18.3 Labour, Puerperium & Neonatology

18.3 Labour, Puerperium & Neonatology

Quick Answer: Define the labour stage first, then ask whether delay is power, passenger, or passage. Score APGAR at 1 and 5 minutes but never delay resuscitation for the score. Jaundice in the first 24 hours is pathological until investigated; physiological jaundice appears later in a well baby.

Labour is the process by which the fetus, placenta, and membranes are expelled through the birth canal via regular, painful uterine contractions that produce progressive cervical change.

Stages of Labour

True versus false labour

True labour: contractions increase in frequency/intensity/duration, discomfort usually starts in back and radiates forward, cervical dilatation/effacement progresses, not relieved by sedation alone.

False labour (Braxton Hicks intensifying): irregular, mainly abdominal, no progressive cervical change, often relieved by rest/hydration.

First-stage detail and the 3 Ps

• Latent phase: cervix effaces and dilates slowly (commonly cited up to ~4–6 cm depending on guideline).
• Active phase: faster dilatation to 10 cm; failure to progress raises questions of power, passenger, passage (the 3 Ps), and may include malposition/malpresentation.

Partograph concepts: alert and action lines, monitoring fetal heart, liquor, moulding, contractions, maternal vitals—recognise arrest of labour patterns in stems.

Second and third stages

Second-stage duration norms differ for primigravida vs multigravida and with epidural use; prolonged second stage increases hypoxia and trauma risk. Cardinal movements (engagement, descent, flexion, internal rotation, extension, restitution, external rotation, expulsion) explain mechanism of normal vertex delivery.

Third-stage signs of placental separation: uterus becomes firm and globular, sudden gush of blood, lengthening of cord, uterus rises. Controlled cord traction only with countertraction and training; never pull before separation signs.

Mechanism of Normal Labour (Vertex) and Malpresentation Cues

Engagement in the pelvic brim precedes effective descent. Flexion presents the smallest diameters; internal rotation brings the occiput under the pubic arch; extension delivers the head; restitution and external rotation align the shoulders for delivery. Failure of rotation (persistent occipito-posterior) prolongs second stage and increases instrumental delivery or caesarean likelihood—stems often hide this as “back labour” with slow progress.

Malpresentations (breech, face, brow, shoulder) change management thresholds; cord prolapse risk rises with ill-fitting presenting parts and ruptured membranes. PROM raises infection and cord-prolapse concern; meconium-stained liquor flags fetal distress risk, especially in post-term or growth-restricted fetuses.

Puerperium Basics

Puerperium is the ~6-week period of maternal physiological return toward non-pregnant state.

High-yield processes:

• Uterine involution: fundus descends ~1 cm/day; by ~2 weeks in pelvis; lochia rubra → serosa → alba
• Lactation: prolactin and oxytocin; engorgement vs mastitis (fever, wedge redness, systemic toxicity)
• Complications: PPH (primary/secondary), puerperal sepsis, DVT/PE, postpartum blues vs depression vs psychosis, urinary retention, perineal wound issues

Secondary PPH often links to retained products or infection—fever + bleeding after day 1 should trigger that differential. Sheehan syndrome (postpartum pituitary necrosis after catastrophic haemorrhage) links obstetric shock to later failure of lactation and secondary amenorrhoea—an elegant cross-chapter trap.

APGAR Score

Named for Virginia Apgar; scored at 1 and 5 minutes (and further if needed):

Interpretation (classic teaching):

• 7–10: reassuring
• 4–6: moderately depressed—needs stimulation/support
• 0–3: severely depressed—needs immediate resuscitation

APGAR is not used to decide whether to start resuscitation; begin neonatal resuscitation based on breathing, tone, and heart rate immediately after birth. Five-minute score correlates better with outcomes than the one-minute score alone.

Neonatal Asphyxia / Perinatal Asphyxia

Birth asphyxia conceptually: impaired gas exchange leading to hypoxia, hypercarbia, and metabolic acidosis, with failure to initiate or sustain breathing. Causes include prolonged labour, cord prolapse, abruption, maternal hypotension, shoulder dystocia, meconium aspiration, and prematurity.

Immediate priorities (ABCD mindset):

1. Warmth and drying; stimulate
2. Open airway; clear secretions if needed
3. Positive-pressure ventilation if not breathing effectively
4. Chest compressions if heart rate remains very low despite ventilation
5. Advanced drugs/volume only as protocol dictates

Hypoxic–ischaemic encephalopathy (HIE) grading and therapeutic hypothermia decisions are advanced neonatology—but AIAPGET may ask early signs: poor tone, seizures, feeding difficulty, multi-organ dysfunction.

Neonatal Jaundice

Jaundice is visible yellowing from elevated bilirubin. Almost all newborns have some rise; the exam task is physiological versus pathological.

Physiological jaundice

• Appears after 24 hours of life
• Peaks around day 3–4 in term babies (later in preterm)
• Baby generally well, feeding adequately
• Resolves within ~1–2 weeks in term infants

Pathological clues

• Visible jaundice in first 24 hours
• Rapid rise, very high levels, conjugated hyperbilirubinaemia
• Anaemia, hepatosplenomegaly, illness, poor feeding, dark urine/pale stools (obstructive pattern)
• Causes: ABO/Rh incompatibility, sepsis, bruising/cephalohematoma, G6PD deficiency, hypothyroidism, biliary atresia (later conjugated picture), breast-milk jaundice (prolonged but usually benign—diagnosis of exclusion)

Kernicterus risk with extreme unconjugated hyperbilirubinaemia—acute bilirubin encephalopathy signs (lethargy, high-pitched cry, arching) are emergencies.

Phototherapy and exchange transfusion thresholds depend on age-in-hours and risk factors; stems often test timing and “first 24 hours = investigate,” not exact irradiance numbers.

Immediate Newborn Care After Delivery

Beyond APGAR documentation: delay cord clamping when mother and baby are stable (protocol-dependent), dry and stimulate, maintain skin-to-skin when appropriate, initiate breastfeeding early, give vitamin K and eye prophylaxis per national schedule, and identify danger signs (poor feeding, grunting, flaring, central cyanosis, seizures, temperature instability). Caput succedaneum crosses suture lines and resolves quickly; cephalhematoma is subperiosteal, does not cross sutures, and may worsen jaundice from blood breakdown.

Linking Labour Events to Neonatal Status

Exam vignettes frequently connect:

• Prolonged second stage / non-reassuring fetal heart → low APGAR / asphyxia
• Prematurity → respiratory distress + jaundice vulnerability
• Instrumental delivery → trauma, cephalhematoma → exaggerated jaundice
• Maternal diabetes → polycythaemia/hypoglycaemia patterns
• Meconium-stained liquor + depression at birth → meconium aspiration risk

For Homoeopathy papers, Chamomilla or Cina may appear in paediatric irritability stems, but labour–neonate physiology remains the scoring backbone of this section’s allopathic MCQs.