NLE Antepartum, Intrapartum & Postpartum Care — Normal Labor & DeliveryCheat Sheet

Section Title

The Five Ps of Labour (Passenger, Passage, Powers, Position, Psyche)

Important Facts

• Lie = relationship of fetal long axis to maternal long axis (longitudinal is normal; transverse/oblique are abnormal).
• Cephalic (head-first) presentation is ideal; breech, face, and brow presentations complicate labour.
• LOA and ROA (right occiput anterior) are most favourable positions; OP (occiput posterior) — 'sunny-side up' — causes longer labour and more perineal trauma.
• Full flexion of the fetal head presents the smallest diameter (~9.5 cm occipitofrontal); deflexion enlarges the diameter → dystocia.
• Gynecoid pelvis (50% of women) has wide pelvic inlet, spacious midpelvis, and wide subpubic angle — ideal for vaginal birth.

Key Definitions

Diagrams To Know

• Fetal lie: longitudinal, transverse, oblique (diagram showing fetal position relative to maternal long axis).
• Cephalic presentations: vertex, brow, face (show diameters presented to pelvis).
• Fetal position: LOA, ROA, LOP, ROP, LOT, ROT, LPT, RPT (diagram of clock method on maternal pelvis).

Section Title

Signs of Impending & True Labour

Important Facts

• CERVICAL CHANGE (dilation and effacement) is the DEFINITIVE sign of true labour — absence of cervical change rules out true labour.
• True labour contractions are REGULAR, increase in frequency/duration/intensity, and INTENSIFY with walking.
• False labour contractions are IRREGULAR, do NOT intensify with activity, and are usually abdominal (not back-to-front).
• Premonitory signs include lightening, Braxton Hicks, cervical ripening, nesting/burst of energy, slight weight loss, and bloody show.
• Vaginal exam in true labour shows progressive cervical dilation and effacement; in false labour, cervix remains unchanged.

Key Definitions

Diagrams To Know

• True vs False Labour comparison table (already in comparison section below).

Common Values

Section Title

Stages of Labour — Duration, Phases, Characteristics

Important Facts

• LATENT PHASE is the longest but least uncomfortable; encourage ambulation, hydration, light meals, and rest.
• ACTIVE PHASE is when analgesia is often requested; contractions are strong and woman becomes serious.
• TRANSITION PHASE is the shortest but most intense; woman may feel despair — continuous support is crucial; DO NOT PUSH until fully dilated (10 cm) to avoid cervical oedema/tearing.
• CERVICAL EFFACEMENT (thinning, 0-100%) accompanies dilation; in primiparas, cervix often effaces before dilating.
• SECOND STAGE in primiparas typically 30 min to 2 hrs; in multiparas, often <30 min.
• Signs of PLACENTAL SEPARATION: (1) gush of vaginal blood, (2) lengthening of umbilical cord, (3) globular/firm uterus, (4) fundus rises.
• FOURTH STAGE is peak PPH risk; boggy (soft) uterus is the first sign of uterine atony — MASSAGE FUNDUS first.
• Controlled cord traction is done ONLY with a contracted uterus and countertraction; DO NOT PULL on the cord passively.

Key Definitions

Diagrams To Know

• Stages of labour timeline: latent (0-4 cm) → active (4-7 cm) → transition (8-10 cm) → second stage (10 cm to delivery) → third stage (delivery to placental expulsion) → fourth stage (first 1-2 hrs post-delivery).

Section Title

Cardinal Movements of Labour (Mechanisms)

Important Facts

• MNEMONIC: Every Decent Family In Elk Ridge Enjoys (Engagement, Descent, Flexion, Internal Rotation, Extension, Restitution, Expulsion).
• These movements occur in SEQUENCE and may overlap; descent continues throughout labour.
• FLEXION is crucial — full flexion presents the smallest diameter (9.5 cm); if head is DEFLEXED (brow or face presentation), diameter increases → risk of dystocia.
• INTERNAL ROTATION aligns the fetal head (widest part) with the widest part of the pelvic outlet → most common final position is OA (occiput anterior).
• OP (occiput posterior / 'sunny-side up') is less favourable; causes longer labour, more maternal exhaustion, and greater perineal trauma; may spontaneously rotate to OA.
• NUCHAL CORD (cord around fetal neck) is common and usually benign; check for it during delivery; gently slip it over the fetal head if present; if tight, clamp and cut before delivering body.
• CROWNING = widest part of fetal head is at the introitus, perineum bulging with each contraction.
• CONTROLLED DELIVERY of the head (support with hands, guide extension slowly) prevents perineal trauma and lacerations.

Key Definitions

Diagrams To Know

• Seven cardinal movements: diagram showing fetal head position at each stage as it traverses the pelvis (engagement at inlet, descent, flexion, rotation at midpelvis, extension at outlet, restitution, expulsion).

Common Values

Section Title

Fetal Heart Rate (FHR) Monitoring — Normal, Abnormal, Interventions

Important Facts

• NORMAL BASELINE FHR is 110-160 bpm (fetal heart beats FASTER than adult due to smaller stroke volume).
• MODERATE BASELINE VARIABILITY (6-25 bpm) is reassuring — indicates intact fetal autonomic nervous system and good oxygenation.
• ABSENT or MINIMAL VARIABILITY (<5 bpm) is concerning — suggests fetal hypoxia, hypoglycemia, or neurologic compromise.
• ACCELERATIONS are the BEST sign of fetal well-being — transient FHR rise ≥15 bpm for ≥15 seconds.
• EARLY DECELERATIONS mirror contractions (benign head compression) — NO intervention needed; reassure mother.
• VARIABLE DECELERATIONS are abrupt, can occur anytime, and suggest cord compression — REPOSITION mother (left lateral, knee-chest), APPLY OXYGEN, and CHECK for cord prolapse.
• LATE DECELERATIONS are ominous — indicate uteroplacental insufficiency and fetal hypoxia — IMMEDIATE intervention required.
• LOSS OF VARIABILITY + LATE DECELERATIONS = severe fetal distress — emergency delivery may be necessary.
• Always check FHR immediately after RUPTURE OF MEMBRANES (risk of cord prolapse); if severe variable decelerations, suspect cord prolapse.

Key Definitions

Diagrams To Know

• FHR patterns: baseline, accelerations, early decelerations (benign, mirror contractions), variable decelerations (abrupt, variable timing), late decelerations (ominous, delayed onset/offset).

Common Values

Section Title

Intrauterine Resuscitation Bundle — Fetal Distress Priority Actions

Important Facts

• PRIORITY BUNDLE for late or variable decelerations (fetal distress):
• 1. STOP OXYTOCIN immediately — remove the cause of hyperstimulation.
• 2. REPOSITION mother to LEFT LATERAL (or knee-chest if cord prolapse suspected) — improve placental perfusion, relieve cord compression.
• 3. APPLY OXYGEN via mask, 8-10 L/min — increase fetal oxygen availability.
• 4. INCREASE IV FLUIDS — correct maternal hypotension and improve placental perfusion.
• 5. NOTIFY PHYSICIAN IMMEDIATELY — may need emergency delivery.
• EARLY DECELERATIONS (benign head compression) — NO intervention; reassure mother.
• VARIABLE DECELERATIONS — apply bundle above; check for nuchal cord or cord prolapse.
• LATE DECELERATIONS + any loss of variability = URGENT; prepare for emergency delivery (likely C-section or assisted vaginal).
• MECONIUM-STAINED FLUID (greenish colour) signals possible fetal distress — increase monitoring frequency; meconium aspiration is risk if newborn depressed at delivery.
• Do NOT panic; perform actions sequentially but rapidly; communicate with team and mother.

Key Definitions

Diagrams To Know

• Fetal distress response algorithm: Detect abnormal FHR → STOP oxytocin → Reposition (left lateral) → Oxygen 8-10 L/min → IV fluids → Notify MD → Consider emergency delivery.

Common Values

Section Title

Contraction Assessment & Uterine Activity Monitoring

Important Facts

• NORMAL contractions in latent phase: frequency 2-3/10 min, duration 20-40 sec, mild intensity, rest 5-10 min.
• NORMAL contractions in active phase: frequency 3-5/10 min, duration 40-60 sec, moderate-strong intensity, rest 2-5 min.
• NORMAL contractions in transition: frequency 5-7/10 min (or more), duration 60-90 sec, strong intensity, rest <2 min.
• HYPERSTIMULATION is defined as: contractions ≤2 min apart OR duration >90 sec OR resting tone never returns to baseline OR >5 contractions in 10 min.
• HYPERSTIMULATION is an ADVERSE EFFECT of oxytocin; STOP infusion immediately, reposition, apply oxygen, increase fluids.
• RISK of hyperstimulation: fetal hypoxia, uterine rupture, placental abruption, and fetal trauma.
• ASSESS CONTRACTIONS every 30 min in latent, every 15-30 min in active, and continuously (or every 5-15 min) in transition/second stage.
• STRONG contractions with no cervical change (arrest of labour) = dystocia; evaluate the 5 Ps; may need augmentation or delivery.

Key Definitions

Diagrams To Know

• Contraction pattern chart: shows frequency (time from start to start), duration (onset to offset), intensity, and rest period.

Formulas

Common Values

Section Title

Oxytocin (Pitocin) — Induction, Augmentation, & Safety

Important Facts

• OXYTOCIN IS A HIGH-ALERT MEDICATION — errors can cause severe maternal/fetal harm.
• Induction/augmentation requires PHYSICIAN ORDER and documentation of indication, baseline FHR, and contraction status.
• ALWAYS use an INFUSION PUMP for titration; NEVER rapid IV push.
• Start at lowest dose (0.5-2 mU/min); increase GRADUALLY (1-2 mU/min every 30-60 min) until adequate labour achieved.
• STOP oxytocin immediately if: (1) hyperstimulation (contractions <2 min apart, >90 sec, or no rest), (2) late decelerations or variable decelerations, (3) fetal distress signs, (4) hypertension, (5) uterine rupture signs (sudden severe pain, loss of contractions, fetal distress).
• SIDE EFFECTS of oxytocin: hypertension, uterine hyperstimulation, uterine rupture, water intoxication (if diluted in hypotonic solution), nausea, vomiting.
• CONTRAINDICATIONS to induction: placenta previa, vasa previa, umbilical cord prolapse, active genital herpes, abnormal FHR, prior uterine rupture (relative).
• After delivery, give oxytocin (10 units IM or 10-20 units in IV fluids) to contract uterus and prevent postpartum haemorrhage (uterine atony is leading cause of PPH).
• Do NOT give oxytocin if there is concern for retained twin or undelivered placenta — risk of placental abruption.

Key Definitions

Diagrams To Know

• Oxytocin titration protocol: start 0.5-2 mU/min → increase 1-2 mU/min every 30-60 min → target frequency 3-5 contractions/10 min → stop if hyperstimulation/distress.

Common Values

Section Title

Analgesia & Anaesthesia in Labour — Types, Risks, Nursing Care

Important Facts

• EPIDURAL ANALGESIA — advantages: excellent pain relief, woman awake and can hear baby cry, minimal neonatal effects, can be titrated or stopped if side effects.
• EPIDURAL RISKS: maternal hypotension (MOST COMMON) → reduced placental perfusion and fetal distress; prevent with IV fluid bolus (~500-1000 mL) BEFORE placement.
• EPIDURAL HYPOTENSION management: position mother LEFT LATERAL, increase IV fluids, apply oxygen, administer vasopressor (e.g., ephedrine) if ordered.
• EPIDURAL SIDE EFFECTS: hypotension, headache (post-dural puncture headache if dura punctured), urinary retention (catheterization often needed), lower-extremity weakness (expected with local anesthetic), delayed labour progress.
• SYSTEMIC OPIOIDS (meperidine, nalbuphine) — advantages: easier access, no special procedure, some pain relief.
• SYSTEMIC OPIOIDS — AVOID close to delivery (within ~1-4 hours); risk of neonatal respiratory depression; if given, have NALOXONE (Narcan) ready for newborn (0.1 mg/kg IV or IM).
• NON-PHARMACOLOGIC pain relief: continuous labour support (doula/companion reduces pain perception and analgesia needs), breathing techniques (Lamaze), ambulation, position changes, hydrotherapy (shower/bath if labour advanced), massage, counter-pressure, hypnobirthing.
• NITROUS OXIDE (laughing gas) — self-administered mask; provides mild analgesia and sedation; woman controls frequency; minimal fetal effects; no urgent need for naloxone.
• LOCAL / PUDENDAL BLOCK — used for perineal anaesthesia during delivery and episiotomy repair; minimal systemic absorption; safe for neonate.

Key Definitions

Diagrams To Know

• Analgesia options in labour: non-pharmacologic (continuous support, breathing, positions, hydrotherapy) → systemic opioids (mild-moderate pain relief, caution near delivery) → regional (epidural, spinal) → local blocks (perineal).

Section Title

Rupture of Membranes (ROM) — Assessment, Cord Prolapse Risk, Infection Risk

Important Facts

• On RUPTURE OF MEMBRANES, perform these STEPS immediately: (1) NOTE time, colour, odour, amount, (2) CHECK FETAL HEART RATE (risk of cord prolapse, especially if high station), (3) if meconium present, note degree of staining; (4) if foul odour, suspect infection.
• NORMAL amniotic fluid is clear or slightly milky; may have white specks of vernix (fetal skin coating).
• MECONIUM-STAINED FLUID (green/brown) — monitor closely; if variable or late decelerations develop, apply resuscitation bundle; alert paediatrician.
• FOUL-SMELLING FLUID — suspect chorioamnionitis (uterine infection); assess maternal temperature, WBC, take cultures, inform physician (may need antibiotics and expedited delivery).
• CORD PROLAPSE RISK is HIGH if: (1) ROM occurs before engagement (high station), (2) breech or transverse lie, (3) multiple pregnancy, (4) polyhydramnios (excess fluid).
• If CORD VISIBLE / PALPABLE after ROM: EMERGENCY — (1) place mother in KNEE-CHEST position (or Trendelenburg), (2) PUSH presenting part off the cord with a gloved hand, (3) GIVE OXYGEN, (4) CALL EMERGENCY (likely emergency C-section), (5) do NOT attempt to push cord back in; keep it MOIST (don't let it dry out/vasoconstrict).
• RISK OF INFECTION increases after ROM: avoid repeated vaginal exams (limit to 1-2 per shift unless clinically indicated); if labour does not progress within 12-24 hours (variable per protocol), physician may consider induction or C-section.
• SPONTANEOUS ROM in latent phase — if no contractions, typically observe ≤12-24 hrs for labour onset; if no labour, induction usually offered (risk of infection increases with time).
• PROLONGED ROM (>18-24 hrs) — increased risk of maternal/fetal infection (sepsis); antibiotics and labour induction typically offered.

Key Definitions

Diagrams To Know

• Cord prolapse emergency response: Detect cord prolapse → Knee-chest position → Lift presenting part → Oxygen → Call emergency → Prepare for immediate delivery.

Common Values

Section Title

Third Stage (Placental Delivery) — Signs of Separation, Controlled Cord Traction, Inspection

Important Facts

• THIRD STAGE begins after delivery of baby; typically lasts 5-30 minutes (can extend to 60 min).
• WAIT for signs of placental separation — do NOT pull cord aggressively or too early; risk of uterine inversion, retained placenta, and haemorrhage.
• SIGNS OF SEPARATION are: (1) SUDDEN gush of vaginal blood (may be 100-500 mL), (2) umbilical cord lengthens (usually 2-3 cm), (3) uterus becomes GLOBULAR and FIRM (not soft/boggy), (4) fundus rises above umbilicus.
• If NO signs of separation after ~10-15 minutes, WAIT longer or inform physician (may have retained placenta / placenta accreta).
• CONTROLLED CORD TRACTION: (1) ensure uterus is CONTRACTED (firm), (2) apply counter-traction on fundus with other hand, (3) gently pull cord in downward direction, (4) as placenta descends, support it in a dish; (5) do NOT pull cord without contracted uterus — risk of inversion.
• DO NOT use PASSIVE traction (just pulling on cord without counter-traction) — risk of cord breakage and inversion.
• After placenta delivers, INSPECT it thoroughly for completeness: (1) all cotyledons present (should look like a complete, intact disc), (2) membranes intact (if torn, fragments may be retained in uterus), (3) note any abnormalities (placenta previa, abruption, infarcts).
• RETAINED PLACENTA or RETAINED PRODUCTS — if placenta not delivered by 30-60 min, physician may perform manual removal (under anaesthesia) or evacuate retained products (curettage).
• SCHULTZE (shiny fetal side first) is more common (~80%) and has less bleeding; DUNCAN (dull maternal side first) is normal variant (~20%) but may have more oozing.
• After placenta delivery, assess uterus — should be FIRM and CONTRACTED; if boggy/soft, uterine atony → massage fundus and give oxytocic.

Key Definitions

Diagrams To Know

• Third stage sequence: signs of placental separation → controlled cord traction with contracted uterus → placenta delivery (Schultze or Duncan) → inspection for completeness → uterine assessment.

Common Values

Section Title

Fourth Stage (Recovery/Observation) — PPH Risk, Fundal Assessment, Vital Signs

Important Facts

• FOURTH STAGE = highest risk for PPH; assess FUNDUS, LOCHIA, PERINEUM, VITAL SIGNS, and BLADDER every 15 minutes for first 1-2 hours.
• NORMAL LOCHIA in first hours: bright red, moderate amount (soaks 1-2 pads/hour is normal; >2 pads/hour suggests excessive bleeding), contains clots (<golf-ball sized are normal; larger clots concerning).
• FIRST SIGN OF UTERINE ATONY: BOGGY (soft, spongy) FUNDUS — NOT firm and contracted. Immediate action: MASSAGE fundus firmly, give OXYTOCIC (10 units IM or in IV fluids), assess bladder (full bladder impedes contraction), increase IV fluids.
• NORMAL FUNDUS in fourth stage: FIRM, MIDLINE (not deviated), at or BELOW the umbilicus, NON-tender.
• RISK FACTORS for PPH (uterine atony): prolonged labour, rapid labour, multiparity, overdistended uterus (polyhydramnios, large baby), retained placenta, infection, placental abruption, uterine fibroid.
• MASSIVE PPH protocol: (1) call for help/emergency, (2) two large-bore IVs, (3) rapid IV fluids, (4) massage fundus, (5) check/empty bladder, (6) oxytocin, (7) notify physician, (8) prepare for possible blood transfusion, surgery (hysterectomy if oxytocin/massage fail).
• VITAL SIGNS in PPH: tachycardia (>100 bpm), hypotension, tachypnoea, pallor, cold/clammy skin, reduced urine output.
• FULL BLADDER impedes uterine contraction — always empty bladder (catheterise if needed) before leaving fourth stage; a full bladder is easily palpable above fundus and is firm.
• CHILL/SHIVERING in early postpartum is NORMAL (not necessarily infection); provide blankets; monitor temperature.
• After 1-2 hours in fourth stage with stable vitals, normal fundus, and moderate lochia, woman can move to postpartum ward; continue frequent fundal checks (every 2-4 hours) first 24 hours.

Key Definitions

Diagrams To Know

• Fourth stage assessment protocol: every 15 min for 1-2 hrs → fundus (firm, midline, at/below umbilicus) + lochia (bright red, moderate clots) + vitals (normal BP/HR/temp) + perineum (intact or sutured) + bladder (empty) → if any concern, intervene immediately.

Common Values

Section Title

Unang Yakap (EINC — Essential Intrapartum and Newborn Care)

Important Facts

• UNANG YAKAP has FOUR core steps, all TIME-BOUND:
• 1. IMMEDIATE and THOROUGH DRYING (within first seconds) — removes amniotic fluid, stimulates breathing, prevents heat loss/hypothermia.
• 2. EARLY SKIN-TO-SKIN CONTACT — place dried baby PRONE on mother's abdomen/chest, cover loosely (baby should touch mother's skin); promotes warmth, bonding, and instinctive crawling/breastfeeding.
• 3. DELAYED CORD CLAMPING — clamp and cut cord AFTER pulsations stop (approximately 1-3 minutes); improves newborn iron stores, reduces anaemia risk (critical in resource-limited settings).
• 4. NON-SEPARATION for EARLY BREASTFEEDING — keep mother and baby together; support breastfeeding initiation within first hour (baby often crawls and latches spontaneously; this is golden window for imprinting).
• UNANG YAKAP ALSO AVOIDS: (1) unnecessary suctioning of newborn (if breathing/crying, DO NOT suction; only suction if clear aspiration risk), (2) routine eye prophylaxis if direct observation ongoing, (3) early bathing (bathe after temp stabilised), (4) routine separation/rooming-in policies.
• BENEFITS of skin-to-skin contact: (1) thermal regulation (mother's body warms baby; baby's temperature monitored continuously by mother), (2) improved breastfeeding success and milk supply, (3) reduced neonatal stress/crying, (4) enhanced maternal-infant bonding and oxytocin release (helps mother's uterus contract → less PPH).
• BENEFITS of delayed cord clamping: (1) additional 40-100 mL blood volume to newborn, (2) improved haemoglobin and iron stores (especially important in developing countries), (3) reduced anaemia in infancy, (4) NO increased risk of polycythaemia or jaundice when clamp delayed to cord stop pulsing.
• COMPLICATIONS of PREMATURE cord clamping: (1) reduced blood volume to baby, (2) lower haemoglobin, (3) increased risk of anaemia in infancy, (4) potential neurodevelopmental impact.
• EARLY BREASTFEEDING (first hour): baby has natural rooting/sucking reflexes; skin-to-skin facilitates crawling and self-attachment; colostrum (first milk) is rich in antibodies and nutrients; stimulates uterine contraction and reduces PPH.
• UNANG YAKAP is a WHO/UNICEF global recommendation and is the DOH standard in Philippines — all birth attendants must be trained and implement it.

Key Definitions

Diagrams To Know

• Unang Yakap sequence: Baby born → Immediate thorough drying (first seconds) → Early skin-to-skin (mother's chest, prone) → Delayed cord clamping (1-3 min until pulsations stop) → Early breastfeeding initiation (first hour) → Non-separation, bonding continues.

Formulas

Common Values

Section Title

Apgar Score & Initial Newborn Assessment

Important Facts

• APGAR SCORE components:
• • APPEARANCE: 0 = pale/blue, 1 = acrocyanosis (blue extremities), 2 = completely pink.
• • PULSE: 0 = absent, 1 = <100 bpm, 2 = ≥100 bpm.
• • GRIMACE: 0 = no response, 1 = grimace only, 2 = cough/sneeze/cry.
• • ACTIVITY: 0 = limp/no tone, 1 = some flexion, 2 = active, well-flexed.
• • RESPIRATION: 0 = absent, 1 = weak/slow, 2 = vigorous cry.
• SCORING: Total each component (0-2 points each) → Apgar range is 0-10.
• AT 1 MINUTE: Apgar 7-10 = reassuring, 4-6 = moderately depressed (may need initial resuscitation), 0-3 = severely depressed (resuscitation needed).
• AT 5 MINUTES: Apgar 7-10 = reassuring, 4-6 = moderate depression (continue resuscitation), 0-3 = severe depression (prepare for intensive resuscitation/NICU).
• REPEAT Apgar at 10 minutes if Apgar <7 at 5 minutes.
• Do NOT delay RESUSCITATION while calculating Apgar; begin based on clinical signs (no cry, pale/blue, limp). Apgar is a SUMMARY, not a TRIGGER for resuscitation start.
• Common causes of LOW APGAR: maternal anesthesia (opioids), intrauterine hypoxia, prematurity, meconium aspiration, sepsis, congenital anomaly.
• CORD BLOOD SAMPLING: arterial and venous cord blood gases may be collected if delivery is operative (forceps, vacuum), low Apgar, or maternal complications; used to assess fetal acidosis/hypoxia.

Key Definitions

Diagrams To Know

• Apgar scoring table: Appearance (0=pale/blue, 1=acrocyanosis, 2=pink) | Pulse (0=absent, 1=<100, 2=≥100) | Grimace (0=none, 1=grimace, 2=cry) | Activity (0=limp, 1=flexion, 2=active) | Respiration (0=absent, 1=weak, 2=vigorous) = total.

Common Values

Section Title

Nursing Care by Stage — Key Interventions & Assessments

Important Facts

• ADMISSION AND FIRST STAGE — ASSESSMENT:
• 1. Confirm TRUE labour (check cervical change) vs false labour.
• 2. Obtain OBSTETRIC HISTORY: gravidity, parity, estimated date of delivery (EDD), complications, medications, allergies, past deliveries.
• 3. Perform LEOPOLD'S MANOEUVRES (4 steps): palpate fundus (identify upper pole — head or buttock?), lateral sides (locate back/small parts), suprapubic (presenting part/engagement), inguinal ligament area (moveable/fixed?).
• 4. Perform STERILE VAGINAL EXAM: cervical dilation, effacement, cervical consistency, station, presenting part, membrane status, presence of cord.
• 5. LIMIT VAGINAL EXAMS after ROM (infection risk); only as clinically indicated.
• FIRST STAGE — NURSING CARE:
• • LATENT PHASE: encourage ambulation, position changes, hydration (light snacks allowed), shower/bath, rest if needed; supportive environment; assess FHR every 30 min.
• • ACTIVE PHASE: continue support, assist with positioning, assess FHR every 15-30 min, assess contractions every 15-30 min, bladder care (empty frequently to avoid obstruction), consider analgesia, continue hydration.
• • TRANSITION PHASE: continuous support, frequent position changes, assess FHR every 5-15 min (or continuously if high risk), assess contractions frequently, prepare for second stage, remind mother NOT to push yet (if not fully dilated), prepare delivery supplies.
• On RUPTURE OF MEMBRANES: note time, colour, odour, amount; CHECK FHR immediately (cord prolapse risk); assess for meconium or foul odour; limit further exams.
• If MECONIUM-STAINED FLUID: increase FHR monitoring, alert paediatrician, prepare for possible suctioning if baby depressed at delivery.
• If CORD PROLAPSE (visible/palpable): emergency response (knee-chest, lift presenting part, oxygen, call MD).
• SECOND STAGE — PREPARATION & CARE:
• 1. Prepare delivery field (sterile field, delivery pack, suction, resuscitation equipment ready).
• 2. Assist with EFFECTIVE PUSHING only when fully dilated (10 cm); teach open-glottis pushing (better oxygenation for baby than breath-holding).
• 3. Support maternal position (squatting, semi-recumbent, side-lying — whatever promotes descent and comfort).
• 4. As CROWNING approaches: prepare perineal support, prepare for controlled delivery of head.
• 5. Check for NUCHAL CORD (cord around baby's neck); if loose, slip over head; if tight, clamp and cut before delivering body.
• 6. After head delivers: CHECK for tight nuchal cord, suction mouth/nose ONLY if meconium present and baby not vigorous, support head, deliver shoulders with gentle downward then upward traction, deliver body.
• 7. NOTE EXACT TIME OF DELIVERY, place baby on mother's abdomen or chest (depending on cord length/placental position), proceed with Unang Yakap.
• 8. Assign APGAR SCORES at 1 and 5 minutes.
• THIRD STAGE — CARE:
• 1. WAIT for signs of placental separation; do NOT rush cord traction.
• 2. After separation signs present: perform CONTROLLED cord traction (counter-traction on fundus, gentle downward pull on cord with contracted uterus).
• 3. Support placenta in dish/bowl as it delivers.
• 4. INSPECT placenta for completeness, intact membranes, abnormalities; note appearance (Schultze vs Duncan).
• 5. Assess UTERUS for firmness; if boggy, massage fundus; give OXYTOCIN per protocol.
• FOURTH STAGE — ASSESSMENT & MONITORING:
• 1. Assess every 15 minutes for first 1-2 hours:
• • FUNDUS: firm, midline, at/below umbilicus, non-tender.
• • LOCHIA: bright red, moderate amount (1-2 pads/hr normal), <golf-ball sized clots normal.
• • PERINEUM: intact, sutured, any swelling/haematoma, pain level.
• • VITAL SIGNS: BP, HR, temp, respirations (watch for tachycardia/hypotension/fever as signs of PPH/infection).
• • BLADDER: empty (palpate, assess voiding); full bladder impedes contraction.
• 2. If uterus becomes BOGGY: MASSAGE fundus, assess bladder, give OXYTOCIN, increase IV fluids, notify MD if not improving.
• 3. If EXCESSIVE LOCHIA (>2 pads/hr): assess fundus, check for retained products, notify MD.
• 4. BONDING & BREASTFEEDING: support early breastfeeding, skin-to-skin contact, answer questions.

Key Definitions

Diagrams To Know

• Leopold's Manoeuvres: 1st step (fundus — upper pole ID) → 2nd step (lateral sides — back location) → 3rd step (suprapubic — engagement) → 4th step (inguinal — moveable or fixed?).

Item

NORMAL BASELINE FHR is 110-160 bpm (NOT 60-100 like adults). Moderate variability is reassuring. EARLY decel = benign (head compression); LATE decel = ominous (uteroplacental insufficiency) — apply resuscitation bundle immediately.

Rank

1

Item

CERVICAL CHANGE (dilation and effacement) is the DEFINITIVE sign of true labour. True labour contractions INTENSIFY with walking; false labour ease with activity.

Rank

2

Item

CARDINAL MOVEMENTS mnemonic: Engagement, Descent, Flexion, Internal Rotation, Extension, Restitution (External Rotation), Expulsion (EDFIREX). Internal rotation typically rotates LOA → OA, aligning fetus with pelvic outlet.

Rank

3

Item

FETAL DISTRESS PRIORITY BUNDLE: STOP oxytocin → Reposition LEFT LATERAL → Oxygen 8-10 L/min → Increase IV fluids → Notify physician. Do these RAPIDLY.

Rank

4

Item

OXYTOCIN for induction/augmentation is a HIGH-ALERT drug: use infusion pump, titrate starting 0.5-2 mU/min, increase 1-2 mU/min every 30-60 min. NEVER IV PUSH. Stop immediately if hyperstimulation (<2 min apart, >90 sec, no rest) or fetal distress.

Rank

5

Item

EPIDURAL ANALGESIA main risk is MATERNAL HYPOTENSION. Prevent with IV fluid bolus 500-1000 mL BEFORE placement. Treat hypotension with LEFT LATERAL position, fluids, oxygen, and vasopressor if ordered.

Rank

6

Item

On RUPTURE OF MEMBRANES: immediately NOTE time/colour/odour/amount, then CHECK FHR (cord prolapse risk). If MECONIUM-STAINED (green), alert paediatrician. If CORD PROLAPSE, emergency response: knee-chest, lift presenting part, oxygen, call MD.

Rank

7

Item

UNANG YAKAP (EINC) — four time-bound core steps: (1) immediate thorough drying, (2) early skin-to-skin contact, (3) delayed cord clamping (1-3 min until pulsations stop), (4) non-separation for early breastfeeding within first hour.

Rank

8

Item

FOURTH STAGE = highest PPH risk. FIRST SIGN of uterine atony is BOGGY (soft) fundus — MASSAGE immediately, assess bladder, give oxytocin, increase fluids. Assess fundus, lochia, vitals, bladder every 15 min for first 1-2 hours.

Rank

9

Item

APGAR SCORE at 1 and 5 minutes: 7-10 = reassuring, 4-6 = moderate depression, 0-3 = severe (resuscitation needed). Components: Appearance, Pulse, Grimace, Activity, Respiration (each 0-2 points).

Rank

10

Tip

LATE DECELERATIONS are OMINOUS — this is the most tested dangerous pattern on NLE. Remember: late decel = DELAY in onset/offset (starts AFTER contraction peak, ends AFTER contraction ends). Cause = uteroplacental insufficiency (hypoxia). Action = FULL resuscitation bundle (stop oxytocin, reposition, oxygen, fluids, call MD). Early decel (mirrors contraction) = benign; no intervention. Variable (abrupt, variable timing) = cord compression; reposition and watch.

Tip Number

1

Tip

OXYTOCIN dosing errors are high-yield NLE items. Remember: ALWAYS infusion pump (NEVER push), START 0.5-2 mU/min, INCREASE 1-2 mU/min EVERY 30-60 MIN. Hyperstimulation = <2 min between contractions OR >90 sec duration OR no rest between contractions → STOP immediately. If you see a question asking 'what is appropriate oxytocin management' or 'what's wrong with giving oxytocin IV push,' these are your answers.

Tip Number

2

Tip

The Five Ps are fundamental to understanding labour progress. If a question describes a difficult labour ('Why is labour not progressing?'), think through each P: Passenger (size, position, flexion), Passage (pelvis shape/adequacy), Powers (contraction strength/frequency), Position (maternal upright?), Psyche (fear, pain). Most NLE questions test if you can identify which P is abnormal.

Tip Number

3

Tip

UNANG YAKAP is DOH protocol — NLE questions love this. Key facts: (1) IMMEDIATE drying (first seconds), (2) SKIN-TO-SKIN on mother's bare chest (not wrapped separately), (3) DELAYED cord clamping (wait 1-3 min until pulsations STOP, not just 30 sec), (4) EARLY breastfeeding (first hour is golden window). Memorise these as FOUR STEPS with TIME frames.

Tip Number

4

Tip

FOURTH STAGE is the PPH danger zone. NLE frequently asks: 'What's the FIRST sign of uterine atony?' Answer: BOGGY (soft, non-contracted) fundus. Next action: MASSAGE the fundus firmly FIRST, then assess bladder (full bladder prevents contraction). If you see lochia >2 pads/hr, assess fundus — if boggy, massage. This is a critical assessment skill tested repeatedly.

Tip Number

5

Rows

Columns

• Feature
• True Labour
• False Labour (Braxton Hicks)

Table Title

True Labour vs False Labour

Rows

Columns

• Feature
• Early Deceleration
• Variable Deceleration
• Late Deceleration

Table Title

Early vs Variable vs Late Decelerations

Rows

Columns

• Phase
• Cervical Dilation
• Contraction Pattern
• Duration (Primigravida)
• Maternal Behaviour

Table Title

First Stage Phases — Cervical Dilation, Duration, Contractions, Maternal Behaviour

Rows

Columns

• Feature
• Epidural Analgesia
• Systemic Opioids (e.g., meperidine, nalbuphine)

Table Title

Epidural vs Systemic Opioids — Efficacy, Risks, Neonatal Effects, Timing