1. What is the latent phase (onset) of labour?

Cervical dilation from 0-3/4cm

2. Describe the nature of contractions during the latent phase of the 1 st

stage of labour.
May be irregular, perhaps every 15-20mins and sometimes stop, gradually
increasing in frequency. By the end (3-4cm) 2:10 minutes, increasingly regular
lasting 20-40secs.
Start painless/mild, gradually become painful but bearable
3. What is the active (established) phase of labour?
Begins at 3-4cm dilatation up to full dilatations
4. Describe the nature of contractions during the active 1st stage.
Contractions are rhythmic and regular.
4-7cm 3:10mins (2min intervals), lasting 60secs
7-9cm 3-4:10mins (2min intervals), lasting 60secs
9-10cm 4-5:10mins (1min intervals) sometimes almost continuous
Increasingly painful and very powerful by end of active stage.
5. What is normal maternal B.P.?
Systolic: 100-140 mmHg
Diastolic: 60-90 mmHg
6. When is maternal B.P. measured?
Tested on admission as baseline and then 4 hourly.
7. What is the normal range for maternal pulse rate?
55-90bpm
8. When is maternal pulse rate taken?
Tested on admission then hourly when checking the fetal heart.
9. What is the normal maternal temperature?
35.8-37.3C
10. When is maternal temperature measured?
Tested at admission then 4 hourly.
11. What can hypertension be caused by?
Anxiety and pain
General anaesthesia
Pre-eclampsia
12. What can hypotension be caused by?
An epidural/top-up
Aortocaval occlusion due to lying supine
Haemorrhage and hypovolaemic shock
13. What is tachycardia and what are the possible causes?

100bpm
Anxiety, pain, hyperventilation
Dehydration, pyrexia
Exertion
Obstructed labour
Haemorrhage, anaemia, shock
14. What is bradycardia and what are the possible causes?
55bpm
Rest and relaxation
Injury and shock
Myocardial infarction
15. What is pyrexia and what are the possible cause?
>37C
Infection
Epidural usually low grade but rises with time
Dehydration
Overheated birthpool
16. What are baseline observations?
B.P., pulse, and temperature, respirations
17. What are the features of the initial assessment of a woman in
suspected labour?
Listening to her story, considering her emotional + physical needs and reviewing
her clinical records.
Physical observations: B.P., pulse, temp, respirations, urinalysis
Length , strength and frequency of contractions
Abdominal palpation- Fundal height, lie, presentation, position and station.
Vaginal loss- show, liquor, blood
Assessment of the womans pain, including her wishes for coping with labour and
range of options for pain relief.
FHR should auscultated for 1min immediately after a contraction. Maternal pulse
palpated to differentiate between the 2.
Vaginal examination if woman is in established labour, if she isnt after a period it
may be helpful to offer one.
18. What actions should be taken after pre-labour rupture of membranes?
No need to carry out speculum exam with a certain history. Women with an
uncertain history should be offered speculum examination to confirm (digital exam
in absence of contractions should be avoided).
Ask women about LIQUOR
Amount, colour, smell.
Should be clear, straw coloured or pink. Bloodstained: if mucoid present its
probably a show.
Smell Offensive= may indicate infection.
Meconium-stained: less of a concern if its light staining but dark green, black and/or
thick means its fresh and could be more serious.

Advise woman that she can wait for the onset of labour in the comfort of her hoe
(away from possible infection or intervention) and advise that 60% go into labour
within 24 hours.
Advise 1% risk of infection and thus to check temp every 4 hours (can be done at
home). Suggest avoiding sex or putting anything in vagina, and wiping from front to
back when opening bowel to avoid infection.
Advise her to report any reduced fetal movements, uterine tenderness, pyrexia,
feverish symptoms.
Ask her to come back after 24hrs if labour hasnt started.
19. What are the non-pharmacological options for pain relief?
Massage and touch
Distraction
Position changes
(TENS- not advised by nice)
Acupuncture, acupressure, hypnosis
Breathing and relaxation techniques (not provided but not prevented))
Water
Music
20. What are the pharmacological options for pain relief?
Entonox
Opioids e.g. pethidine, diamorphine
Regional analgesia i.e. epidural analgesia, spinal analgesia, combined epiduralspinal analgesia
21. What should women be advised about entonox?
That is might make them feel nauseous and/or light-headed.
22. What should women be advised about opioids?
That they will provide pain relief only to a certain extent.
That they carry side effects both for woman (drowsiness, nausea and vomiting) and
baby (short-term respiratory depression and drowsiness which may last a few days).
Advise that this might interfere with breastfeeding.
23. What should be given alongside IV/IM opioids?
Antiemetics e.g. metoclopramide
24. Whats the normal respiration rate?
12-20 times in minute.
25. What should women be advised about the risks and benefits of
epidural analgesia?
It provides more effective pain relief than opioids.
It is associated with a longer 2nd stage and an increased chance of instrumental
birth.
Can cause pyrexia, leg weakness
Accompanied by more intensive level of monitoring

Modern epidural solutions contain opioids which cross the placenta and in larger
doses (greater than 100mg) can cause short term respiratory depression and make
the baby drowsy.
26. What are the observations undertaken for women with regional
analgesia?
During establishment of regional analgesia or after boluses (10ml or more of lowdose solutions) B.P. should be measured every 5 minutes for 15 minutes.
If the woman isnt pain free 30 minutes after each administration of local
anaesthetic/opioid solution, the anaesthetist should be recalled.
Hourly assessment of the level of sensory block be undertaken.
CTG for 30 mins following establishment of block and following bolus administration
(top-up)
Regular position changes and non-supine (NICE) side lying or all fours (if possible)
Bladder care: regular (in and out) catheter or continuous drainage
Avoidance of aortocaval compression
27. What is the average length of the 1st stage of labour?
1st labour 8 hours on average (unlikely to last over 18 hours)
2nd + labours 5 hours on average (unlikely to last over 12 hours)
28. What are the observations during the 1st stage of labour?
4 hourly temperature and blood pressure
Hourly pulse
Half-hourly documentation of frequency of contractions
Frequency of emptying the bladder
VE offered 4 hourly or where there is concern about progress or in response to
womans wishes (after palpation and assessment of vaginal loss)
Intermittent auscultation for a minute at least every 15 mins
29. When is the fetal heart assessed?
At 1st contact in early labour and at each further assessment undertaken to
determine whether labour has become established.
Once established labour is confirmed, intermittent auscultation of fetal heart after a
contraction for 1m every 15mins. (Remember palpation of maternal pulse).
30. What is the transition period?
Period between full dilatation and the time when active maternal pushing efforts
start.
Contractions may be almost continuous or space out a little.
Characterised by maternal restlessness, discomfort, desire for pain relief, a sense
that the process is never-ending and demand to get it over with
Distressed or panicky statements
Non-verbal sounds grunting, groaning
Withdrawing from the activities and conversation of people around.
31. What features of care are especially important during the transitional
period?
Support birth partners- they can become tired and stressed.

Keep it calm change dynamics if the woman panics e.g. suggest a walk to the
toilet, position change, focus on breathing
Avoid temptation of VE likely to yield disappointment of 8-9 dilated.
32. What is the 2nd stage of labour
Passive second stage: finding full dilatation prior to or in the absence of
involuntary expulsive contractions.
Onset of active 2nd stage:
Baby is visible
Expulsive contractions with a finding of full dilatation of the cervix or other signs of
full dilatation of the cervix
Active maternal effort following confirmation of full dilation of the cervix in the
absence of expulsive contractions
33. What is the average dilatation of the second stage?
Nulliparous- Birth expected within 3hrs of the start of active 2 nd stage
Parous- Birth expected within 2hrs of the start of the active 2 nd stage
34. What are the characteristics of 2nd stage?
Vomiting- often accompanied by involuntary pushing
Show- or bright red vaginal loss
SROM- can occur at any tire but often at full dilatation
Slowing of FH- at the peak of contraction, usually due to head compression
Purple line- a line which gradually extends from the anus to the nape of the
buttocks once it reaches nape = full dilatation
Urge to push- Powerful, expulsive contractions every 2-3mins, lasting <60 secs.
Most women make a distinctive throaty expulsive sound at the peak of the
contraction
Rectal pressure- As presenting art descends, it exerts great pressure on the
bowel- woman often feels urge to open bowels.
External signs- e.g. anal dilatation, bulging perineum, gaping vagina
35. What is the nature of care during the 2nd stage?
Observations- hourly B.P. and pulse
Continued 4hrly temperature
Perform VE hourly in active 2nd stage or in response to womans wishes (often after
ab palpation and assessment of vaginal loss)
Half-hourly documentation of frequency of contractions
Frequency of emptying the bladder
Ongoing consideration of womans emotional + psychological needs
Assessment of progress- Include
Maternal behaviour
Fetal wellbeing
Taking into account fetal position and station at the onset of 2 nd stage.
Intermittent auscultation of FH after a contraction for at least 1min, at least every 5
mins. Maternal pulse should be palpated if fetal bradycardia or other anomaly
suspected
Ongoing consideration given to the womans position, hydration, coping strategies
and pain relief.

36. What measures can aid effective pushing during 2nd stage?
Enable spontaneous involuntary pushing women should push as they wish
Push only when ready- women push naturally as the contraction builds up and
the urge to push is present. (The earliest part of the contraction pulls the vagina
taut, preventing it from being push down in front of the descending part)
Avoid forced pushing (valsalva)
Try stopping pushing for a few contractions If pushing doesnt feel effective
(some women find this increases urge to push)
Verbal support- speak soothingly, give simple explanations and praise woman for
doing well.
Birthing positions- squatting, kneeling or side lying increases pelvic outlet
discouragement from supine or semi supine position
Emptying bladder
37. What is directed pushing?
Directed pushing occurs when the woman is told how to push - usually this involves
breath holding, taking breaths quickly between pushes and 3-4 sustained pushes
from when the contraction begins to when it ends. Breath holding increases
intrathoracic pressure which can decrease the venous return to the heart, thereby
reducing cardiac output and blood pressure. This in turn can reduce uterine blood
flow and placental perfusion, and the amount of oxygen available to the fetus,
increasing the likelihood of fetal heart rate abnormalities occurring.
38. What is spontaneous pushing?
Spontaneous pushing is likely to occur when the woman reaches the active phase of
the second stage of labour due to the strong urge to push that accompanies this
stage. Women may not begin to push until the contraction has built up and will
often use short pushes lasting 5-7 seconds 3-5 times during a contraction (Di Franco
et al 2007, Perez-Botella & Downe 2006). The duration of the second
stage is not significantly increased with the use of spontaneous pushing (SampseDe
et al 2005), with
some studies suggesting the time is reduced (Yildirim & Beji 2008). Women should
be encouraged to push spontaneously or breathe through a contraction where fetal
heart rate abnormalities occur until the fetus recovers. Additionally there is more
strain placed on the urinary, pelvic and perineal structures increasing their risk of
damage (Roberts & Hanson 2007, Schaffer et al 2005). Breath holding can make
women feel dizzy, causing them to gasp; a sudden surge of blood back to the heart
may occur, resulting in rebound hyper* tension (Perez-Botella & Downes 2006).
Women should be encouraged to follow what their bodies are telling them to do and
push when they have the urge (NICE 2007).
39. Describe the mechanism of the birth of baby.
Descent of fetus takes place due to contraction and retraction exerting pressure.
Pressure exerted down the fetal axis increases flexion, resulting in smaller
presenting diameters for easier negotiation through pelvis.
During a contraction, leading part is pushed downwards onto pelvic floor, the
resistance brings about internal rotation of the head. In well flexed vertex
presentation, occiput leads, meets pelvic floor and rotated anteriorly 1/8 circle in
line with symphysis pubis. Head is no longer is alignment with shoulders.
Anteriorposterior diameter of the head now lies in the widest (anteroposterior)

diameter of the pelvic outlet. Occiput slips beneath the subpubic arch and crowning
occurs when head no longer recedes between contractions and the widest diameter
(biparietal) is born.
Once crowned, extension of the head occurs, pivoting around the pubic bone.
Sinciput, face and chin sweep perineum and are born.
The twist from internal rotation is corrected by restitution. Occiput moves 1/8
circle back to where it started. At the same time anterior shoulder is the first to
reach levator ani muscle and thus internally rotates anteriorly to lie under
symphysis pubis.
Anterior shoulder usually born 1st, although in upright or kneeling positions the
posterior shoulder is often commonly seen 1st and the remainder of body is born by
lateral flexion as spine bends sideways through curved birth canal .
40. What is the 3rd stage of labour?
The time from birth of the baby to expulsion of placenta and membranes.
41. What is active management of the 3rd stage of labour?
3 components:
- Routine use of uterotonic drugs. Incl. use of oxytocin (10
IU by IM injection)
Early clamping of the cord
Controlled cord traction.
42. What is physiological management of the 3rd stage
3 components:
- No routine use of uterotonic drugs.
No clamping of the cord until pulsation has ceased.
Delivery of the placenta by maternal effort.
43. What is the procedure of a normal delivery
* Prepare the environment and gather equipment:
O delivery trolley or surface to work from
O sterile delivery pack, including warm towels to dry/wrap the baby
O sterile gloves, gown, etc. O disposable sheets, gloves and sanitary towels
O extras: urinary catheter, amnihook, lidocaine, needles and syringes, oxytocic
(ecbolic) agent
O an infectious waste refuse bag should be available, usually a floor bin.
* Ensure that the room temperature is correct (21-24C) and draughts are excluded.
* Give ongoing reassurance and explanations to the woman, support her in her
choice of position and analgesia and maintain maternal and fetal observations.
* Place the disposable sheets strategically in the area of the perineum, while
wearing disposable gloves.
* When delivery is imminent, put on apron and eye protection, wash and dry hands
and open the outer covering of the delivery pack.
* Place all other sterile items onto the delivery pack using a non-touch technique.
* Apply hand rub, allow to dry and then put on sterile gloves.
* Check the swabs and instalments in the delivery pack.
* Arrange the trolley in a way that suits, having cord clamps and the receiver for the
placenta accessible.
* Continue to observe the advancing fetus while carrying out these procedures
(some women experience short second stages of labour).
* Place sterile drapes appropriately to provide a sterile field.

* Position the anal pad if being used, have a warm towel on hand, e.g. on woman's
abdomen, ready to receive the baby.
* As the fetus reaches the perineum, the perineum is seen to stretch.
* As the head crowns, consider applying gentle pressure to it with one hand to slow
the delivery, guard the perineum with the other hand if adopting a hands-on
approach.
* Encourage the woman to breathe and give gentle pushes as the head extends and
emerges, note the time.
* Restitution will be seen followed by external rotation of the head as the shoulders
rotate internally.
* As the next contraction occurs and the woman has urges to push again, apply
traction to the anterior shoulder (in a direction away from the symphysis pubis) to
deliver it, followed by traction in the opposite direction to deliver the posterior one.
a Deliver the body and limbs of the baby by lateral flexion, following the curve of
the birth canal, in an upward direction towards the womans abdomen; the woman
may assist.
* Note the time of delivery.
* The baby is placed ideally skin to skin with his mother and is dried completely;
parents or midwife will check the gender. 217 Skills for Midwifery Practice
* Drying acts as stimulation, during which time the baby will take its first breath and
cry; complete Apgar score (see Chapter 37) at 1 minute. Act swiftly (before 1
minute) if resuscitation is required (see Chapter 56).
* Clamping and cutting of the cord will be undertaken according to the parents'
wishes and chosen management of the third stage of labour. Breastfeeding may be
facilitated.
* Share in the joy of the moment, but stay alert to the clinical situation.
* Care moves into management of the third stage of labour; this may have included
the administration of an intramuscular or intravenous oxytocic agent following
delivery of the anterior shoulder or the birth of the baby.
44. What is the procedure for the clamping of the umbilical cord?
With active management, the cord is clamped immediately after delivery, usually
within 30 seconds; with expectant management, it is not cut until it has stopped
pulsating . put a plastic clamp about a cm from the umbilicus then one set of
spencer wells about 2cm's away from the plastic clamp and then another set of
spencer wells near the vulva that way the cord can be cut and i can do CCT without
losing the blood in between the spencer wells in case i need cord gases or cord
bloods.
45. What are the observations in the 3rd stage?
Her general physical condition- as shown by her colour, respiration and her own
report of how she feels.
Vaginal blood loss.
46. What is the physiology of the third stage of labour?
Phase 1 -latent- Contraction and retraction of myometrium continues causing
extensive thickening of the myometrium, however, area of myometrium beneath
the placental sire is unable to thicken to same extent.
Phase 2 -contraction/detachment- With further contraction + retraction,
myometrium under lower pole of placenta begins to contract reducing surface area.

Consequently shearing forces cause placenta to tear away from spongy layer of the
decidua. Wave of separation passes upwards and uppermost part of placenta
detaches last. At this point maternal sinuses within decidua are expose, oblique
muscle fibres surrounding blood vessels contract, sealing off torn ends of maternal
vessels, helping to prevent haemorrhage.
Phase 3 -expulsion phase- Placenta descends into L.U.S. causing membranes to
peel away from uterine walls. As uterus contracts, placenta descends into vagina,
assisted by gravity, with membranes following. Placenta and membranes then
expelled by maternal effort- fetal surface appears 1 st at vulva, with membranes
behind, and any blood loss is contained within this Schultze method. Sometimes
lower edge of placenta descends 1st, so that maternal surface appears at vulva,
sliding out lengthways with membranes Matthews Duncan method- this is a slower
process with increased blood loss.
47. What are the steps for active management of the third stage of
labour?
Give prophylactic oxytocic- following birth. Syntometrine commonly used
although NICE recommends oxytocin (Syntocinon) 10 IU IM
Clamp and cut the cord- Ensuring both ends are secure, placing maternal end in
a sterile receiver close to the vulva. Often done immediately (NICE recommended).
However delayed cord clamping for several mins shown to benefit babies. There is
the suggestion that unclamping the maternal end and allowing it to drain into a
bowl may shorten 3rd stage (Cochrane review)
Deliver the placenta by controlled cord traction- Place non dominant hand
over fundus and await contraction. When uterus is contracted press the lower
uterine area (guard the uterus), placing non dominant hand above symphysis
pubis, with dominant hand grasp the cord and gently but firmly apply steady
downward traction, keeping hand traction close to vulva. If resistance felt, stop,
relieve pressure from the dominant and then non-dominant hand and wait a min
before attempting again (ensuring uterus is contracted). When placenta appears at
vulva, traction can be applied in upward direction to follow curve of birth canal.
Typically done several mins after administration of oxytocic. Takes approx. 5-10
mins for placenta and membranes to be expelled.
48. What are the steps for physiological management of the third stage
of labour?
Encourage breastfeeding to increase oxytocin level (Nipple stimulation can
also help)
Make sure environment is relaxed to promote oxytocin release and reduce
stress levels.
Watch blood loss and observe for signs of separation e.g. cord lengthening,
trickle of blood/passage of small clots, the woman may groan, have a period-type
ache or urge to push. Placenta may be visible at vagina.
Assist the mother to an upright position e.g. kneeling, squatting or sitting:
gravity will help her birth placenta.
Push with a contraction as expulsive efforts are usually more effective then.
49. What should women be advised about active management of third
stage?

Women should be informed that active management of the third stage reduces the
risk of maternal haemorrhage and shortens the third stage. BUT that oxytocic drugs
carry side affects.
50. What is a prolonged third stage?
An undelivered placenta after 30mins of active management and 60 minutes with
physiological management. PPH is a risk after this time.
51. What are the oxytocics used during active management of 3 rd stage
and what are their risks?
Syntocinon- Causes uterus to contract rhythmically and strongly. Given IV. Can
cause water retention and hyponatremia (low blood sodium levels). 5 or 10 IU
Ergometrine- Causes continuous spasm of uterus and cervix and thus useful in
prevention of PPH. Given IV or IM. Can cause nauseam vomiting and hypertension.
Thus shouldnt be given to hypertensive women.
Syntometrine- Combines syntocinon and ergometrine and thus commonly drug of
choice. Unfortunately combines side effects of both drugs. Given IM.
52. What are the observations during the 3rd stage?
Her general physical condition, as shown by colour, respiration + her own report of
how she feels
Vaginal blood loss
53. When is the change from physiological to active management of
physiological management of 3rd stage indicated?
Haemorrhage
Failure to deliver the placenta within 1hr
The womans desire to artificially shorted 3rd stage
54. When should pulling the cord or palpating the uterus be carried out
during 3rd stage?
Only as part of active management after the administration of oxytocin
55. What is the procedure for physiological management of 3 rd stage?
* Note the time of delivery of the baby.
* Keep the baby on the womans abdomen skin to skin.
* Maintain a safe, warm and private environment, taking steps to reduce any
anxiety in the woman.
* The midwife can continue to wear the gloves worn for delivery of the baby but
these will need to be changed prior to examining the genital tract.
* Ensure the woman's bladder is empty.
* Encourage the woman to adopt an upright position.
* Observe the general condition of the woman throughout, particularly any blood
loss per vaginam, colour, respirations (NICE 2007) and recording the maternal pulse
every 15 minutes or more frequently if indicated.
* Do not touch the cord, allowing it to stop pulsating naturally.
* Encourage and assist the woman to breast feed when the baby is ready.
* Do not palpate the uterus unless blood loss becomes excessive.
* Place a bedpan or suitable receptacle under or next to the woman when she is
ready to push the placenta out.

* Encourage the woman to deliver the placenta by her own efforts, bearing down to
expel the placenta.
* Note the time the placenta and membranes are expelled (usually within 1 hour of
the birth).
* The cord can be clamped and cut when it has stopped pulsating (unless the
woman has requested a lotus birth), applying the clamp 3 -4 cm from the abdominal
wall (longer if the baby is preterm, as catherisation of the umbilical vein may be
required; this is more successful when the cord is longer).
* Assess the condition of the woman, noting the condition of the uterus, amount of
blood loss, pulse and blood pressure following completion of the third stage; the
condition of the genital tract should also be determined, suturing can be undertaken
when appropriate.
* Assist the woman into a comfortable position, removing any soiled linen; if all her
observations are within the expected parameters, leave the woman and her baby
together (with her partner or labour supporter), ensuring the call bell is close at
hand.
* Examine the placenta (Chapter 33) and record total blood loss.
* Dispose of the placenta and equipment correctly (if the woman is taking the
placenta home, it should be double wrapped and placed in a suitable container).
* Document findings and act accordingly.
56. What is the procedure for active management of 3rd stage?
* As the anterior shoulder of the baby is born or the baby is delivered, an
intravenous or intramuscular oxytocic drug is given.
* Clamp and cut the cord at birth within 3 minutes unless this is contraindicated
(e.g. Rhesus isoimmunisation with antibodies; discussed earlier), ensuring both
ends are secure and placing the maternal end (often clamped with artery forceps) in
a sterile receiver, positioned close to the vulva.
* Place a sterile towel over the womans abdomen and place the non-dominant
hand over the fundus and await a contraction, keeping the hand still, during which
time signs of placental separation and descent may be seen.
* When the uterus is contracted and signs of separation and descent are noted,
place the nondominant hand above the symphysis pubis, with the thumb and
fingers stretched across the abdomen and palm facing inwards (Fig. 32.3).
* Grasp the cord with the dominant hand and apply steady downward traction
(controlled cord traction); at the same time, push the uterus upwards towards the
umbilicus with the nondominant hand (to reduce the risk of uterine inversion).
* Controlled cord traction is best achieved if the midwife is able to keep the hand
applying traction close to the vulva. The grip should be secure by holding the artery
forceps on the cord close to the vulva; as the cord lengthens the clamp should be
moved up to remain near to the vulva. Alternatively, wrap the cord around the
fingers of the dominant hand, moving them nearer the vulva as necessary.
* If resistance is felt, stop, relieve the pressure from the dominant then the nondominant hand (the placenta may not have separated) and wait for a minute before
attempting again, ensuring the uterus is contracted.
* When the placenta appears at the vulva, traction should be applied in an upward
direction to follow the curve of the birth canal.
* The non-dominant hand is moved down to help ease the placenta into the
receiver, allowing the membranes to be expelled slowly.

* If there is any difficulty delivering the membranes, they should be 'teased out'
either by moving them gently up and down (artery forceps can be positioned on the
membranes to help with this) or by twisting the placenta round to make the
membranes into a rope-like structure, either way encouraging the membranes to
separate and be expelled.
* Observe the condition of the woman throughout, particularly any blood loss per
vaginam.
* Note the time the placenta and membranes are expelled (often within 5-10
minutes).
* Assess the condition of the woman, noting the condition of the uterus, amount of
blood loss, pulse and blood pressure following completion of the third stage; the
condition of the genital tract should also be determined, suturing can be undertaken
when appropriate.
* Assist the woman into a comfortable position, removing soiled sheets; if all her
observations are within the expected parameters, leave the woman and her baby
(skin to skin) together (with her partner or labour supporter), ensuring the call bell
is close at hand.
* Examine the placenta (see Chapter 33) and record total blood loss.
* Dispose of the placenta and equipment correctly (if the placenta is being taken
home by the woman, it should be double wrapped and placed in a suitable
container).
* Document findings and act accordingly.
If there is concern that the placenta is not delivering within 30 minutes (NICE 2007),
the midwife should determine whether the placenta has separated (pp. 225, 228)
and refer to an obstetrician if it has not separated, if blood loss is excessive or if a
manual removal of placenta is required.
Once third-stage management is complete the delivery records are completed in
detail, including the birth notification. The new family are given time together, vital
sign observations are checked, as is the woman's uterus and lochial loss.
Refreshments are given and the baby care is attended to; infant feeding should
begin.
57. What are the measures done immediately after birth?
Encourage uninterrupted skin-to-skin contact as soon as possible after birth unless
baby has an obvious problem needing a prompt response.
Record the Apgar score at 1 and 5 minutes
Dry baby and cover with warm dry blanket, while maintaining skin-to-skin contact
Avoid separating the mother and baby during the first hour
Encourage breastfeeding as soon as possible or within the first hour
Record head circumference, temperature and weight after the first hour
Conduct an initial examination of the baby to detect major physical abnormality and
Gain consent prior to examination or treatment of the baby
Conduct examinations in the presence or knowledge of the parents.
58. What is the Apgar score and how is it scored?
Colour: Blue or pale; Body pink, limbs blue; Pink
Respiratory rate: Absent; Irregular gasps; Strong cry
Heart rate: Absent; <100bpm; >100bpm
Muscle tone: Limp; Some limb flexion; Strong active movements

Reflex irritability: None; Grimace or sneeze; Cry

59. What should be done if a baby is in poor condition (has an Apgar
score is 5 or less at 1 min)?
Tine to the onset of regular respirations should be recorded and the cord doubleclamped to allow paired cord blood gases to be taken. Apgar scoring should
continue until babys condition is stable.
60. What are the benefits of skin-to-skin contact?
Appears toImprove mother and baby interaction.
Keep babies warmer
Make breastfeeding more likely + improves duration of breastfeeding, remember
some animals are known not to attach to their young unless able to lick+smell them
immediately after birth
Probably improves the early relationship between mothers and babies
61. What are some of common problems related to the colour of a baby at birth?
Blueness around the mouth and trunk (central cyanosis): Could indicate
respiratory or cardiac problems. (Darker skinned babies can look greyish white when
cyanosed). Oxygen should be administered, respiratory effort+ HR assessed and
resuscitation initiated if required. Paediatric support should be requested.
Very pale baby: Cardiac anomalies, anaemia or shock considered. Resuscitation if
required.
Facial congestion: Petechial rash seen as blue/mauve discolouration of skin
around babys face due to rapid delivery, cord around neck or shoulder dystocia.
Lips and mucous membranes should be pink
Red baby
Jaundice
62. What are some possible neonatal respiratory problems at birth?
Persistent tachypnoea (respirations >60/min at term), grunting, nasal flaring or
sternal recession are signs of respiratory distress. Causes include infection,
prematurity, meconium aspiration and cardiac problems. Refer to a paediatrician.
A baby who does not breathe following attempted inflation breaths may require
gentle suction of mucus or meconium. Excessive secretions may indicate
oesophageal atresia.
A distinctly high-pitched or 'irritable' cry may indicate pain, cerebral irritation,
metabolic abnormalities or drug withdrawal
63. What are some possible neonatal cardiac problems at birth?
Bradycardia (HR < 100 bpm) may result from hypoxia. With adequate respiration
the HR can recover quickly. If <60 bpm cardiac massage will be necessary (see
Chapter 18).
Tachycardia (HR > 160 bpm) may indicate a healthy response to a hypoxic episode.
Again with adequate respiration it can recover quickly. It can however indicate
infection or a respiratory/cardiac problem. Refer to paediatrician if it persists.
64. What is the normal birth weight range?
About 2.74kg

65. What is the weight of a low birth weight baby?

<2.5 kg is considered low birth weight; and <1.5 kg is very low birth weight.
66. What is the weight of a macrosomic baby?
4-4.5 kg
67. What is a pre-term baby?
<37 weeks
68. What is vitamin K and why, how and when is it give?
Essential for the formation of prothrombin, which enables blood to clot. If low it can
rarely lead to Haemorrhagic disease of the newborn (HDN) or vitamin K deficiency.
Given orally or via IM injection.
69. What is the normal range of head circumference?
Normally 32-37 cm at term
70. What are the elements checked of the top to toe newborn
examination?
Head: Head circumference, shape of face, eyes, nose, mouth, ears
Neck: symmetry, swelling, ability to move from side to side, no webbing or skin
folds.
Clavicles: Feel along to ensure they are intact especially for breech or shoulder
dystocia- both increase risk of fractured clavicle (resulting in little or no movement
in associated arm).
Arms: Arms same length (straighten arms comparing the 2), should move freely
and spontaneously (check by stroking). Digits counted, examined for webbing,
palmar creased noted, nails
Chest: Symmetry of movement with respiration. Nipples and areolae well-formed
and symmetrical and not widely spread.
Abdomen: Should appear rounded + move in synchrony with chest during
respiration, gently palpate to ensure no abnormal swellings. Check umbilical cord
securely clamped, inspected to make sure no sign of haemorrhage.
Genitalia: boys: length of penis (should be about 3cm) and position of urethral
meatus confirmed. Foreskin shouldnt be retracted. Scrotum should be gently
palpated for presence of 2 testes. Girls: Vulva examined by parting labia gently to
ensure presence of clitoris, urethral + vaginal orifices. Mucoid discharge is normal.
Legs: Asses legs + feet for symmetry, size, position, shape and posture. Confirm
same length by straightening together at hips and knees. Should be moving freely,
good motor control. Feet should not be turned inwards, outwards, upwards or
downwards. Feet noted for oedema. Toes counted, examined for webbing by
separating.
Spine: Turn baby over, looking for spina bifida, swelling, dimpling or hairy patches.
Assess curvature of vertical column by running fingers over spine. Easier to do by
straddling baby over one hand (ensuring head is supported). Part cleft of buttocks,
look for dimples or sinues + confirm presence of anal sphincter
Skin: Condition observed. Colour noted. Presence of rashes or marks. Obvious
swelling or should be recorded. Mongolian blue spot can sometimes be noted in the
sacral area (observed over next few days to make sure not a bruise)

Elimination: Passage or urine or meconium should be recorded as it indicated

patency of renal and lower gastrointestinal tract.
Weight: Weight recorded in kg, undertaken at beginning or end of exam.
Length: Crown-heel length (not always undertaken). 2 stages: from crown to base
of spine and from base of spine to heel. Can also be mark on paper below.
71. What is the procedure of examining the newborn head?
Signs of moulding and caput succedaneum. Signs of trauma noted (i.e. lacerations
from scalp electrode, forceps marks), signs of bruising (this may increase risk of
physiological jaundice). Feel along suture lines and fontanelles- normal size,
appearance? Posterior fontanelle often closed due to moulding. Anterior fontanelle
should be palpated- large or small?
Head circumference: measured at birth, using occipitofrontal circumferencemeasurement around occiput and forehead. Likely to change over 48 hours so
better to do 2-4 days after birth.
Shape of face: Symmetry, size , position of features in relation to each other.
Eyes: Size shape and presence of slanting. Discharge (not normal and could
indicate infection). Pupils round.
Nose: Shape . Width of bridge (shouldnt be greater than 2.5cm). Squashed isnt
unusual but should be noted especially if it affects breathing. Nostrils shouldnt flare
Mouth: Lips- formed, symmetrical. Presence of cleft lip. Inside of mouth observedpalate intactness. Digital exam only undertaken if submucous palate suspected.
Epsteins pearls on gums or palate noted.
Ears: fully formed, in correct position, contain enough cartilage to spring back when
moved forward gently. Pinna well formed. Presence of accessory skin tags noted.
72. What is the procedure of the newborn assessment?
Explain procedure to parents and gain informed consent
Wash, dry hands
Ensure good lighting and warmth
Examine baby methodically: head, face and neck, clavicles, arms, hands, chest,
abdomen, genitalia, legs, feet, spine.
Note colour, tone and activity of baby.
Passage of urine, meconium noted.
Other obs e.g. head circumference, length and weight
Baby placed skin-to-skin with mother or dressed following procedure
Discuss findings
Document findings
73. What are the indications of a VE?
Establish the onset of labour; membrane sweep; induce labour
Prior to pain relief (analgesia)
Assessing progress of labour : dilatation, determine presenting part/position,
presence/absence of membranes
Before ARM
Apply fetal skin electrode for electronic FH monitoring
To exclude cord prolapse
Determining onset of second stage of labour
To examine for genital tract for trauma at the end of labour.

74. What are the contraindications to VE during labour?

Woman declines the examination refusal
Vaginal bleeding and placental site unknown
Known placenta praevia
75. What are the preparations for a VE?
Midwife
Review history and general well-being of mother + fetus.
Make sure there is a clear rationale and indication.
Informed consent, which is clearly documented
Prior abdominal examination to determine presentation, position and engagement
abdominally. FH auscultated.
Equipment- Pinard / doppler device (sonicaid), VE pack, Lubricant, Water / lotion,
Gloves
Wash hands / don gloves consider infection control.
Mother
Informed consent (for initial and subsequent VE)
Consider appropriate language / terminology
Empty bladder
Privacy / warmth / comfort
Position - usually dorsal but VE can be carried out with woman in any position
76. What is assessed during a VE?
External genitalia (vulva) any abnormalities? Any inflammation, lesions, warts,
scarring
Vaginal discharge colour, amount, odour?
Vagina warm & moist / dry / tight?
Rectum full?
Cervix position, effacement, dilatation
Membranes present or absent?
Presenting part what / where in the pelvis
Cord presentation or prolapse?
Pelvis normal shape and size (gynaecoid)
Important to maintain a structured approach to the examination and subsequent
documentation
77. What is the assessment of cervix & membranes during a VE?
Position of Cx posterior, central, anterior?
Consistency of Cx firm, soft, stretchy?
Effacement of Cx uneffaced; partially or fully effaced? Thick / thin?
Dilatation of Cx 0 to 10 cms
Application to the presenting part (PP) to Cx poorly applied? Well applied?
Membranes fore waters present / bulging / absent (colour and consistency of
liquor).
78. How is position of cervix relevant during a VE?
Prior to labour, the cervix is usually in a central or posterior position In the latter
weeks of pregnancy position of the os is in an anterior position.
79. What is the relevance of application of the presenting part to cervix?

Well applied cx to the pp. is associated with good uterine activity. Thus a poorly
applied cx associated with less efficient uterine activity and slower progress. If fetus
is in the OP position, there is decreased effectiveness of uterine contractility, slower
cervical dilatation and prolonged labour because fetal head is not pushed directly
onto cx; rather downwards and forwards against the back of the symphysis pubis.
Application of the cx to the PP can be assessed by feeling between them.
80. What is effacement and how is it assessed during a VE?
Usually precedes dilatation with the primps; may appear to occur simultaneously
with the multips. Assessed by the length of the cx and the degree to which it
protrudes into the vagina. Non-effaced feels long and tubular, os closed or partly
dilated. As effacement occurs, cx thins out and feels shorter, as the lower uterine
segment takes it up (Fig. 30.1). Fully effaced feels continuous with the lower uterine
segment and does not protrude into the vagina.
81. How is dilatation assessed during a VE?
assessed by inserting one or both fingers through the external os and parting the
fingers to assess the diameter. In early labour, when the cervix is less than 2 cm
dilated, usually only one finger can be inserted. Towards the end of the first stage it
may be easier to feel around the remaining rim of cervix to estimate dilatation; for
example, a rim of 1 cm equates to a dilatation of 8 cm, as there is 2 cm of cx
remaining When the cervix can no longer be felt, full dilatation has occurred, equal
to 10 cm.
82. How are the membranes felt during a VE?
Intact membranes may be felt as a shiny surface over the presenting part. When
the presenting part is poorly applied to the cervix, membranes contain a greater
amount of fluid and may bulge through the cx. If felt intact but amniotic fluid is
leaking, hindwater rupture is the likely cause. Pulsation felt beneath membranes
may be indicative of cord presentation or vasa praevia.
83. How is presentation assessed during a VE?
Cephalic presentation: smooth, round + firm. Sutures or fontanelles may be felt.
Moulding can be assessed by degree of overlapping of the bones of the vault. Caput
succedaneum may be felt as a soft or firm mass on presenting part (can make
identification of sutures/fontanel les more difficult.)
Breech: feels soft and irregular. Sacrum may be palpable as a hard bone, with the
anus close by and landmarks are felt in a straight line. If finger is inadvertently
inserted into the anus, it will be gripped. Fresh meconium is likely to be present.
Face presentation: like Breech feels soft and irregular. Orbital ridges may be felt
and a finger inserted into the mouth may be sucked, and marks are located in a
triangular position. If a face presentation is suspected or confirmed, care taken to
avoid damaging eyes; fetal scalp electrode not recommended and obstetric cream
shouldnt be used as it could initiate a chemical conjunctivitis.
Cord presentation: pulsations can be palpated through the membranes
membranes should not be ruptured due to the danger of cord prolapse. If cord is felt
without membranes the emergency procedure for managing cord prolapse should
be instigated whilst the examining midwife keeps her fingers in the vagina in an
attempt to push the presenting part off the cord.

84. How the level of the presenting part assessed during a VE?
By assessing the distance between the presenting part and the ischial spines in
centimetres. The ischial spines are referred to as zero station, with the presenting
part being above ( cm) or below (+ cm) this. The ischial spines may be difficult to
palpate; this becomes a subjective measurement. It is important for the midwife to
ensure it is the level of the presenting part being assessed and not caput
succedaneum. Descent of the presenting part is one indicator of progress during
labour and the assessment should correlate with the findings from the degree of
engagement determined during the abdominal examination.
85. How is position assessed for a cephalic presentation during a VE?
By identification of sutures and fontanelles will confirm the position and attitude:
Sagittal suture is easily identified as a long straight suture; its position is taken in
relation to
the maternal pelvis, moving from back to front. A sagittal suture in the right oblique
is felt
moving from the posterior right quadrant of the maternal pelvis obliquely forwards
to the left anterior quadrant (Fig 30.3) and is indicative of LOA position or ROP
position.
Posterior fontanelle felt as a small triangular area, with 3 sutures running from it;
it is indicative of a well-flexed cephalic presentation, usually OP position.
Anterior fontanelle felt as a larger, diamond-shaped area, with 4 sutures running
from it and is associated with a deflexed head, usually with an OP position.
86. How is the pelvic outlet assessed during a VE?
Assessed by feeling for the ischial spines; if prominent, the transverse diameter of
the outlet is reduced and could affect progress, particularly in 2 nd stage.
Subpubic angle is assessed by moving the top part of the two examining fingers
towards the pubic arch. 2 fingers should fit snugly under the pubic arch, indicating
an angle of 90 or greater. A reduced subpubic angle is often found with prominent
ischial spines and may be associated with an android pelvis. This can result in more
pressure being placed on the perineum and increased perineal trauma as well as
delay in the second stage of labour. Care should be taken when assessing the
subpubic angle to avoid the clitoris; pressure on this structure can be painful.
87. What is the assessment of the fetus during a VE?
Presenting part cephalic / breech / compound
Sutures or fontanelles - what and where?
Caput & / or moulding?
Station in relation to ischial spines
88. What is the assessment of the pelvis during a VE?
Is it contracted or an android pelvis?
Sacral curve: can you reach the sacrum easily?
Ischial spines: prominent & very easily reached?
Gynaecoid pelvis
Sub pubic arch: Do 2 fingers fit side-by-Side under the arch?
89. What is done after a VE?
Listen to fetal heart

Maternal position & comfort

Discuss findings and care plan with woman
Record findings and care plan
90. When should VEs be offered during labour?
NICE (2007) 1st stage VE should be offered every 4 hours.
2nd stage- Offered hourly or in response to the womans wishes (after abdominal
palpation and assessment of vaginal loss)
91. What is the procedure for a VE?
Discuss the procedure fully with woman and gain informed consent
Ensure privacy
Gather equipment: apron, sterile gloves, lubricant, disposable sheet, other
equipment e.g. amnihook, fetal scalp electrode, Pinard or Sonicaid.
Encourage woman to empty bladder
Undertake abdominal palpation to ascertain lie, presentation, position, degree of
engagement and auscultate FH.
Ask the woman to adopt an almost recumbent position, knees bent, ankles together
and knees parted, disposable sheet placed beneath her buttocks (be aware of
difficulty experienced by women with pelvic girdle pain when opening their legs).
Remove any sanitary towels or underwear, keeping the genital area covered.
Apply apron; wash and dry hands.
Open the equipment to be used including the lubricating gel.
Apply hand gel, allow to dry then put on gloves.
Ask the woman to lift up the cover to allow access to the genital area.
Lubricate the first two fingers of the dominant hand with antiseptic cream.
With the thumb and forefinger of the non-examining hand, part the labia, observing
the condition of the vulva.
Inform the woman of what you are about to do and then, if no contraction present,
gently insert the first two fingers of the examining hand into the vagina, in a
downwards and backwards direction along the anterior vaginal wall, ensuring the
thumb does not come into contact with the woman's clitoris or anus.
Locate the cervix and determine the position, tone, degree of effacement and
dilatation and application to the presenting part
Move the fingers through the cervical os to ascertain the presence of the forewaters
and the presentation, position, degree of flexion and level of the presenting part;
the presence of caput succedaneum and degree of moulding should be noted.
If necessary and consent has been gained prior to the examination, rupture the
membranes and/or apply a fetal scalp electrode (pp. 207-209).
Withdraw the fingers gently, assessing the pelvic outlet.
Auscultate the fetal heart.
Assist the woman into a comfortable position, reapply sanitary pad if required and
discuss the findings.
Dispose of equipment appropriately and wash hands.
Document the findings and act accordingly.
92. What is the main reason for undertaking an examination per abdomen
during pregnancy?
To determine fetal wellbeing and to detect deviations from normality.
93. When is an EPA performed?

At every antenatal visit or as required.

Before Examination per vaginam (EPV).
94. What should be done before the examination is started?
Preparation of the environment to assure the womans confidentiality, privacy and
dignity.
Preparation of the midwife Required equipment, inspection of womans maternity
notes and hand hygiene.
Preparation of the woman Informed consent, appropriate position preventing
postural hypotension; womans comfort.
95. What are the common components of EPA in pregnancy?
Inspection: for visual appearance of the abdomen, to observe the size and shape;
skin changes in pregnancy normal pigmentation, scars, rashes, bruises and
trauma.
Palpation: To ascertain the lie, position and presentation. To feel for the abdominal
landmarks. Measurement of the symphysis-fundal height in correspondence to the
gestational age, it can be 2cm+/- to assess fetal growth. Fundal palpation to
detect and identify the fetal part(s) in the fundus, helps to determine the lie and
presentation. Lateral palpation to detect and identify the fetal part(s) in the body
of the uterus, carried out to locate fetal back or limbs and determine the position.
Pelvic palpation - to detect and identify the fetal part(s) in the lower pole of the
uterus, helps to determine the presentation and engagement in the latter weeks of
pregnancy, at term and in labour.
Auscultation: to listen to the fetal heart sounds. For maternal reassurance. Mother
should routinely be asked of fetal activity.
96. What are the examples of when the abdomen may be measuring
small or large for dates?
Small for dates Intra-uterine growth retardation (IUGR) due to placenta
insufficiency. Oligohydramnios, multiple pregnancy, uterine fibroids, large fetus,
maternal obesity.
97. What devices may be used for auscultation?
Pinard stethoscope or Doppler device sonicaid
98. Where can the fetal heart be located for auscultation?
Locating the fetal back and can be heard at a point over the fetal shoulder.
99. What is the normal fetal heart rate and how long is it auscultated for?
110-150 beats per minute (bpm) for 1 minute.
100. What are you listening to?
Normality of the fetal heart rate (FHR) and the rhythm (Regular).
101. What else should be simultaneously palpated?
Maternal pulse.
102. When trying to auscultate the fetal heart, what other noises can the
sonicaid up?
Uterine souffl soft blowing sound, corresponding to maternal pulse, which is
caused by the flowing of blood through the uterine arteries.

103. What is the lie?

The relationship of the long axis of the fetus to the long axis of the uterus. It could
be longitudinal, oblique or transverse.
104. What is the attitude
The relationship of the fetal head and limbs to its body. It may be fully flexed,
deflexed or extended.
105. What is the presentation
The part of the fetus lying in the lower pole of the uterus. It can be cephalic (vertex,
face, brow) breech or shoulder.
106. What are the position and the 6 possible positions in a cephalic
presentation.
The relationship of the denominator to six areas of maternal pelvis. The 6 possible
positions in a cephalic position are: Right and Left anterior: ROA and LOA. Left and
Right Lateral: ROL and LOL. Left and Right Posterior: ROP and LOP.
107. What is the denominator ?
The part of the presentation used to indicate the fetal position. It is the occiput in a
cephalic presentation. It is the sacrum in a breech presentation. It is the mentum in
a face presentation.
108. What is engagement and how is it measured during EPA?
Engagement of the fetal head occurs when the widest presenting transverse
diameter of the fetal head has passed through the pelvic brim. The amount of fetal
head above the pelvic brim is measured and described in fifths.
109. What are the key recommendations from NICE Guidelines (2008) for
antenatal care regarding the measurement of Symphysis Fundal Height?
NICE Clinical Guideline62 (2008) recommends measuring SFH at each schedule of
antenatal appointments from 25weeks gestation.
110. What should your actions be after the completion of EPA?
Discuss the findings with the woman.
Inform the mentor of EPA findings.
Assure dignity and assist the woman into an upright position.
Document the findings in the handheld notes or IT records.
Refer appropriately if there are deviations from normality.
111. AF
Artificial Feed
112. ANC
Antenatal Clinic
113. ANP
Advanced Neonatal Practitioner
114. APH
Antepartum Haemorrhage
115. ARM
Artificial Rupture of Membranes

116. BAT
Brown Adipose Tissue
117. BBA
Born before Arrival
118. BCP
Biochemical profile
119. BD
Twice Daily
120. BF
Breast Feeding
121. BFI
Baby Friendly Initiative
122. BMI
Body Mass Index
123. BNO
Bowels Not Open
124. BO
Had Bowels Open
125. BP
Blood Pressure
126. BPM
Beats per minute
127. CCT
Controlled Cord Traction
128. CEMACH
Confidential Enquiry into Maternal and Child Health
129. CESDI
Confidential Enquiry into Stillbirth and Deaths in Infancy
130. CSU
Catheter Specimen of Urine
131. CTG
Cardiotocograph
132. CS
Caesarean Section
133. C and S
Culture and Specimen
134. CVS
Chorionic Villus Sampling
135. CX
Cervix
136. D & C
Dilatation and Curettage
137. D & V
Diarrhoea and Vomiting
138. DIC
Disseminated Intravascular Coagulation
139. DNA
Did Not Attend
140. DTA
Deep Transverse Arrest

141. DVT
Deep Vein Thrombosis
142. EBM
Expressed Breast Milk
143. ECV
External Cephalic Version
144. EDD
Estimated Date of Delivery
145. EFM
Electronic fetal monitoring
146. EFW
Estimated Fetal Weight
147. Epis
episiotomy
148. EMLSCS
Emergency Lower Segment Caesarean Section
149. ERPC
Evacuation of Retained Products of Conception
150. FAS
Fetal Alcohol Syndrome
151. FBC
Full Blood Count
152. FBS
Fetal Blood Sample
153. FE
Iron
154. FGM
Female genital mutilation
155. FHR
Fetal Heart Rate
156. FHHR
Fetal Heart Heard Regular
157. FMF
Fetal Movements Felt
158. FSE
Fetal Scalp Electrode
159. GA
General anaesthetic
160. G and S
Group and Save
161. GBS
Group B Streptococcus
162. GI
Gastro-intestinal
163. GTT
Glucose Tolerance Test
164. HAI
Hospital Acquired Infection
165. HB
Haemoglobin

166. HBAC
Home Birth After Caesarean
167. HFFD
Haigh Ferguson Forceps Delivery
168. HELLP
Haemolysis, Elevated Liver Proteins and Low Platelets
169. HR
Heart Rate
170. HPV
Human Papilloma Virus
171. HVS
High Vaginal Swab
172. HSE
Health and Safety Executive
173. HSV
Herpes Simplex Virus
174. HX
History of...
175. I/P
Intrapartum
176. IOL
Induction of Labour
177. IM
Intramuscular
178. IU
International units
179. IUD
Intrauterine Device
180. IUD
Intrauterine Death
181. IUGR
Intrauterine Growth Retardation
182. IV
Intravenous
183. IVF
In vitro fertilisation
184. IVI
Intravenous infusion
185. KFD
Kielland Forceps Delivery
186. KSF
Knowledge Skills Framework
187. LBW
Low Birth Weight
188. LFD
Light for Dates
189. LFT
Liver Function Test
190. LMP
Last Menstrual Period

191. LOA
Left Occipto- Anterior
192. LOL
Left Occipito- Lateral
193. LOP
Left Occipito- Posterior
194. LOT
Left Occipito- Transverse
195. LSCS
Lower Segment Caesarean Section
196. LVS
low vaginal swab
197. MAP
Mean arterial pressure
198. MDT
Multi-Disciplinary Team
199. MEC
Meconium
200. MOT
Medical Obstetric Team
201. MRI
Magnetic Resonance Imaging
202. MSSU
Mid-Stream Specimen of Urine
203. MSU
Mid-Stream Urine
204. NAD
Nothing Abnormal Detected
205. NAS
Neonatal Abstinence Syndrome
206. NB
Normal Birth
207. NBFD
Neville Barnes Forceps Delivery
208. ND
Normal Delivery
209. NEC
Necrotizing enterocolitis
210. NICU
Neonatal Intensive Care Unit
211. NICE
National Institute of Clinical Excellence
212. NIEL
Not In Established Labour
213. NIDDM
Non- Insulin Dependent Diabetes Mellitus
214. NND
Neonatal Death
215. NNU
Neonatal Unit

216. NMC
Nursing and Midwifery Council
217. NSAID
Non- Steroidal Anti- Inflammatory Drug
218. NSF
National Service Framework
219. O/E
On Examination
220. ODA
Operating Department Assistant
221. ODP
Operating Department Practitioner
222. OP
Occipito Posterior
223. O/P
On Palpation (often written this way by the docs!)
224. P
Pulse
225. P/A
Par Abdomen (sometimes seen before documenting palpation)
226. PCT
Primary Care Trust
227. P/S
Per Speculum
228. PCA
Patient Controlled Analgesia
229. PE
Pulmonary Embolus
230. PIH
Pregnancy Induced Hypertension
231. PGD
Patient Group Directive
232. PKU
Phenylketonuria
233. PN
Postnatal
234. PO
Orally
235. PPH
Postpartum Haemorrhage
236. PP
Presenting Part
237. PPROM
Prelabour Premature Rupture of Membranes
238. PR
Per Rectum
239. PRN
As required
240. PROM
Premature Rupture of Membranes

241. PU
Pass Urine
242. PV
Per Vaginum
243. QDS
Four Times Daily
244. RDS
Respiratory Distress Syndrome
245. Rh
Rhesus factor
246. ROA
Right Occipito-Anterior
247. ROL
Right Occipito-Lateral
248. ROP
Right Occipito-Posterior
249. ROT
Right Occipito-Transverse
250. SB
Still Birth
251. SBR
Serum Bilirubin
252. SC
Subcutaneous
253. SCBU
Special Care Baby Unit
254. SFD
Small for Dates
255. SGA
Small for Gestational Age
256. SHO
Senior House Officer
257. SIDS
Sudden Infant Death Syndrome
258. SIGN
Scottish Intercollegiate Guidelines Network
259. SOB
Sub Occipto-Bregmatic
260. SOB
Shortness of Breath
261. SPD
Symphysis Pubis Disorder
262. SROM
Spontaneous Rupture of Membranes
263. STD
Sexually Transmitted Disease
264. STI
Sexually Transmitted Infection
265. STS
Skin To Skin

266. SVD
Spontaneous Vaginal Delivery
267. TCI
To Come In
268. TDS
Three times daily
269. TEDs Thromboembolic deterrent stockings
270. TTO
To take out (medications)
271. U and E
Urea and Electrolytes
272. USS
Ultrasound Scan
273. UTI
Urinary Tract Infection
274. VBAC
Vaginal Birth After Caesarean
275. VE
Vaginal Examination. Would be more correctly written epv (examination per
vaginam) as you are examining via the vagina, not examining the vagina itself!
276. VX
Vertex - the clinical name for the fetal head. Usually used during vaginal birth- the
first sighting of the fetal head would be written as VX (vertex) visible in the notes.