrict
Controlled Cord Traction (CCT):
• Wait for signs of separation (don't pull before!)
• Clamp cord near perineum
• GENTLE traction in direction of birth canal
• Counter-traction on uterus (other hand holds fundus)
• Placenta delivers with minimal effort
Transaction uterine massage:
• Immediately after placenta delivery
• Rub fundus in circular motion
• Keeps uterus contracted
• Prevents atony & bleeding
Oxytocin: 10 IU IM within 1 minute of baby's birth
→ Causes uterine contraction → placenta separates → vessels constrict
Controlled Cord Traction (CCT):
• Wait for signs of separation (don't pull before!)
• Clamp cord near perineum
• GENTLE traction in direction of birth canal
• Counter-traction on uterus (other hand holds fundus)
• Placenta delivers with minimal effort
Transaction uterine massage:
• Immediately after placenta delivery
• Rub fundus in circular motion
• Keeps uterus contracted
• Prevents atony & bleeding
⚠️ CRITICAL TIMING: Oxytocin must be given WITHIN 1 MINUTE of baby's birth - before placenta delivery! This is WHO standard.
🩺 Physiological (Expectant) Management:
- When: ONLY if mother declines active management
- What: Watch for separation signs, allow placenta to deliver spontaneously
- Cons: Higher PPH risk, takes longer (up to 60 min)
- UGANDA: Active management is STANDARD - avoid physiological!
🌍 UGANDA CONTEXT: AMTSL is MANDATORY in all facilities! Ensure enough oxytocin stock. Some rural HCs use oxytocin 10 IU IM immediately after birth + ergometrine 0.5mg IM after placenta if heavy bleeding.
8. EXAMINATION OF PLACENTA - "COMPLETE CHECK"
🎯 Steps - The "FELT COMPLETE" Method:
🩸 MNEMONIC: "SAFE DELIVERY NEEDS COMPLETE PLACENTA CHECK"
1. EXAMINE MATERNAL SURFACE:
Surface: Should be smooth, dark red, complete (no missing cotyledons)
Areas of infarction? (white patches = vascular insufficiency)
Fetal membranes intact? (amnion + chorion)
Edges complete? No tears
2. EXAMINE FETAL SIDE:
Disc shape normal (15-20cm)
Examine vessels: 2 arteries + 1 vein (check for abnormalities)
Look for knotting or thrombosis
Insertion of cord: Central, eccentric, marginal, velamentous?
Vessels should radiate from insertion
Ensure no vasa praevia remnants
3. CHECK MEMBRANES:
Rupture site - how many holes? (check for extra holes = missing twin?)
Yellow color may indicate infection
4. WEIGHT: Normal = 1/6th of baby's weight (500-600g for term)
ABNORMALITIES TO NOTE: Succenturiate lobe, battledore placenta, circumvallate placenta
1. EXAMINE MATERNAL SURFACE:
Surface: Should be smooth, dark red, complete (no missing cotyledons)
Areas of infarction? (white patches = vascular insufficiency)
Fetal membranes intact? (amnion + chorion)
Edges complete? No tears
2. EXAMINE FETAL SIDE:
Disc shape normal (15-20cm)
Examine vessels: 2 arteries + 1 vein (check for abnormalities)
Look for knotting or thrombosis
Insertion of cord: Central, eccentric, marginal, velamentous?
Vessels should radiate from insertion
Ensure no vasa praevia remnants
3. CHECK MEMBRANES:
Rupture site - how many holes? (check for extra holes = missing twin?)
Yellow color may indicate infection
4. WEIGHT: Normal = 1/6th of baby's weight (500-600g for term)
ABNORMALITIES TO NOTE: Succenturiate lobe, battledore placenta, circumvallate placenta
💡 EXAM ALERT: Single umbilical artery (SUA) is found in 0.8% of placentas. Associated with congenital anomalies, especially kidney/heart defects. Must refer baby for full examination!
9. AFTER PLACENTA DELIVERY - IMMEDIATE CARE
🩸 Check for Bleeding:
- NORMAL: <500ml vaginal delivery, <1000ml CS
- Assess: Fundal tone (must be firm!), pad count, pooling
- Action: Rub fundus if soft/boggy (uterine massage)
- Drugs: 2nd dose oxytocin if heavy bleeding
🔍 Perineal Check:
- Examine: Vagina, perineum for tears
- Grades:
- 1st degree: Skin only
- 2nd degree: Involves perineal muscle
- 3rd degree: Involves anal sphincter
- 4th degree: Through rectal mucosa
- Repair: All tears >1st degree require suturing
LIKELY EXAM QUESTIONS FOR DAYS 5 & 6
1. FILL-IN-THE-BLANK (2 marks)
The active phase of first stage begins at ______ cm dilation and the expected rate is ______ cm per hour for a primipara.
ANSWER: 4cm, 1cm/hour
2. MULTIPLE CHOICE (3 marks)
A primigravida has been fully dilated for 2.5 hours with no descent and normal contractions. The most likely diagnosis is:A) Normal progress
B) Prolonged active phase
C) Obstructed labour ⭐ CORRECT
D) False labour
EXPLANATION: Primip >2 hours in 2nd stage = abnormal. With no descent + good contractions = obstruction. Needs urgent CS!
3. SHORT ANSWER (5 marks)
Outline the three components of Active Management of Third Stage of Labour (AMTSL) and state the timing of oxytocin administration.
ANSWER GUIDE:
1. Oxytocin 10 IU IM within 1 minute of birth (2 marks)
2. Controlled Cord Traction after separation signs (1.5 marks)
3. Uterine massage after placenta delivery (1.5 marks)
TIMING: Oxytocin WITHIN 1 MINUTE (1 mark)
1. Oxytocin 10 IU IM within 1 minute of birth (2 marks)
2. Controlled Cord Traction after separation signs (1.5 marks)
3. Uterine massage after placenta delivery (1.5 marks)
TIMING: Oxytocin WITHIN 1 MINUTE (1 mark)
4. PRACTICAL SCENARIO (10 marks)
You are conducting a VE on a woman in labour: cervix 6cm dilated, fully effaced, station 0, membranes intact, fetal head in OA position, contractions 3/10min palpated as moderate. What is your assessment? What actions will you take?
ANSWER:
Assessment: Active phase, normal progress (2 marks)
Actions:
• Start/review partograph (2 marks)
• Plot cervical dilation (6cm), station (0), contractions (2 marks)
• Continue monitoring - FHR every 30min, BP every 4hr (2 marks)
• Encourage ambulation if comfortable (1 mark)
• Encourage fluids, provide support (1 mark)
Assessment: Active phase, normal progress (2 marks)
Actions:
• Start/review partograph (2 marks)
• Plot cervical dilation (6cm), station (0), contractions (2 marks)
• Continue monitoring - FHR every 30min, BP every 4hr (2 marks)
• Encourage ambulation if comfortable (1 mark)
• Encourage fluids, provide support (1 mark)
5. TRUE/FALSE (2 marks each)
a) A retained placenta is diagnosed if not delivered within 15 minutes of baby's birth.b) Mebendazole should be given in the first trimester of pregnancy.
c) A primigravida's cervix should dilate at least 1.5cm per hour in active phase.
ANSWERS:
a) FALSE - Retained = >30 minutes
b) FALSE - Give after 13 weeks (2nd trimester)
c) FALSE - 1cm/hour for primip, 1.5cm for multip
a) FALSE - Retained = >30 minutes
b) FALSE - Give after 13 weeks (2nd trimester)
c) FALSE - 1cm/hour for primip, 1.5cm for multip
6. LIST QUESTION (8 marks)
List four signs of placental separation and four parameters you would monitor in first stage of labour.
ANSWER:
Separation signs: Cord lengthening, fundal rise, gush of blood, uterus globular (any 4)
First stage monitoring: Cervical dilation, FHR, BP, contractions, temperature, urine output (any 4)
MARKING: 1 mark per correct answer
Separation signs: Cord lengthening, fundal rise, gush of blood, uterus globular (any 4)
First stage monitoring: Cervical dilation, FHR, BP, contractions, temperature, urine output (any 4)
MARKING: 1 mark per correct answer
📊 STATISTICS: Labour management questions are 40% of midwifery exams! Focus on partograph interpretation, AMTSL, and emergency recognition. These are PASS/FAIL topics!
📚 DAYS 5 & 6 SUMMARY: LABOUR MASTERY
🎯 First Stage = MONITOR & WAIT PATIENTLY:
- Latent 0-4cm: Let mother rest, ambulate, hydrate
- Active 4-10cm: Partograph starts! 1cm/hour expected
- Watch: Alert line = action indicator
- Monitor: FHR 30 min, BP 4hr, contractions continuously
- VE: Every 4 hours, assess 5Ps
🎯 Second Stage = PUSH WITH CONTROL:
- Diagnosis: 10cm + urge to push + descent
- Duration: ≤2hr primip, ≤1hr multip
- Support: Encourage, upright positions, rest between
- Episiotomy: Mediolateral ONLY if essential
- Crowning: Controlled delivery, check for nuchal cord
🎯 Third Stage = PREVENT PPH:
- AMTSL: Oxytocin within 1 min + CCT + massage
- Placenta: Examine completeness, weight, vessels
- PPH prevention: Rub fundus, monitor bleeding
- Documentation: Time, blood loss, placenta status
🎯 FINAL MASTER MNEMONIC: "LABOUR IS A 3-STAGE JOURNEY"
Stage 1: Cervix opens (0 → 10cm)
Stage 2: Baby born (push to prize)
Stage 3: Plac expelled (ocin prevents bleed)
Complications = Prolonged, Obstructed, PPH
Be vigilant, monitor, act fast
Prevent death with AMTSL
REMEMBER: THE 4 HOUR RULE (action line) AND THE 1 MINUTE RULE (ocin)!
Stage 1: Cervix opens (0 → 10cm)
Stage 2: Baby born (push to prize)
Stage 3: Plac expelled (ocin prevents bleed)
Complications = Prolonged, Obstructed, PPH
Be vigilant, monitor, act fast
Prevent death with AMTSL
REMEMBER: THE 4 HOUR RULE (action line) AND THE 1 MINUTE RULE (ocin)!
⚠️ FINAL EXAM WARNING: These two days cover 40% of exam content! Master the partograph, AMTSL, and emergency recognition. These are life-and-death topics that examiners test heavily!
"Labour is the ultimate test of your midwifery skills. Thorough knowledge, vigilant monitoring, and timely actions save lives. Trust your training, trust the process, and be the guardian mothers need!"
"For I know the plans I have for you." - Jeremiah 29:11