Obstetrics and Gynaecology — Labour and Delivery, NMC MBBS licence examination syllabus (Nepal Medical Council).
Labour: normal progress, and what to do when it stops
Most labour needs watching rather than treating — the skill is knowing which is which.
Labour is one of the few things in medicine where the default correct action is to observe carefully and do nothing. Most women in most labours need monitoring, encouragement, hydration and patience. Intervening unnecessarily causes harm, and so does intervening too late. The whole discipline sits in telling those two situations apart.
What makes that hard is that labour goes wrong slowly. There is no dramatic moment when normal becomes obstructed — there is a gradual failure of progress that is easy to miss across a shift change, easy to explain away, and easy to treat with the one intervention that makes it catastrophic. That is precisely why labour care is built around a chart rather than around clinical impression.
🩺 Where this lives: Obstructed labour remains a major cause of maternal death and disability in settings where access to timely caesarean section is limited, and the injuries it leaves behind — ruptured uterus, obstetric fistula — fall hardest on young women far from a functioning theatre. What converts a difficult labour into a disaster is usually not a missing diagnosis but a missing decision: the recognition happened, and the delivery did not follow. Recognising obstruction is only half of the skill; acting on it is the other half.
💡 A note on doses. This chapter gives none. Oxytocin augmentation regimens and uterotonic doses are protocol-driven, differ between national guidelines, and are titrated against contractions and fetal wellbeing. Learn the principles and the sequence here; take every number from your local protocol.
The stages of labour
The distinction that matters most clinically is between the latent and active phases of the first stage. The latent phase is genuinely long and genuinely variable, and diagnosing "poor progress" during it leads to unnecessary augmentation and unnecessary caesarean sections. Assessment of progress belongs to the active phase — which is also where the partograph is designed to be used.
Poor progress: the three P's
WHY THE ORDER OF THINKING MATTERS
When labour is not progressing, the question is NOT
"should I give oxytocin?" It is:
1. Is she actually in ACTIVE labour?
Latent phase is slow by nature.
2. Is this OBSTRUCTION?
Severe moulding, large caput, no descent despite
good contractions, a distressed exhausted mother.
3. ONLY IF OBSTRUCTION IS EXCLUDED — are the POWERS
inadequate, and would augmentation help?
Getting this order wrong is how uteruses rupture.
Augmenting an obstructed labour drives a fetus that
cannot pass against a pelvis that will not yield.
POWER is the only correctable P. The passage cannot be
changed, and the passenger usually cannot either — which
is why the answer to an unyielding passage or passenger
is DELIVERY BY ANOTHER ROUTE, not stronger contractions.
The partograph
💡 Exam angle: the partograph is asked about constantly, and the reason it exists is worth stating plainly. Labour is managed by different people across shift changes, over many hours, and slow deterioration is exactly what handovers lose. A graph makes a trend visible in a way that a written note does not — the alert line prompts reassessment and, in a peripheral unit, arrangements for transfer; the action line means a decision is now required, not that observation should continue.
Obstructed labour
Notice how much of the picture is maternal rather than obstetric: a rising pulse, fever, dehydration, scanty concentrated urine, exhaustion, constant pain. A woman who has been in labour a long time and now looks systemically unwell is telling you something the cervix has not yet said. The treatment for obstructed labour is delivery — and in a genuinely obstructed labour that means caesarean section, not augmentation and not further waiting.
Malposition and malpresentation
A DISTINCTION THAT IS ROUTINELY MUDDLED
MALPOSITION — the presenting part is the vertex, but it
is rotated the wrong way.
e.g. occipito-posterior. Labour may be
longer and more painful; many rotate and
deliver vaginally.
MALPRESENTATION — something other than the vertex is
presenting.
e.g. breech, brow, face, shoulder.
Some are deliverable vaginally, some are
not deliverable at all.
BROW presents the largest diameter of the fetal head and
is not deliverable vaginally at term.
TRANSVERSE LIE cannot deliver vaginally and carries a
particular risk of CORD PROLAPSE when the membranes
rupture, because no presenting part is filling the pelvis.
CORD PROLAPSE is an immediate emergency. Relieve pressure
on the cord, do not handle it more than necessary, and
arrange immediate delivery.
Clinical reasoning: four presentations
🔍 Case 1 — slow progress, strong contractions
PresentationA primigravida in active labour has made no cervical progress and no descent over several hours despite strong, frequent contractions. There is severe moulding and a large caput. She is exhausted, pulse rising, passing scanty dark urine. Oxytocin augmentation is proposed.
TrapTreating "not progressing" as automatically a problem of power.
ReasoningStrong contractions with severe moulding and no descent is obstruction, not inadequate powers. The maternal signs — tachycardia, dehydration, concentrated urine — support a long obstructed labour.
AnswerDo not augment. Augmenting an obstructed labour risks uterine rupture. Resuscitate the mother, monitor the fetus, and arrange delivery by caesarean section.
🔍 Case 2 — "she has been in labour all night"
PresentationA woman has had irregular painful contractions for 14 hours. The cervix is 3 cm, soft and effacing. Contractions are irregular. She is tired but well, and the fetal heart is normal. A caesarean section for "failure to progress" is being considered.
Key questionIs she in the active phase at all?
ReasoningThis is the latent phase, which is long and variable by nature. Diagnosing failure to progress here is one of the commonest causes of avoidable intervention.
AnswerSupport, hydration, analgesia and continued monitoring. Assess progress properly once she is in established active labour.
🔍 Case 3 — sudden change in a long labour
PresentationAfter many hours of obstructed labour, a woman develops sudden severe abdominal pain. Contractions cease. The fetal heart cannot be heard, the presenting part has receded, and she becomes shocked.
Key cluesCessation of contractions and a receding presenting part after prolonged obstruction.
ReasoningThis is uterine rupture — the end point of obstructed labour that is allowed to continue. Bleeding is largely concealed, so hypotension may appear before any external loss is visible.
AnswerImmediate resuscitation, major haemorrhage protocol and immediate laparotomy. This is a surgical emergency for both patients.
🔍 Case 4 — after the membranes rupture
PresentationA woman with a transverse lie has spontaneous rupture of membranes. The fetal heart rate falls abruptly, and a loop of cord is felt in the vagina.
DiagnosisCord prolapse — an immediate emergency.
ReasoningWith no presenting part filling the pelvis, the cord can descend when the membranes rupture. It is then compressed between the presenting part and the pelvis, cutting off fetal oxygenation within minutes.
AnswerCall for help immediately, relieve pressure on the cord, handle the cord as little as possible, position to reduce compression, and arrange immediate delivery — here by caesarean section.
Commonly confused
Confusion
The distinction
Why it matters
Latent vs active phase
Latent is long and variable by nature
Diagnosing poor progress too early causes needless intervention.
Poor powers vs obstruction
Moulding and descent separate them
Augmenting an obstruction risks uterine rupture.
Malposition vs malpresentation
Vertex rotated wrongly, versus something else presenting
One often delivers vaginally; some of the other cannot.
Brow vs face presentation
Brow presents the largest diameter
Brow is undeliverable vaginally at term.
Alert line vs action line
Reassess and consider transfer, versus decide now
The action line is not an invitation to keep watching.
Caput vs descent
Caput can increase while the head does not descend
Apparent progress that is only scalp swelling.
Concealed vs revealed loss
Uterine rupture bleeds internally
Shock may precede any visible bleeding.
Rapid revision
MUST-KNOW FACTS
1. First stage: onset of labour to full dilatation.
2. Second stage: full dilatation to delivery of the baby.
3. Third stage: delivery of the baby to delivery of the placenta.
4. The latent phase is LONG AND VARIABLE — do not diagnose delay in it.
5. The partograph is used in ACTIVE labour.
6. ALERT line — reassess, consider transfer from a peripheral unit.
7. ACTION line — a decision is required now.
8. The partograph exists because slow deterioration survives handovers badly.
9. The three P's: POWER, PASSENGER, PASSAGE.
10. Power is the ONLY directly correctable P.
11. NEVER augment before excluding obstruction.
12. Obstruction: severe moulding, large caput, no descent, good contractions.
13. Obstructed labour also looks MATERNAL: rising pulse, fever, scanty urine.
14. The treatment of obstructed labour is DELIVERY.
15. Uterine rupture: sudden pain, contractions stop, fetal heart lost, shock.
16. Uterine rupture bleeding is largely CONCEALED.
17. Uterine rupture needs immediate laparotomy and resuscitation.
18. Obstructed labour that survives may leave an OBSTETRIC FISTULA.
19. Malposition = vertex rotated wrongly (e.g. occipito-posterior).
20. Malpresentation = something other than vertex presenting.
21. Occipito-posterior: back pain and slow labour; many rotate spontaneously.
22. BROW presentation is not deliverable vaginally at term.
23. Transverse lie cannot deliver vaginally.
24. Transverse lie and unengaged parts carry a CORD PROLAPSE risk.
25. Cord prolapse: relieve pressure, handle minimally, DELIVER IMMEDIATELY.
26. Third stage is short and the most dangerous — PPH happens here.
27. Active management of the third stage reduces blood loss.
28. Active management: uterotonic, controlled cord traction, uterine massage.
29. Meconium-stained liquor is recorded on the partograph and matters.
30. Observation in the hours after delivery is when PPH is caught early.
💡 Exam angle: labour questions overwhelmingly test restraint versus action. The two classic wrong answers are augmenting a labour that is obstructed, and operating on a latent phase that was never abnormal. When a stem gives strong contractions with severe moulding and no descent, the answer is delivery. When it gives irregular contractions at 3 cm in a well mother and baby, the answer is support and patience.
Syllabus points
The three stages of labour
Latent versus active phase, and why it matters
The three P's: power, passenger, passage
Why obstruction must be excluded before augmentation
The partograph and what it records
Alert line versus action line
Recognising obstructed labour
Uterine rupture and obstetric fistula
Malposition versus malpresentation
Brow, breech and transverse lie
Cord prolapse as an immediate emergency
Active management of the third stage
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