Intrapartum Care and Fetal Monitoring
This domain tests intrapartum assessment: diagnosing labour, using the partogram, choosing intermittent auscultation or continuous cardiotocography (CTG), and interpreting fetal heart patterns. The exam expects you to classify a trace accurately and state the next action, not just list features.
Core rules and concepts
- Established labour: regular painful contractions with progressive cervical change, usually from 4 cm. Document dilatation, station, position, caput and moulding.
- Partogram: plot cervical dilatation, descent, contractions per 10 minutes, liquor and maternal observations. Alert and action lines prompt review, not automatic intervention.
- Intermittent auscultation (IA): for low-risk labour, listen for 1 minute after a contraction every 15 minutes in the first stage and every 5 minutes in the second stage, over the fetal back.
- Continuous CTG: recommended for meconium, suspected sepsis, hypertension, bleeding, oxytocin use, prolonged labour or abnormal IA. Use DR C BRAVADO: define risk, contractions, baseline rate, variability, accelerations, decelerations and overall impression.
- Baseline 110–160 bpm; variability 5–25 bpm; accelerations at least 15 bpm for 15 seconds after 32 weeks. Early decelerations reflect head compression; variable decelerations reflect cord compression; late decelerations reflect uteroplacental insufficiency.
- Category 3 trace: abnormal baseline, reduced variability with late or variable decelerations, or a prolonged deceleration over 3 minutes. Escalate immediately.
Worked example
A low-risk primigravida at 5 cm has a CTG showing baseline 155 bpm, variability 10 bpm, accelerations present and late decelerations after three contractions. Reasoning: baseline and variability are normal, but recurrent late decelerations indicate fetal hypoxia. This is not a normal trace despite the normal baseline. Reposition left lateral, stop any oxytocin, give IV fluids, call obstetric and neonatal teams and prepare for expedited delivery.
Traps
- Calling a trace normal because the baseline is 140 bpm.
- Using CTG for low-risk women instead of intermittent auscultation.
- Timing auscultation during a contraction rather than after it.
- Ignoring a prolonged deceleration because it resolved.
- Treating the partogram action line as a mandatory caesarean threshold.
Key points
- IA: every 15 minutes in first stage, every 5 minutes in second stage, for 1 minute after a contraction.
- CTG baseline 110–160 bpm; variability 5–25 bpm; late decelerations suggest hypoxia.
- Category 3 trace needs immediate escalation and delivery planning.
- The partogram action line triggers senior review, not automatic intervention.
- Oxytocin requires continuous CTG and contraction monitoring.