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HEALTH ASSESSMENT OF THE INTRANATAL WOMAN - Complete Viva Guide

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1. IDENTIFICATION AND ASSESSMENT OF A WOMAN IN LABOUR

Definition of Labour

True vs. False Labour (Differential Diagnosis)

Signs of True Labour

1. Painful, regular uterine contractions - initially every 10-15 min, progressing to every 2-3 min
2. Bloody show - pink/blood-tinged mucous discharge (operculum)
3. Progressive cervical effacement and dilatation
4. Descent of presenting part
5. Rupture of membranes (may occur before or during labour)

Stages of Labour

• First stage: Onset of true labour to full cervical dilatation (10 cm)
  • Latent phase: 0-3 cm dilatation (up to 8-20 hours in primigravida)
  • Active phase: 3-10 cm dilatation (rate: 1 cm/hour in primigravida, 1.5 cm/hour in multigravida)
• Second stage: Full dilatation to delivery of baby (up to 2 hours in primigravida, 1 hour in multigravida)
• Third stage: Delivery of baby to delivery of placenta (up to 30 minutes)
• Fourth stage: First 1-2 hours postpartum (observation for complications)

Assessment Parameters

• Frequency, duration, and intensity of contractions
• Fetal heart rate (FHR)
• Cervical status (effacement, dilatation, position, consistency)
• Presenting part, station, position
• Status of membranes
• Maternal vital signs

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2. ADMISSION OF WOMAN IN LABOUR

Objectives of Admission Assessment

• Confirm onset of true labour
• Assess maternal and fetal well-being
• Identify risk factors and complications
• Establish baseline findings for monitoring
• Plan individualized care

History Taking at Admission

1. Personal details: Name, age, parity, gestational age
2. Chief complaint: Onset, duration, and nature of contractions; show; leaking per vaginum
3. Obstetric history: G/P/A/L (gravida, para, abortions, living children), last menstrual period (LMP), expected date of delivery (EDD)
4. Current pregnancy details: Antenatal care (ANC) visits, reports (USG, blood group, Hb, VDRL, HIV)
5. Past medical/surgical history: Hypertension, diabetes, previous caesarean, uterine surgeries
6. Drug allergies
7. Last oral intake (important for anaesthesia if needed)

Physical Examination

• General condition (well/ill-looking, anxiety level)
• Vital signs: BP, pulse, temperature, respiratory rate, SpO2
• Pallor, oedema, jaundice
• Height and weight

• Inspection: Shape/size of abdomen, linea nigra, striae, scars
• Fundal height: Corresponds to gestational age
• Leopold's manoeuvres (4 manoeuvres):
  1. Fundal grip: Identify what is in the fundus (breech = soft, irregular; head = hard, round, ballotable)
  2. Lateral/umbilical grip: Identify fetal back (smooth, resistant) and limbs (knobby, irregular)
  3. Pawlik's grip: Identify presenting part above symphysis pubis
  4. Pelvic grip (deep pelvic): Confirm presenting part, assess engagement (5/5 = not engaged, 0/5 = fully engaged)
• Fetal heart rate: Auscultate with Pinard stethoscope or Doppler (normal: 110-160 bpm)
• Uterine contractions: Frequency, duration, intensity (palpation - mild/moderate/strong)

Investigations at Admission

• Urine: albumin, sugar, ketones
• Blood: Hb, blood group, Rh type (if not previously done)
• Blood pressure charting
• Review ANC records

Nursing Care at Admission

• Receive patient warmly, reduce anxiety
• Provide identification band
• Ensure privacy during examination
• Explain all procedures
• Inform and involve support person/family
• Record all findings in admission notes / case record
• Initiate CTG if indicated
• IV access if high-risk
• Restrict oral intake as per protocol (sips of water allowed in active labour by most guidelines)
• Encourage ambulation in latent phase
• Inform obstetrician of high-risk cases

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3. PERFORMING / ASSISTING CTG (CARDIOTOCOGRAPHY)

Definition

Types

1. External (Non-Stress Test - NST / External EFM):
   • Transducer placed on abdomen
   • No need to rupture membranes
   • Most common in labour
2. Internal EFM:
   • Fetal scalp electrode (FSE) for FHR
   • Intrauterine pressure catheter (IUPC) for contractions
   • Requires ruptured membranes and engaged head

Indications for CTG

• Previous caesarean section
• Meconium-stained liquor
• Oxytocin augmentation/induction
• Epidural analgesia
• High-risk pregnancy (hypertension, diabetes, IUGR, post-dates, preeclampsia, antepartum haemorrhage, multiple pregnancy)
• Prolonged labour
• Preterm labour
• Pyrexia in labour

• Reduced fetal movements
• Suspected fetal compromise

Equipment Required

• CTG machine (electronic fetal monitor)
• Ultrasound transducer (for FHR)
• Tocodynamometer/toco transducer (for contractions)
• Straps/belts
• Ultrasound gel
• CTG paper
• Patient ID stickers
• IV trolley (if required)

Procedure for Performing CTG

1. Explain procedure to the woman; obtain consent
2. Ensure privacy and comfort
3. Position: Semi-recumbent (45 degrees) or left lateral (to avoid aortocaval compression)
4. Wash hands

1. Switch on the CTG machine; enter patient details (name, age, date, time, gestation)
2. Apply gel on the ultrasound transducer
3. Locate the fetal back using Leopold's manoeuvres
4. Place the ultrasound transducer on the area where FHR is best heard (usually below umbilicus on fetal back side); secure with belt
5. Place the tocodynamometer over the uterine fundus (firmest part for contractions); secure with belt
6. Confirm FHR signal on the machine display
7. Set baseline on tocodynamometer to zero between contractions
8. Press the start button; ensure paper is running (standard speed: 1 cm/min)
9. Document maternal pulse every 15-30 minutes
10. Record for minimum 20-30 minutes (antenatal) or continuously in active labour

• Mark events on the trace (maternal movement, contractions felt, pushing, vaginal examination)
• Document maternal vitals
• Observe for aortocaval compression; encourage left lateral tilt if needed

CTG Interpretation (FIGO / NICE Classification)

• DR - Define Risk (maternal and fetal)
• C - Contractions
• BR - Baseline Rate
• A - Accelerations
• V - Variability
• D - Decelerations
• O - Overall impression

1. Baseline Fetal Heart Rate

• Normal: 110-160 bpm
• Bradycardia: < 110 bpm
• Tachycardia: > 160 bpm

2. Baseline Variability

• Normal: 5-25 bpm (fluctuations in FHR amplitude)
• Reduced/Absent: < 5 bpm (for > 40 minutes) - concerning
• Marked: > 25 bpm

3. Accelerations

• Rise in FHR of ≥ 15 bpm above baseline, lasting ≥ 15 seconds
• Presence = reassuring (indicates fetal well-being)
• Reactive CTG: ≥ 2 accelerations in 20 minutes

4. Decelerations

CTG Classification (NICE 2022)

• Normal: All 4 features normal
• Suspicious: 1 non-reassuring feature
• Pathological: 2+ non-reassuring features or 1 abnormal feature

Actions for Abnormal CTG

1. Inform senior midwife/obstetrician immediately
2. Change maternal position to left lateral
3. Stop oxytocin if running
4. IV fluids (correct dehydration)
5. O2 via face mask (controversial but used in some settings)
6. Fetal blood sampling (FBS) or expedite delivery based on clinical picture

Documentation

• Record start/end time on trace
• Patient identifiers on paper
• Mark all events (VE, repositioning, medication)
• File trace in case notes with interpretation note

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4. VAGINAL EXAMINATION DURING LABOUR INCLUDING CLINICAL PELVIMETRY

Purpose of Vaginal Examination (VE) in Labour

• Confirm diagnosis of labour
• Assess cervical progress
• Determine presentation, position, and station of presenting part
• Assess status of membranes
• Assess pelvis (clinical pelvimetry)
• Diagnose cord prolapse, malpresentation

Frequency of VE

• On admission
• Every 4 hours in active labour (WHO recommendation) or as clinically indicated
• Before epidural, before pushing, when abnormal CTG, when membranes rupture

Pre-procedure Preparation

• Explain procedure; obtain verbal consent
• Ensure privacy; maintain dignity
• Empty bladder
• Position: Dorsal recumbent (dorsal lithotomy position)
• Wash hands; wear sterile gloves
• Use antiseptic solution for perineal swabbing (if facility practice)

Findings Assessed During VE

A. Cervical Assessment (Modified Bishop's Score)

• Score ≥ 6: Favourable cervix (induction likely to succeed)
• Score < 6: Unfavourable (cervical ripening needed)

B. Presentation

• Cephalic: Head first (most common, 96%)
• Breech: Buttocks/feet first
• Shoulder/transverse

C. Position (in cephalic presentation)

• Anterior fontanelle (bregma): Diamond-shaped, larger, 4 sutures meet
• Posterior fontanelle: Triangular, smaller, 3 sutures meet
• LOA (Left Occipito-Anterior) = most favourable
• ROP, LOP = occipito-posterior positions (may cause prolonged labour)

D. Station

• 0 station = at ischial spines
• -1 to -5 = above spines (in cm)
• +1 to +5 = below spines (engaged and descending)
• Engagement = station 0 or below; head is fixed

E. Status of Membranes

• Intact: Bag of foetal membranes felt as a bulging mass
• Ruptured: Absent bag; liquor may be draining
  • Note color of liquor: Clear (normal), Meconium-stained (amber/green), Bloodstained

F. Cord Presentation / Prolapse

• Cord felt alongside presenting part = prolapse = EMERGENCY (immediate obstetric intervention)

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Clinical Pelvimetry

Definition

Bony Landmarks Assessed

• Diagonal conjugate: Distance from lower border of symphysis pubis to sacral promontory (normal ≥ 12.5 cm; can be felt if < 12 cm - promontory is prominent = contracted)
• True conjugate (obstetric conjugate) = diagonal conjugate - 1.5 cm (normal ≥ 11 cm)

• Ischial spines: Should be blunt (not prominent); prominent spines = contracted midpelvis
• Sacrospinous ligament: Should accommodate ≥ 3 fingers (≥ 4.5 cm); short = contracted
• Sacrum: Should be hollow and curved; flat sacrum = reduced anteroposterior diameter

• Intertuberous diameter: Distance between ischial tuberosities (normal ≥ 8 cm; ≥ 4 knuckles' breadth)
• Sub-pubic angle: Should be > 90 degrees (wide angle = adequate outlet)
• Sacrococcygeal joint: Coccyx should be mobile (immobile = reduces outlet)

Types of Pelvis (Caldwell-Moloy Classification)

Documentation of VE

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5. INTRANATAL CARE

Definition

Goals of Intranatal Care

• Monitor maternal and fetal well-being
• Support progress of labour
• Prevent, identify, and manage complications
• Provide emotional support and reduce anxiety
• Ensure a positive birth experience

Nursing Care During First Stage of Labour

• Uterine contractions: frequency, duration, intensity
• Fetal heart rate (Pinard/Doppler - after each contraction or every 15 min in active phase)
• Maternal vital signs: BP (every 2-4 hours), pulse (every 30 min), temperature (every 4 hours)
• Input/output charting: urine output, IV fluids
• Vaginal examination every 4 hours

• Encourage mobility and position changes (upright positions speed labour)
• Offer pain relief options
• Oral hydration (sips of water/clear fluids)
• Bladder care: encourage voiding every 2 hours (full bladder impedes descent)
• Back massage, encouragement

• Continuous supportive presence (doula/birth companion)
• Information sharing (explain what is happening)
• Address fears and anxieties
• Maintain privacy and dignity

Nursing Care During Second Stage

• Encourage effective pushing with contractions (Valsalva or breathing-down technique)
• Monitor FHR every 5 minutes or after each contraction
• Assist in delivery position of choice
• Perineal support to prevent tears
• Prepare delivery equipment (see Section 7)
• Provide continuous encouragement

Nursing Care During Third Stage (Active Management - AMTSL)

1. Oxytocin 10 IU IM within 1 minute of delivery of baby (drug of choice)
2. Controlled cord traction (Brandt-Andrews technique): apply counter-pressure on lower uterine segment while applying gentle downward traction on clamped cord
3. Uterine massage after placenta is delivered

• Check placenta for completeness (maternal and fetal surfaces)
• Check membranes for completeness
• Inspect perineum, vagina, cervix for lacerations
• Check uterine fundal tone and height

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6. PLOTTING AND INTERPRETATION OF PARTOGRAPH

Definition

Purpose

• Monitor progress of labour
• Early identification of prolonged/obstructed labour
• Reduce maternal and neonatal mortality
• Guide timely decision for referral or intervention

Components of the Partograph

SECTION 1: FETAL CONDITION (Top section)

• Fetal heart rate: Recorded every 30 min (normal 110-160 bpm); plotted as a graph
• Membranes and liquor: I = Intact; C = Clear; M = Meconium; B = Blood; A = Absent (dry)
• Moulding: 0 = No moulding; 1+ = Bones touching; 2+ = Overlapping (reducible); 3+ = Overlapping (fixed) = obstructed labour

SECTION 2: PROGRESS OF LABOUR (Middle section - the key part)

• Cervical dilatation (X): Plotted on the y-axis (0-10 cm); observed 4-hourly
• Descent of head (O): Plotted as fifths of head palpable above pelvic brim (5/5 = fully palpable; 0/5 = not palpable)
• Alert line: Begins at 4 cm dilatation; progresses at 1 cm/hour - represents expected MINIMUM rate of cervical progress
• Action line: Drawn 4 hours to the right of the alert line (WHO modified partograph)
• Uterine contractions per 10 minutes (frequency and duration)

Alert and Action Lines

SECTION 3: MATERNAL CONDITION (Bottom section)

• Vital signs: BP (every 4 hours), pulse (every 30 min), temperature (every 2 hours)
• Urine: Output volume, protein, ketones (every 2 hours)
• Drugs/IV fluids: All medications, dosage, time
• Oxytocin augmentation: Dose, concentration, drip rate

WHO Modified Partograph (Currently Used)

• Starts plotting only when the woman is in the active phase (≥ 4 cm dilatation)
• Eliminates latent phase charting (simplification for resource-limited settings)

Interpretation Points

• Normal labour: X-marks (cervical dilatation) stay to the left of the alert line with regular descent
• Slow progress/prolonged labour: Dilatation curve flattens or crosses the alert line
  • Causes: Inefficient uterine contractions (most common), CPD, malpresentation, malposition
  • Action: Assess cause, consider amniotomy + oxytocin augmentation (if no CPD)
• Obstructed labour: Curve reaches action line, moulding 3+, no descent, late decelerations
  • Action: Emergency caesarean section

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7. PREPARATION FOR BIRTHING / DELIVERY - PHYSICAL AND PSYCHOLOGICAL

Physical Preparation

Maternal Physical Preparation:

1. Empty bladder (catheterize if unable to void)
2. Perineal preparation: Clean perineum with antiseptic lotion; shaving is no longer routinely recommended
3. IV access: Ensure patent IV line (large bore, 18G)
4. Blood drawn for crossmatch if needed
5. Consent obtained for episiotomy (if anticipated), repair, and emergency procedures
6. Positioning: Transfer to delivery table; dorsal lithotomy or upright/squatting if preferred
7. Sterile draping of the delivery field
8. NPO status confirmed
9. Enema is no longer routinely recommended (evidence-based practice)

Equipment and Supplies for Delivery:

• Sterile delivery pack (scissors, needle holder, artery forceps, thumb forceps, kidney trays)
• Sterile gloves (multiple pairs)
• Sterile drapes and leggings
• Episiotomy scissors + suture material (chromic catgut/Vicryl)
• Cord clamp x2, scissors
• Oxytocin 10 IU ampoule and syringe
• Antiseptic solution (povidone iodine)
• Kidney dish for placenta
• Controlled cord traction: sterile gauze

Psychological Preparation

1. Establish rapport: Address the woman by name; introduce all staff attending
2. Explain the process: Tell her what will happen during delivery in simple language
3. Address fears: Listen to anxieties; validate feelings; reassure
4. Involve birth companion: Encourage presence of partner/family/doula if woman wishes
5. Informed consent: Explain all procedures planned and obtain consent
6. Empower the woman: Explain her role in pushing; give breathing instructions
7. Reduce fear-tension-pain cycle (Dick-Read theory): Fear increases tension, which increases pain perception - education and reassurance break this cycle
8. Privacy and dignity: Maintain at all times; only essential personnel in room
9. Cultural sensitivity: Respect cultural and religious preferences

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8. SETTING UP THE BIRTH ROOM / DELIVERY UNIT AND NEWBORN CORNER / CARE AREA

Birth Room / Delivery Unit Setup

Environmental Requirements:

• Warm (temperature 25-28°C, especially for newborn area)
• Well-lit (including focused examination lamp)
• Privacy maintained (screens/curtains)
• Clean and clutter-free
• Emergency call system accessible

Maternal Delivery Area:

• Delivery bed/table with leg rests (stirrups) and adjustable height
• IV stand
• BP apparatus, pulse oximeter, thermometer, stethoscope
• Focused light source (adjustable lamp)
• Suction apparatus (for mother)
• Oxygen source with mask/nasal cannula
• Emergency drug tray: oxytocin, misoprostol, ergometrine, MgSO4, IV fluids
• Foley catheter set
• Sterile delivery pack (as listed in Section 7)
• Episiotomy and repair set
• Specimen containers (for placenta histology, cord blood if needed)
• Sharps disposal container
• Infectious waste bins

CTG / Monitoring Equipment:

• CTG machine in functional condition
• Doppler / Pinard stethoscope
• Partograph chart available

Newborn Corner / Care Area Setup

Essential Equipment for Newborn Corner:

• Radiant warmer / warm cot (pre-warmed before delivery)
• Warm, dry towels (pre-warmed)
• Hat for newborn

• Suction device (bulb syringe or mechanical with 10 Fr catheter)
• Appropriate suction pressures: < 100 mmHg

• Bag and mask (self-inflating bag, 250 mL neonatal; 3 masks sizes: preterm, term, large)
• Oxygen source with flow meter
• Blender (if available)
• Pulse oximeter with neonatal probe

• Neonatal ECG leads or pulse oximeter (for HR assessment during NRP)
• Adrenaline (epinephrine) ampoules
• Syringes (1 mL, 5 mL)
• Umbilical catheter set (for emergency access)

• Cord clamp, scissors (sterile)
• Vitamin K ampoule (1 mg/0.5 mL IM)
• Eye prophylaxis (tetracycline eye ointment or erythromycin)
• Identification bands (for newborn)
• Weight scale
• Measuring tape (for length, head circumference)
• Resuscitation clock / timer
• APGAR chart and documentation forms
• Gloves for all attendants

• Radiant warmer ON and warm
• Suction functioning
• Bag and mask assembled and checked (mask seal tested)
• Oxygen flowing
• Warm towels ready
• Drugs drawn and labelled

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9. PAIN MANAGEMENT DURING LABOUR - NON-PHARMACOLOGICAL

Theoretical Basis

Categories of Non-Pharmacological Pain Relief

A. Psychological / Cognitive Methods

1. Continuous Emotional Support (Doula/Companion):
   • Most evidence-based non-pharmacological method
   • Reduces caesarean rate, reduces analgesia use, shortens labour
   • Birth companion (partner, doula, nurse) provides continuous presence
2. Childbirth Education / Antenatal Classes:
   • Preparatory education reduces fear and improves coping
3. Breathing Techniques (Lamaze Method):
   • Controlled, rhythmic breathing patterns during contractions
   • Relaxation breathing (slow, deep), transitional breathing
4. Guided Imagery and Visualization:
   • Woman focuses on a calming image or peaceful place
5. Hypnobirthing:
   • Self-hypnosis to achieve deep relaxation and positive association with contractions
6. Attention Focussing / Distraction:
   • Music, conversation, meditation apps

B. Physical / Touch Methods

1. Massage and Counterpressure:
   • Lower back massage (sacral pressure) during contractions
   • Firm bilateral hip squeezing reduces sacral pain
   • Perineal massage reduces likelihood of severe perineal tears
2. Therapeutic Touch / Reflexology:
   • Pressure on specific reflex points (feet, hands)
3. Heat Application:
   • Warm packs on lower back, abdomen, perineum
   • Vasodilates tissues, reduces muscle spasm, increases pain threshold
4. Cold Application:
   • Cold compresses to lower back or perineum
5. Hydrotherapy (Water Immersion):
   • Warm bath or shower during first stage of labour
   • Buoyancy reduces musculoskeletal pain; warm water promotes relaxation
   • Evidence: Reduces epidural use; does not increase infection risk with intact membranes
6. Transcutaneous Electrical Nerve Stimulation (TENS):
   • Electrodes on lower back (T10-L1 and S2-S4 dermatomes)
   • Low-level electrical current stimulates Aβ fibres → closes pain gate
   • Safe, woman-controlled, no systemic side effects

C. Positional / Movement Methods

1. Upright Positions and Mobility:
   • Walking, rocking, sitting on birth ball
   • Uses gravity to aid descent of presenting part
   • Reduces duration of first stage, reduces backache
2. Hands-and-Knees / All-Fours Position:
   • Reduces pressure on sacrum; useful for posterior positions (OP)
3. Birth Ball (Pelvic Rocking):
   • Sitting/rocking on gym ball opens pelvic dimensions
   • Encourages rotation of fetal head
4. Squatting:
   • Opens pelvic outlet by up to 28%
   • Gravity-assisted descent
5. Left Lateral Position:
   • Reduces aortocaval compression; improves uteroplacental blood flow

D. Alternative / Complementary Therapies

1. Aromatherapy: Essential oils (lavender, clary sage) for relaxation
2. Acupressure / Acupuncture: Stimulation of SP6 (Sanyinjiao) point
3. Sterile Water Injections: 0.1-0.5 mL sterile water injected intradermally at 4 sacral points; provides relief from back pain (stinging injection blocks pain by gate control)

Benefits of Non-Pharmacological Pain Management

• No systemic effects on mother or fetus
• Promotes active participation and empowerment
• Reduces use of pharmacological analgesia
• Shorter labour, less instrumental delivery
• Improves satisfaction with birth experience

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10. SUPPORTING NORMAL BIRTHS / CONDUCT OF NORMAL CHILDBIRTH IN VARIOUS POSITIONS

Definition of Normal Birth

Evidence-Based Care for Normal Labour (WHO Recommendations 2018)

• Continuous one-to-one midwifery support
• Freedom to mobilize and choose birth position
• Oral fluid intake during labour
• Partograph for monitoring progress
• Active management of third stage (AMTSL)
• Delayed cord clamping (≥ 1 minute after birth)
• Skin-to-skin contact immediately after birth
• Early breastfeeding initiation

• Routine episiotomy
• Routine IV fluids
• Routine enema/perineal shaving
• Routine fetal scalp electrode
• Fundal pressure during second stage (Kristeller manoeuvre)
• Lithotomy as the only available position

Mechanism of Normal Labour (in LOA position)

1. Engagement: Head enters pelvic inlet in transverse/oblique diameter
2. Descent: Progressive descent throughout all stages
3. Flexion: Chin meets chest - smallest diameter (suboccipitobregmatic 9.5 cm) presents
4. Internal Rotation: Occiput rotates anteriorly from LOT/LOA to direct OA position (sagittal suture = AP diameter of outlet)
5. Extension: Head extends under symphysis pubis; brow, nose, mouth, chin are born
6. Restitution: Head rotates back to its natural position (45 degrees)
7. External Rotation: Shoulders rotate to AP diameter; head rotates further
8. Expulsion: Anterior shoulder born under pubic arch; posterior shoulder born; body follows

Conduct of Normal Delivery (Vertex Presentation)

1. Confirm full dilatation (VE)
2. Position woman in position of her choice (see below)
3. Provide encouragement; guide pushing with contractions
4. FHR auscultation after every contraction
5. Wash and don sterile gloves
6. Prepare delivery field with sterile drapes
7. As head crowns:
   • Apply perineal support (left hand over fetal occiput - Ritgen's manoeuvre or modified)
   • Apply downward pressure to prevent rapid extension
   • Guard perineum with right hand (folded sterile towel)
   • Episiotomy ONLY if clinically indicated (severe fetal distress, rigid perineum, large baby, previous third-degree tear)
8. Allow head to deliver slowly between contractions
9. Check for cord around neck - if present, slip over head; if tight, double clamp and cut
10. Wipe face; suction only if meconium/secretions obstruct airway
11. Support head; external rotation occurs
12. Deliver anterior shoulder (gentle downward traction)
13. Deliver posterior shoulder (gentle upward traction)
14. Rest of body delivered
15. Note time of birth
16. Clamp cord (delayed clamping ≥ 1 min recommended)
17. Dry baby; APGAR at 1 and 5 min
18. Skin-to-skin with mother

Birth Positions

1. Dorsal/Supine/Semi-Recumbent

• Traditional position; allows perineal visualization
• Disadvantage: Aortocaval compression, works against gravity
• Modified: Semi-recumbent with head elevated 30-45 degrees

2. Left Lateral (Sims' Position)

• Woman lies on left side with right knee drawn up
• Reduces aortocaval compression
• Slow delivery of head, reduced perineal lacerations
• Good for hypertensive women, epidural anaesthesia

3. Squatting

• Widens pelvic outlet (up to 28%)
• Gravity-assisted
• Good for second stage progress
• Requires support; tiring for prolonged use

4. Kneeling / All-Fours

• Excellent for occipitoposterior positions
• Reduces backache
• Reduces risk of perineal trauma
• Good for shoulder dystocia (McRoberts variation)

5. Standing / Walking

• Gravity assists descent
• Comfortable for some women
• Requires assistant for support

6. Sitting (on birthing stool/chair)

• Upright with pelvic mobility
• Gravity-assisted
• Opens pelvic outlet

7. Water Birth

• Birth in a warm pool
• Reduces perineal trauma
• Less pain, more relaxed second stage
• Evidence: Safe for low-risk term women; no increased infection risk

Evidence Summary on Upright Positions:

• Shorter second stage (by ~6 minutes on average)
• Fewer abnormal FHR patterns
• Reduced severe perineal trauma (third/fourth degree tears)
• Reduced episiotomy rates
• Higher satisfaction
• Slightly increased blood loss (quantifiable difference but not clinically dangerous)

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11. APGAR SCORING

History

Purpose

• Rapid, standardized assessment of the newborn's condition at birth
• Guides the need for and response to resuscitation
• Provides documentation of newborn status
• Does NOT diagnose asphyxia alone; not used as the only criterion

When is it Assessed?

• At 1 minute after birth (assesses need for resuscitation)
• At 5 minutes after birth (assesses response to resuscitation / effectiveness)
• At 10, 15, 20 minutes if score remains < 7 at 5 minutes

APGAR Score Chart

Interpretation

Factors Affecting APGAR Score (False Interpretation)

• Prematurity: Lower muscle tone and color → lower score not indicating distress
• Maternal sedative drugs (opioids, magnesium): Reduce tone and respiration
• Congenital anomalies: Cardiac defects affect color; neuromuscular disorders affect tone
• Infection: Sepsis reduces activity and tone
• Examiner subjectivity: Scoring can vary between observers

Important Points for Viva

• APGAR is an assessment tool, not a resuscitation trigger. Resuscitation must begin at birth if the baby is not breathing/crying - do NOT wait for 1-minute APGAR.
• A low 5-minute score is associated with increased risk of neurological sequelae
• APGAR score does NOT predict long-term neurological outcome by itself
• A persistently low score (< 7 at 10+ minutes) is associated with increased risk of hypoxic-ischaemic encephalopathy (HIE) - consider cooling/therapeutic hypothermia

Extended/Expanded APGAR (for Premature Infants)

Documentation

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QUICK VIVA REVISION SUMMARY TABLE

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• The APGAR table (every examiner asks you to recite it)
• Partograph lines (alert vs action, what to do when crossed)
• CTG interpretation (FIGO classification, types of decelerations)
• Mechanism of labour (7 cardinal movements)
• Active Management of Third Stage (AMTSL) components
• Clinical pelvimetry measurements (the actual numbers)