Normal labour and birth — structured oral station (12 minutes)

Opening prompt — "Is this labour normal?"

Model response — lead with the definition, then the judgement: ^[1][2]

• "She is in the active first stage, which RANZCOG C-Obs 31 defines as regular painful contractions with substantial effacement and dilatation from 5 cm to full dilatation."
• "She has gained 1 cm in 4 hours, so this meets the RANZCOG consensus definition of slow labour — less than a 2 cm increase in dilatation over 4 hours from 5 cm. That is a prompt for me to reassess, not a diagnosis of obstruction."
• "The active first stage usually does not extend beyond 18 hours in a first labour and 12 hours in a subsequent labour, so she is well inside that envelope."^[1][3]

Examiner is listening for: the correct threshold, the parity split, and the word "reassess" rather than "augment". ^[1]

Probe 1 — "Reassess her, then. Talk me through it."

• The woman: pain relief and how she is coping, hydration and oral intake, ketones, exhaustion, temperature and pulse, and I would empty the bladder, because a full bladder mechanically obstructs and sustains inefficient contractions.^[1]
• The labour: abdominal palpation for fifths palpable and for contraction frequency, duration and strength by hand — the tocograph does not tell me strength; then vaginal examination for dilatation, effacement, station, position from the sagittal suture and fontanelles, and caput and moulding.^[1][3]
• The fetus: intermittent auscultation is appropriate while the labour is low risk, because continuous cardiotocography in low-risk labour increases caesarean and instrumental birth without reducing cerebral palsy or perinatal death. I would move to continuous monitoring if I started oxytocin or if anything changed.^[8]
• "I would then document a plan with a named review time."^[1]

Probe 2 — "Her partner is asking for the drip. What do you tell him?"

This is a scored communication domain, so speak the words out loud. ^[1][4]

• Sit down, at her eye level, address her first and bring him in: "Can I tell you both what I have found?"
• "Your labour is going more slowly than average, but slower than average is not the same as unsafe. You are both well, the baby is happy, and the cervix is opening."
• "The drip does shorten labour, but it does not reduce the chance of needing a caesarean, and it means continuous monitoring and less freedom to move. Right now I do not think you need it."
• "Here is what I would like to do instead — empty your bladder, keep you moving and upright, keep the midwife with you, and reassess in a set time. If things change, or if you change your mind, we will talk again."
• Name the evidence for what you are doing: continuous one-to-one support increases spontaneous vaginal birth and reduces caesarean birth.^[4]

Probe 3 — "She reaches full dilatation at 18:00, starts pushing at 18:30, and it is now 20:30. Head at plus 1, descending. What now?"

• "That is 2 hours of active pushing in a nulliparous woman, so RANZCOG recommends escalation — I would inform the consultant and document the review."^[1]
• "Escalation is not the same as operating. With a normal cardiotocograph, a well mother and a head that is descending, it is reasonable to support a further hour of active pushing if resources and transfer times allow."^[1][5]
• "I would justify that with outcomes: spontaneous vaginal birth falls from about 85% when the second stage is under an hour to 9% at 5 hours or more, and chorioamnionitis, severe perineal tears and atony all rise — but the second stage does not need to be terminated for duration alone."^[5]
• "What would change my mind: an abnormal fetal heart rate, maternal exhaustion or request, rising caput and moulding with a station that stops moving, or a head that is no longer descending."^[5][8]

Probe 4 — "She has a normal birth. Her plan says physiological third stage. Manage it."

• "I would have had this conversation antenatally or in early labour, not with a baby on her chest. Active management reduces postpartum haemorrhage and the need for transfusion — approximately halving the risk — but physiological management is a legitimate informed choice for a woman at low risk."^[6]
• "If she chooses active management: oxytocin 10 IU intramuscularly with or immediately after birth of the baby, controlled cord traction with suprapubic counter-traction only once the uterus is contracted and there are signs of separation, and deferred cord clamping for at least 60 seconds or until pulsation stops."^[6][7]
• "If she chooses physiological management: no uterotonic, no cord traction, await the signs of separation and maternal effort — and I would agree the conversion triggers with her in advance: more bleeding than expected, an undelivered placenta at the agreed time limit, or her changing her mind."^[6]
• "I would defer cord clamping either way, and I would tell her the one trade-off honestly — a slightly higher chance the baby needs phototherapy for jaundice."^[7]

Probe 5 — "Why did the WHO abandon the 1 cm per hour partograph line?"

• "Because it was never physiology. In a systematic review of 99 971 low-risk women with normal perinatal outcomes, the median time to advance by 1 cm in nulliparous women was longer than an hour until 5 cm was reached, and many women reached 10 cm despite rates far slower than 1 cm per hour throughout."^[2]
• "The Labour Care Guide replaced the fixed alert line with parity-specific reference thresholds, a 5 cm entry to the active phase, and a decision-support column. FIGO now supports it over the classic partograph."^[1][3]