Intrapartum Care, Labor, and Delivery
Domain 3 - Intrapartum Care, Labor, and Delivery
This domain tests the mechanics of normal and abnormal labour: partograph interpretation, fetal heart rate classification, second-stage manoeuvres, and third-stage prophylaxis. Questions often ask what you do in the next five minutes.
Core rules
- Active phase begins at 5 cm dilatation (WHO); slower progress is not automatically dystocia - assess power, passenger, passage.
- Partograph/Labour Care Guide: plot dilatation, descent, contractions, FHR, BP, urine, and fluids; act on the alert line.
- FHR baseline 110–160 bpm, variability 5–25 bpm. Early decelerations = head compression (benign); variable = cord compression (reposition, consider amnioinfusion); late = uteroplacental insufficiency (intrauterine resuscitation, expedite delivery). Absent variability with late or prolonged decelerations is a category III tracing - deliver.
- Second stage limits: nullipara 3 hours with epidural (2 without), multipara 2 hours with epidural (1 without).
- Episiotomy only for indication - mediolateral, 60 degrees from midline.
- AMTSL: oxytocin 10 IU IM within 1 minute, controlled cord traction, uterine massage. Delayed cord clamping 1–3 minutes.
- Shoulder dystocia: McRoberts plus suprapubic pressure, then internal rotation, posterior arm; never fundal pressure.
- Cord prolapse: elevate the presenting part, knee–chest or Trendelenburg, fill the bladder, immediate delivery.
Worked example
At 38 weeks, fully dilated, the CTG shows late decelerations with minimal variability for 30 minutes. That is category III. Start left lateral position, oxygen, IV fluid, stop oxytocin, then perform immediate operative vaginal or caesarean delivery while preparing neonatal resuscitation.
Traps
Calling early decelerations hypoxia; diagnosing arrest of labour at 3 cm; routine episiotomy; fundal pressure in shoulder dystocia; waiting for a category III tracing to improve.