Labor, Delivery, and Postpartum Care
What this domain tests
Labor and postpartum questions test your ability to read the progress of labor, recognize obstructed and prolonged labor, run a structured postpartum hemorrhage response, and manage immediate postpartum complications.
Core rules
- Stages. Latent phase to about 5–6 cm; active phase from 5–6 cm with expected dilation of ≥1 cm/h on the WHO partogram. Second stage: up to 3 hours in a nullipara with epidural, 2 hours in a multipara. Third stage normally completes within 30 minutes.
- Postpartum hemorrhage. Blood loss ≥500 mL after vaginal birth or ≥1000 mL after cesarean, or any loss causing hemodynamic compromise. Atony causes 70–80%. Causes: tone, trauma, tissue, thrombin.
- Stepwise response. Call for help, two large-bore IV lines, cross-match, bimanual uterine massage, oxytocin 10 IU IM/IV then infusion, tranexamic acid 1 g IV within 3 hours, carboprost 250 µg IM every 15 minutes (max 2 mg), misoprostol 800 µg sublingual, balloon tamponade, B-Lynch, hysterectomy. Methylergonovine 0.2 mg IM is contraindicated in hypertension.
- Shoulder dystocia. McRoberts, suprapubic pressure, rotational maneuvers, then posterior arm; document the sequence.
- Postpartum fever. After cesarean, endometritis is treated with clindamycin plus gentamicin until afebrile 24–48 hours.
Worked example
After a 4.1-kg vaginal birth the placenta delivers, but bleeding continues and the uterus is soft at the umbilicus with 900 mL collected. This is atony: massage, oxytocin, tranexamic acid 1 g, then carboprost because BP is normal. If bleeding persists, pack the uterus and move to theatre.
Traps
Visually underestimating blood loss; giving methylergonovine to a preeclamptic patient; using 200 µg instead of 800 µg sublingual misoprostol; forgetting to examine for genital tract trauma and retained placenta.