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OG13.5-7 | Normal Labour Skills — SDL Guide (Part 3)

Applied and Supervised Practice

The NMC competency levels for these three skills define the exact scope of practice expected of a final-year MBBS student at the end of their obstetrics posting. Understanding these levels prevents both under-confidence (not participating when you should) and over-confidence (attempting procedures beyond your scope).

OG13.5 — ARM (SH: observe/assist): At this level, you are expected to understand every step of the procedure and be present for its performance. In the skill lab, practise the technique on a simulator — identifying the internal os, inserting the amnihook in the correct plane, and releasing fluid without cord prolapse. At the bedside, your role is to prepare the instrument set, confirm the indication, check for cord presentation before the procedure, and monitor the fetal heart rate before and after. You do NOT perform ARM on a real patient independently at this stage.

OG13.6 — Stages of normal labour in simulated environment (SH: demonstrate): This is your OSCE-ready skill. In the skill lab with a birthing mannequin, you should be able to demonstrate: (1) engaging the fetal head model in the transverse diameter of the inlet; (2) flexing the head; (3) rotating 45 degrees to OA (internal rotation); (4) extending around the sub-pubic arch with perineal protection; (5) delivering the head; (6) checking for nuchal cord; (7) waiting for external rotation; (8) delivering the anterior then posterior shoulder; (9) lateral flexion for body delivery. Narrate each step aloud as you demonstrate it.

OG13.7 — Observe and assist normal vaginal delivery (P: observe/assist): In the delivery room, your role is active observation and participation in the surrounding tasks: setting up the delivery trolley, preparing the cord clamp, handing instruments, assisting with the AMTSL procedure, receiving and documenting the time of delivery, supporting the mother, and assisting with neonatal handover. You are not a passive bystander — you are a prepared, attentive participant who is building the experiential foundation for independent practice during internship.

Self-Assessment

This SDL has covered the three practical skills of intrapartum care — the partograph, ARM, and delivery conduct — in enough depth to prepare you for both your clinical assessment and your internship. The self-assessment for skills-based learning is different from factual recall: it requires you to visualise yourself performing the skill, anticipating decision points, and knowing when to escalate. A useful self-check for each skill is to ask yourself: 'If I were in the delivery room at 3 AM with a junior midwife and an unstable CTG, do I know what to do?' That question tests not just factual knowledge but procedural confidence and clinical judgement. Another effective self-check is to walk through a delivery in your mind from entry into the second stage to delivery of the placenta, narrating every action and identifying the exact moment at which each drug is given, each decision is made, and each escalation criterion is met.

Key consolidation points:
- Partograph: alert line starts at 4 cm at 1 cm/h; action line 4 h to the right; FHR auscultated every 30 min in first stage, every 5 min in second stage.
- Late decelerations = uteroplacental insufficiency = stop oxytocin, left lateral, oxygen, call senior.
- ARM contraindications: unengaged head, placenta praevia, cord presentation, active herpes.
- Post-ARM: always check FHR immediately; bradycardia = check for cord prolapse.
- Meconium: grade I = vigilance; grade II = alert paediatrics; grade III + late decelerations = emergency.
- Modified Ritgen manoeuvre = perineal protection during head delivery.
- AMTSL = oxytocin 10 IU IM with anterior shoulder delivery, CCT, uterine massage.
- Delayed cord clamping (1–3 min) recommended for term, non-compromised neonates.