Labor, Birth, and Immediate Postpartum

The largest domain. It spans normal labor support, intrapartum complications, immediate newborn care, third stage, hemorrhage, repair, and breastfeeding initiation.

Normal labor. Support the normal physiologic process. Assess maternal and fetal status: vital signs, hydration/intake, membrane status, contraction frequency/duration/intensity, fetal heart tones, and fetal lie, presentation, position, and descent (station), along with cervical effacement and dilation. Provide comfort — position changes, counter-pressure, movement, hydrotherapy — and counsel on early labor and on waterbirth benefits/risks and setup.

Stalled or abnormal labor. Recognize and respond to causes of slow progress: an anterior/swollen cervical lip, occiput-posterior or asynclitic position, maternal exhaustion, fear, dehydration, deep transverse arrest, and obstructed labor. Use positioning, rest, hydration/nutrition, and non-allopathic measures, and know when slow progress warrants consultation or transfer.

Intrapartum emergencies. Recognize and manage or transfer:

• Abnormal fetal heart-rate patterns — persistent bradycardia, or late/variable decelerations that don't resolve.
• Cord prolapse — relieve pressure on the cord (knee-chest/Trendelenburg, lift the presenting part) and transport emergently.
• Nuchal cord — reduce over the head, or use the somersault maneuver; clamp/cut only if truly tight and reduction fails.
• Shoulder dystocia — a stepwise drill: call for help, McRoberts (hyperflexed hips) and suprapubic pressure, Gaskin (hands-and-knees) maneuver, deliver the posterior arm, and internal rotational (Rubin/Woods) maneuvers; avoid fundal pressure.
• Breech, face, and brow presentations — understand the mechanisms and be ready to support delivery or transfer, and to resuscitate.
• Meconium-stained fluid — assess degree and follow standard neonatal resuscitation (per AAP/NRP) if the newborn is non-vigorous.
• Uterine rupture, uterine inversion, amniotic-fluid embolism, and stillbirth — recognize, stabilize, and transport.

Second stage and birth. Recognize progress, support spontaneous/physiologic pushing and positions, protect the perineum with appropriate hand techniques, and know the (limited) indications for episiotomy.

Immediate newborn care. Support normal transition: keep the newborn warm and skin-to-skin, assign APGAR at 1 and 5 minutes (and 10 if needed), and assess breathing and heart rate. If the newborn is not breathing/vigorous, begin NRP steps — warm, dry, stimulate, position the airway, and provide positive-pressure ventilation as the priority intervention. Delay cord clamping until pulsation stops when appropriate; assess the cord vessels (normally two arteries and one vein). Recognize and transport for birth defects, meconium aspiration syndrome, and signs of CNS compromise.

Third stage. Recognize signs of placental separation (a gush of blood, cord lengthening, a rise in the fundus, the urge to push). Facilitate delivery with maternal effort, nipple stimulation/position change, an empty bladder, and guarded (controlled) cord traction — never uncontrolled traction, which risks inversion. Inspect the placenta and membranes for completeness.

Blood loss and hemorrhage. Estimate and monitor blood loss. For a trickle, find the source, massage the fundus, empty the bladder, and encourage breastfeeding. For postpartum hemorrhage, the most common cause is uterine atony — respond in a stepwise way: fundal massage first, then uterotonics (oxytocin, then methylergonovine — not if hypertensive — or misoprostol), bimanual compression, IV fluids, treat for hypovolemic shock, and consult/transfer while activating the emergency plan. Remember the "4 T's" of PPH: Tone, Trauma, Tissue, Thrombin.

Maternal assessment and repair. Assess the bladder (encourage voiding or catheterize), and inspect the vagina, cervix, and perineum for hematoma, prolapse, and lacerations (know the degrees: 1st = skin/mucosa, 2nd = perineal muscle, 3rd = anal sphincter, 4th = rectal mucosa). Repair first- and second-degree tears within scope using local anesthetic; 3rd/4th-degree tears require referral. Instruct on perineal care and monitor vital signs.

Breastfeeding initiation and newborn exam. Facilitate early breastfeeding — colostrum, skin-to-skin, latch, positioning, and normal output. Perform a complete newborn exam head-to-toe (fontanels, red reflex, palate and tongue-tie, clavicles, heart/lung sounds, abdomen, genitalia, hip check for dislocation, spine, tone, and reflexes — suck, root, Moro, grasp, Babinski, step). Assess gestational age; administer eye prophylaxis and vitamin K with informed consent; and review GBS status with a follow-up plan.