Stages of labour and APGAR score

Question 1

When does the first stage of labour begins?

Answer 1

It begins with regular contractions or on admission to hospital with obvious signs of labour.

Question 2

Where is the presenting part at the first stage of labour?

Answer 2

The presenting part has descended into the true pelvis.

Question 3

When does the first stage of labour end?

Answer 3

When the cervix is fully dilated to 10 cm.

Question 4

How many phases is the first stage of labour divided into?

Answer 4

Two phases.

Latent phase and active phase.

Question 5

What happens in the latent phase?

Answer 5

• Contractions are not particularly painful and at 5- to 10-minute intervals.
• Contractions become stronger with shorter intervals, although the cervix is still dilating relatively slowly, with membranes possibly breaking later in this phase.

Question 6

What happens in the active phase?

Answer 6

• Starts with the cervix 3-4 cm dilated and is associated with more rapid dilatation normally at 0.5-1.0 cm/hour.
• Once the cervix is dilated to 9 cm, towards the end of the active phase, contractions may be more painful and women may want to push.
• During this time the fetal head descends into the maternal pelvis and the fetal neck flexes.

Question 7

Is pushing desirable in the first stage of labour?

Answer 7

-Pushing is undesirable at this stage; there is the need to establish by vaginal examination whether the cervix is fully dilated.

Question 8

Management of the first stage of labour

Answer 8

o Reassure and advise the patient on how her labour is progressing.
o Measure pulse hourly and temp and BP 4-hourly.
o Fetal HR should be auscultated for at least 1 minute immediately after a contraction. This should be carried out every 15 minutes.
o Offer a vaginal examination to assess cervical dilatation and fetal head descent every 4 hours and when the woman appears to be in established labour.
o Discuss the patient’s need and plan for pain relief in labour.
o Assess the position of the fetal head with regard to the mother’s pelvis.

Question 9

What is a partogram?

Answer 9

This is a pictorial record of active labour.

Question 10

What is the central feature of a partogram?

Answer 10

A graph used to record cervical dilatation as determined by vaginal examination.

Question 11

When should you start the graph to record cervical dilation?

Answer 11

5 cm.

In induction of labour, this will be 4 cm.

Question 12

What is the alert line of the partogram?

Answer 12

This shows that closer monitoring of the mother and foetus is indicated

Question 13

What is the action line of the partogram?

Answer 13

WHO recommendation of a four-hour action line should be used. This means that, if the labour does not progress as predicted, some ACTION will be taken - eg, amniotomy, augmentation and caesarean section.

Question 14

What are the maternal indicators plotted on a partogram?

Answer 14

• Vital signs (heart rate, blood pressure and temperature)
• Time of spontaneous or artificial rupture of the membranes
• Uterine contractions (number per 10 minutes and duration)
• Urine output
• Drugs administered (oxytocin, antibiotics, etc.)

Question 15

What are the foetal indicators plotted on a partogram?

Answer 15

• Foetal heart rate
• Amniotic fluid (colour, odour and quantity)
• Descent of the foetal head and head moulding

Question 16

When does the second stage of labour starts?

Answer 16

When the cervix is fully dilated.

Question 17

When does the second stage of labour ends?

Answer 17

When the baby is born

Question 18

What happens during the second stage of labour?

Answer 18

o Contractions are stronger, occur at 2- to 5-minute intervals and last 60-90 seconds.
o The fetal head descends deeply into the pelvis and rotates anteriorly so that the back of the fetal head is behind the mother’s symphysis pubis (98% of cases).
o The fetal head becomes more visible with each contraction until a large part of the head can be seen.
o The head is now born with first the forehead, then the nose, mouth and chin.
o The head rotates to allow the shoulders to be born next, followed by the trunk and legs.
o After this, the baby should start to breathe and to cry loudly.

Question 19

Management of second stage of labour

Answer 19

o Check for level of pain relief and supplement if required.

o Ensure a midwife/doctor is present at all times to encourage pushing during contractions and relaxing in between.

o Monitor contractions and FHR - measure every 5 minutes - this should be 100-160 bpm.

o If this stage is >2 hours for a nulliparous woman or >1 hour for a multiparous woman then instrumental delivery should be considered.

Question 20

What methods are used to guard the baby’s head?

Answer 20

• ‘Hands on’ - where pressure is placed on the baby’s head and the perineum supported. The application of a warm compress appears to reduce the severity of perineal trauma.
• ‘Hands poised’ - where these manoeuvres are not carried out. The ‘hands poised’ method may reduce episiotomy rates but more trials are needed to decide the issue.

Question 21

When does the third stage of labour starts?

Answer 21

It starts with the birth of the baby.

Question 22

When does the third stage of labour end?

Answer 22

With the delivery of the placenta and membranes.

Question 23

When does the separation of the placenta occurs?

Answer 23

Separation of the placenta occurs immediately after birth due to forceful uterine contractions along with retraction of the uterus, thus greatly reducing the size of the placental bed.

Question 24

How long does it take for the placenta to be separated from the uterus?

Answer 24

Approximately 5 minutes

Question 25

How does the body prevent haemorrhaging during labour?

Answer 25

Haemorrhaging is prevented by the contraction of uterine muscle fibres closing off the blood vessels that were supplying the placenta.

Question 26

How does separation of the placenta present?

Answer 26

Without active management, after 10-20 minutes, separation is shown by a gush of blood, prominence of the fundus in the abdomen and apparent lengthening of the umbilical cord.

Question 27

Types of management for placental delivery?

Answer 27

Expectant

Active

Question 28

Expectant management of placental delivery

Answer 28

Once the placenta lies in the vagina, the uterus is ‘rubbed up’ to produce a contraction and the uterus is pushed towards the vagina to help with expulsion of the placenta and membranes.

These are held and twisted whilst pulling constantly so that membranes are kept intact.

The cord is not clamped until pulsation has stopped and no uterotonic drugs are used.

Should last <60 minutes.

Question 29

Active management of placental delivery

Answer 29

• Give intramuscular (IM) synthetic oxytocin with the delivery of the anterior shoulder or as soon as the baby is born.
• The umbilical cord is clamped between 1-5 minutes after the birth and cut soon after delivery.
• After the cord has been cut and once there are signs of separation of the placenta, controlled traction on the umbilical cord (with simultaneous suprapubic pressure by the other hand - to prevent uterine inversion) will facilitate expulsion of the placenta and membranes.
• In a small proportion of cases, the placenta is not removed - repeat the attempt after 10 minutes and then remove manually.
• In all cases, the placenta and membranes are examined for completeness and any retained material removed under anaesthetic.
• Should last <30 minutes.

Question 30

Why is active management of placental delivery better than expectant delivery?

Answer 30

Active management of the third stage has been shown to be superior to expectant management with respect to blood loss, blood transfusion, PPH and other serious complications of the third stage.

Question 31

What is the APGAR score?

Answer 31

Apgar is a quick test performed on a baby at 1 and 5 minutes after birth.
Each category is scored with 0, 1, or 2, depending on the observed condition.

Question 32

What does the 1 minute score show?

Answer 32

The 1-minute score determines how well the baby tolerated the birthing process.

Question 33

What does the 5 minute score show?

Answer 33

The 5-minute score tells the health care provider how well the baby is doing outside the mother’s womb.

Question 34

What is examined during the APGAR test?

Answer 34

Breathing effort
Heart rate
Muscle tone
Reflexes
Skin colour

Question 35

How does the APGAR score determines if the baby is doing well?

Answer 35

The Apgar score is based on a total score of 1 to 10. The higher the score, the better the baby is doing after birth.

Question 36

Why is a score of 10 unusual?

Answer 36

A score of 10 is very unusual, since almost all newborns lose 1 point for blue hands and feet, which is normal for after birth.

Question 37

What score would suggest the baby is not doing well?

Answer 37

Any score lower than 7 is a sign that the baby needs medical attention. The lower the score, the more help the baby needs to adjust outside the mother’s womb.

Question 38

What can cause a difficult birth?

Answer 38

Difficult birth
C-section
Fluid in the baby’s airway

Question 39

What does a baby with a low APGAR score need?

Answer 39

o Oxygen and clearing out the airway to help with breathing

o Physical stimulation to get the heart beating at a healthy rate

Question 40

What is not indicated by the APGAR score?

Answer 40

A lower Apgar score does not mean a child will have serious or long-term health problems.

The Apgar score is not designed to predict the future health of the child.