Normal Labour — SAQ · MBBS SAQ

Question

10 marks10 min

Stem

A 28-year-old primigravida at 39 weeks gestation presents with regular painful contractions every 3 minutes lasting 45 seconds. Cervical dilation is 5cm. Membranes are intact. Fetal heart rate is 140 bpm. [1]

Questions

a) What stage of labour is she in and what is the expected rate of progress? (2 marks) [1]

Stage 1 (ACTIVE PHASE) — cervical dilation 5cm (between 4 and 10cm). Expected progress: at least 1 cm/hour (primigravida in active phase). [1]

b) Describe the three components of active management of the third stage. (3 marks) [1]

Prophylactic oxytocin 10 IU IM at delivery of the anterior shoulder.
Controlled cord traction (CCT): clamp and cut cord, gentle traction with suprapubic counter-pressure, after signs of separation.
Uterine massage: massage fundus after placental delivery to ensure contraction. [1]

This reduces PPH by 60%. [1]

c) Name four signs of placental separation. (2 marks) [1]

Lengthening of the umbilical cord.
Gush of blood from vagina.
Uterus becomes firm and globular.
Uterus rises in abdomen. [1]

d) What is the Apgar score and what does it assess? (2 marks) [1]

Apgar score assesses newborn condition at 1 and 5 minutes. Five components (each 0 to 2, total 0 to 10): Appearance (colour), Pulse (heart rate), Grimace (reflex), Activity (tone), Respiration. Score 7 to 10 = normal. [1]

e) What should be monitored during the fourth stage of labour? (1 mark) [1]

First hour postpartum: fundal height and tone (must be firm), lochia (blood loss), maternal vitals (pulse, BP, temperature). This is when most PPH occurs. [1]

References

[1]Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour BMJ, 1988.PMID 3144366
[2]Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The effects of routine oxytocic administration in the management of the third stage of labour: an overview of the evidence from controlled trials Br J Obstet Gynaecol, 1988.PMID 3277663
[3]Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes Obstet Gynecol, 2010.PMID 21099592
[4]The development of the WHO Labour Care Guide: an international survey of maternity care providers Reprod Health, 2021.PMID 33752712
[5]McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes Cochrane Database Syst Rev, 2013.PMID 23843134
[6]Apgar V. A proposal for a new method of evaluation of the newborn infant Curr Res Anesth Analg, 1953.PMID 13083014
[7]Geimonen E, Jiang W, Chou K, et al. Activation of protein kinase C in human uterine smooth muscle induces connexin-43 gene transcription through an AP-1 site in the promoter sequence J Biol Chem, 1996.PMID 8798588
[8]Alterations in gap junction connexin43/connexin45 ratio mediate a transition from quiescence to excitation in a mathematical model of the myometrium J R Soc Interface, 2014.PMID 25401181
[9]Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth Cochrane Database Syst Rev, 2012.PMID 23076901
[10]Kinugasa M, Hashimoto K, Nakanishi H, et al. Safety and efficacy of a combination of pethidine and levallorphan for pain relief during labor: An observational study J Obstet Gynaecol Res, 2019.PMID 30362203
[11]Dohbit JS, Foumane P, Tochie JN, et al. The increasing use of the WHO Safe Childbirth Checklist: lessons learned at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon BMC Pregnancy Childbirth, 2021.PMID 34238244
[12]Oladapo OT, Tunçalp Ö, Bonet M, Lawrie TA, Portela A, Downe S, Gülmezoglu AM. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing BJOG, 2018.PMID 29637727
[13]National Institute for Health and Care Excellence. Fetal monitoring in labour: summary and update of NICE guidance BMJ, 2022.PMID 36526275

Questions

a) What stage of labour is she in and what is the expected rate of progress? (2 marks) [1]

Stage 1 (ACTIVE PHASE) — cervical dilation 5cm (between 4 and 10cm). Expected progress: at least 1 cm/hour (primigravida in active phase). [1]

b) Describe the three components of active management of the third stage. (3 marks) [1]

Prophylactic oxytocin 10 IU IM at delivery of the anterior shoulder.

Controlled cord traction (CCT): clamp and cut cord, gentle traction with suprapubic counter-pressure, after signs of separation.

Uterine massage: massage fundus after placental delivery to ensure contraction. [1]

This reduces PPH by 60%. [1]

c) Name four signs of placental separation. (2 marks) [1]

Lengthening of the umbilical cord.

Gush of blood from vagina.

Uterus becomes firm and globular.

Uterus rises in abdomen. [1]

d) What is the Apgar score and what does it assess? (2 marks) [1]

e) What should be monitored during the fourth stage of labour? (1 mark) [1]

First hour postpartum: fundal height and tone (must be firm), lochia (blood loss), maternal vitals (pulse, BP, temperature). This is when most PPH occurs. [1]

References

[1]Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of third stage of labour BMJ, 1988.PMID 3144366
[2]Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The effects of routine oxytocic administration in the management of the third stage of labour: an overview of the evidence from controlled trials Br J Obstet Gynaecol, 1988.PMID 3277663
[3]Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes Obstet Gynecol, 2010.PMID 21099592
[4]The development of the WHO Labour Care Guide: an international survey of maternity care providers Reprod Health, 2021.PMID 33752712
[5]McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes Cochrane Database Syst Rev, 2013.PMID 23843134
[6]Apgar V. A proposal for a new method of evaluation of the newborn infant Curr Res Anesth Analg, 1953.PMID 13083014
[7]Geimonen E, Jiang W, Chou K, et al. Activation of protein kinase C in human uterine smooth muscle induces connexin-43 gene transcription through an AP-1 site in the promoter sequence J Biol Chem, 1996.PMID 8798588
[8]Alterations in gap junction connexin43/connexin45 ratio mediate a transition from quiescence to excitation in a mathematical model of the myometrium J R Soc Interface, 2014.PMID 25401181
[9]Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth Cochrane Database Syst Rev, 2012.PMID 23076901
[10]Kinugasa M, Hashimoto K, Nakanishi H, et al. Safety and efficacy of a combination of pethidine and levallorphan for pain relief during labor: An observational study J Obstet Gynaecol Res, 2019.PMID 30362203
[11]Dohbit JS, Foumane P, Tochie JN, et al. The increasing use of the WHO Safe Childbirth Checklist: lessons learned at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, Cameroon BMC Pregnancy Childbirth, 2021.PMID 34238244
[12]Oladapo OT, Tunçalp Ö, Bonet M, Lawrie TA, Portela A, Downe S, Gülmezoglu AM. WHO model of intrapartum care for a positive childbirth experience: transforming care of women and babies for improved health and wellbeing BJOG, 2018.PMID 29637727
[13]National Institute for Health and Care Excellence. Fetal monitoring in labour: summary and update of NICE guidance BMJ, 2022.PMID 36526275