History

Fact Explanation
Parity Normal labour is defined as term pregnancy with spontaneous onset of labor, with a vertex fetal presentation, vaginal delivery and normal neonatal outcomes. [3] Normal labor is a retrospective diagnosis. Usually the onset of labour is associated with painful uterine contractions palpated per abdomen, with progressive cervical dialatation with effacement. Rupture of the membranes are not essential for the diagnosis of onset of labour. Normal labour is divided into three phases. First phase starts from the first cervical dialatation upto the fullest dialatation of the cervix. Second phase is from the full dialatation of the cervix to the delivery of the fetus and third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes. [2] Duration for the each phase would be: first phase lasts 8-12 hours in a first labour, 3-8 hours in subsequent labours, second phase lasts 1-2 hours in a first labour, 0.5-1 hour in subsequent labours and third phase lasts up to an hour if physiological, 5-15 minutes if actively managed. [2] High parity (giving birth to the fifth to ninth baby) is associated with serious consequences to the fetus, the mother, such as abruptio placenta, anemia, placenta previa, and fetal malpresentation,s fetal macrosomia and cephalopelvic disproportion. Increase in the fetal size with birth order may be the cause for the macrosomia . [1] Grand multiparity is associated with low socioeconomic status and poor literacy level.
Age Elderly mothers [7] are more prone to complications during normal labour.
Ethnicity Indigenous ethnicity is a risk factor for postpartum haemorrhage. [1]
Past obstetric history Poor progression of labour [4] , macrosomic babies during the previous pregnancies are important as they can recur in subsequent pregnancies.
History of maternal diseases Hypertension [5] , diabetes mellitus, heart disease, seizures, thrombophilia like co-morbid disorders may influence the management. Ecclamptic fits can occur during the delivery. Gestational diabetes mellitus needs blood sugar checking and insulin as and when needed.
History of subfertility Current pregnancy following subfertility needs extra attention. [6]
Past history of caesarian section Vaginal birth after caessarian section [9] carries a risk of uterine rupture. If there has been vaginal births after caessaian section, success of this VBAC is increased.
History of antepartum haemorrhage Certain grades of placenta previa [8] (grade 2 posterior, 3 and 4) are unsuiyable for the vaginal delivery as they may cause massive bleeding.
References
  1. OMOLE-OHONSI A, ASHIMI AO. Grand multiparity: obstetric performance in Aminu Kano Teaching Hospital, Kano, Nigeria. Niger J Clin Pract [online] 2011 Jan-Mar, 14(1):6-9 [viewed 21 August 2014] Available from: doi:10.4103/1119-3077.79231
  2. STEER P, FLINT C. Physiology and management of normal labour BMJ [online] 1999 Mar 20, 318(7186):793-796 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115220
  3. ZHANG J, LANDY HJ, BRANCH DW, BURKMAN R, HABERMAN S, GREGORY KD, HATJIS CG, RAMIREZ MM, BAILIT JL, GONZALEZ-QUINTERO VH, HIBBARD JU, HOFFMAN MK, KOMINIAREK M, LEARMAN LA, VAN VELDHUISEN P, TROENDLE J, REDDY UM. Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes Obstet Gynecol [online] 2010 Dec, 116(6):1281-1287 [viewed 22 August 2014] Available from: doi:10.1097/AOG.0b013e3181fdef6e
  4. LAUGHON SK, ZHANG J, TROENDLE J, SUN L, REDDY UM. Using a Simplified Bishop Score to Predict Vaginal Delivery Obstet Gynecol [online] 2011 Apr, 117(4):805-811 [viewed 19 September 2014] Available from: doi:10.1097/AOG.0b013e3182114ad2
  5. UZAN J, CARBONNEL M, PICONNE O, ASMAR R, AYOUBI JM. Pre-eclampsia: pathophysiology, diagnosis, and management Vasc Health Risk Manag [online] 2011:467-474 [viewed 19 September 2014] Available from: doi:10.2147/VHRM.S20181
  6. HART R. Unexplained infertility, endometriosis, and fibroids BMJ [online] 2003 Sep 27, 327(7417):721-724 [viewed 19 September 2014] Available from: doi:10.1136/bmj.327.7417.721
  7. Editorial: Care of elderly primigravida. Br Med J [online] 1975 Jun 21, 2(5972):650-651 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1673554
  8. VAN WYCK HB. Antepartum Haemorrhage Can Med Assoc J [online] 1943 Dec, 49(6):504-509 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1827987
  9. GUISE JM, EDEN K, EMEIS C, DENMAN MA, MARSHALL N, FU RR, JANIK R, NYGREN P, WALKER M, MCDONAGH M. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) [online] 2010 Mar:1-397 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20629481

Examination

Fact Explanation
General abdominal signs of normal pregnancy: Enlarged abdomen, linea nigra, abdominal striae, inverted umbilicus These are usual changes seen in a normal pregnancy. [9]
Lie of the fetus This is the relation of the long axis of the fetus to that of the mother, and is either longitudinal or transverse. [5]
Fetal presentation [3] Portion of the fetal body that is enters the birth canal or in closest proximity to it is the presenting part. [3] This may be fetal head or breech (cephalic and breech presentations).
Position of the fetus Majority of them are in left oocipito anterior position. Occipito-posterior (OP) fetal head position during the first stage of labour occurs in 10-34% of cephalic presentations. Spontaneous rotaion in anterior position before delivery, may occurs and 5-8% will persist in OP position. [2]
Cervical examination Bishops score [4] is used to assess the favourabillity of the cervix. Cervical dialatation, effacement, length, station and position of the cervix are the 5 components and if the total score is 9-10 she is already in labour, 7-9 induction is possible, less than 6 is not suitable for induction.
Assessment of fetal descent abdominally Progression of labour [4] is assessed abdominally and expressed in fifths. If no finger breaths are palpated abdominally, head is engaged.
Abdominal tenderness Mothers presenting with vaginal birth after caessarian section [8] has a risk 0f uterine rupture.
Abdominal contractions Onset of labour is associated with painful uterine contractions that can be palpated perabdomen. Usually there will be 3 contractions/minute under normal conditions. If there is more than 4 contractions per minute , one has to be alerted on hyperstimulation [7] of the uterus. There are painless contractions: Braxton hicks contractions which are less efficient and are not true contractions.
Fetal heart sound Monitoring the fetal heart rate(FHR) is done by listening to the heart beat using a pinard stethoscope. which is a special trumpet shaped device. [1] Usually heart rate is between 110-160bpm. More than 160 is considered as tachycardia, and less than 110 is bradycardia. Fetal tachycardia (>160-180 bpm) may be due to infections, fetal distress anaemia.
Maternal tachycardia Maternal tachycardia (>120 beats per minute [bpm]) may be due to chorioamnionitis [6] or ny other infection.
References
  1. SMITH VALERIE, BEGLEY CECILY M, CLARKE MIKE, DEVANE DECLAN. Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. Array [online] 2012 December [viewed 22 August 2014] Available from: doi:10.1186/1471-2393-12-166
  2. GUITTIER MJ, OTHENIN-GIRARD V, IRION O, BOULVAIN M. Maternal positioning to correct occipito-posterior fetal position in labour: a randomised controlled trial BMC Pregnancy Childbirth [online] :83 [viewed 22 August 2014] Available from: doi:10.1186/1471-2393-14-83
  3. SWANSON RW. Maternal Counting of Fetal Movements. Part II: Case Presentations Can Fam Physician [online] 1988 Mar:567-569 [viewed 22 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219039
  4. LAUGHON SK, ZHANG J, TROENDLE J, SUN L, REDDY UM. Using a Simplified Bishop Score to Predict Vaginal Delivery Obstet Gynecol [online] 2011 Apr, 117(4):805-811 [viewed 19 September 2014] Available from: doi:10.1097/AOG.0b013e3182114ad2
  5. BANCROFT-LIVINGSTON G, GORDON H. Unstable lie in pregnancy and in labour. Postgrad Med J [online] 1967 Feb, 43(496):92-96 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466233
  6. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 19 September 2014] Available from: doi:10.1016/j.clp.2010.02.003
  7. ARROWSMITH S, KENDRICK A, WRAY S. Drugs acting on the pregnant uterus Obstet Gynaecol Reprod Med [online] 2010 Aug, 20(8):241-247 [viewed 19 September 2014] Available from: doi:10.1016/j.ogrm.2010.05.001
  8. GUISE JM, EDEN K, EMEIS C, DENMAN MA, MARSHALL N, FU RR, JANIK R, NYGREN P, WALKER M, MCDONAGH M. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) [online] 2010 Mar:1-397 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20629481
  9. KAR S, KRISHNAN A, SHIVKUMAR PV. Pregnancy and Skin J Obstet Gynaecol India [online] 2012 Jun, 62(3):268-275 [viewed 19 September 2014] Available from: doi:10.1007/s13224-012-0179-z

Differential Diagnoses

Fact Explanation
Urinary Tract Infection [4] Dysuria, urgency, frequency, flank pain with suprapubic and costovertebral angle tenderness may be present. Upper tract involvement is suggested by fever, chills, and malaise. Urine full report will show pus cells and red blood cells. Inflammatory markers will be high. Urine culture may be positive. If left untreated UTIs can lead to complications, such as pyelonephritis, low-birth-weight infants, premature delivery and stillbirth. [1]
Chorioamninitis [3] Chorioamnionitis may be associated with fever (an intrapartum temperature >100.4ºF or >37.8ºC), maternal tachycardia (>120 bpm), fetal tachycardia (>160 bpm), purulent or foul-smelling amniotic fluid or vaginal discharge and uterine tenderness. [2] Investigations will reveal maternal leukocytosis and high CRP.
False abdominal contractions Braxton Hicks contractions [5] are seen in most pregnancies from about 24 weeks gestation which are usually painless. These are not true uterine contractions.
References
  1. LEE M, BOZZO P, EINARSON A, KOREN G. Urinary tract infections in pregnancy Can Fam Physician [online] 2008 Jun, 54(6):853-854 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426978
  2. TITA AT, ANDREWS WW. Diagnosis and Management of Clinical Chorioamnionitis Clin Perinatol [online] 2010 Jun, 37(2):339-354 [viewed 19 September 2014] Available from: doi:10.1016/j.clp.2010.02.003
  3. BOHRER JC, KAMEMOTO LE, ALMEIDA PG, OGASAWARA KK. Acute Chorioamnionitis at Term Caused by the Oral Pathogen Fusobacterium Nucleatum Hawaii J Med Public Health [online] 2012 Oct, 71(10):280-281 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3484970
  4. EMIRU T, BEYENE G, TSEGAYE W, MELAKU S. Associated risk factors of urinary tract infection among pregnant women at Felege Hiwot Referral Hospital, Bahir Dar, North West Ethiopia BMC Res Notes [online] :292 [viewed 19 September 2014] Available from: doi:10.1186/1756-0500-6-292
  5. DUNN P. John Braxton Hicks (1823-97) and painless uterine contractions Arch Dis Child Fetal Neonatal Ed [online] 1999 Sep, 81(2):F157-F158 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1720982

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan This is useful to detect the lie, presentation and position of the fetus at the onset of labour. It also simultaneously detects the mother’s contractions using a pressure sensor. Therefore can be used to monitor the maternal contractions. [1]
Cardiactocography (CTG) Is done when there is suspicion about the fetal well being. [2] Toco is placed over the uterine fundus to detect the uterine contractions. Usual rate of contractions will be 3/minute.
References
  1. SMITH VALERIE, BEGLEY CECILY M, CLARKE MIKE, DEVANE DECLAN. Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. Array [online] 2012 December [viewed 22 August 2014] Available from: doi:10.1186/1471-2393-12-166
  2. CHERN CJ, BEUTLER E. Biochemical and electrophoretic studies of erythrocyte pyridoxine kinase in white and black Americans. Am J Hum Genet [online] 1976 Jan, 28(1):9-17 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2009

Investigations - Fitness for Management

Fact Explanation
Haemoglobin If there is anaemia it should be corrected before the delivery. [2]
Blood grouping and Rh typing Rh negative previously unsentizised mothers should receive rhogum after delivery. [3]
Oral glucose toleranse test/post prandial blood sugar [1] Suspected fetal macrosomia may be due to the gestational diabetes mellitus. [1]
References
  1. ZECK W, SCHLEMBACH D, PANZITT T, LANG U, MCINTYRE D. Management of Diabetes in Pregnancy: Comparison of Guidelines with Current Practice at Austrian and Australian Obstetric Center Croat Med J [online] 2007 Dec, 48(6):831-841 [viewed 26 July 2014] Available from: doi:10.3325/cmj.2007.6.831
  2. BAROOTI E, REZAZADEHKERMANI M, SADEGHIRAD B, MOTAGHIPISHEH S, TAYERI S, ARABI M, SALAHI S, HAGHDOOST AA. Prevalence of Iron Deficiency Anemia among Iranian Pregnant Women; a Systematic Review and Meta-analysis J Reprod Infertil [online] 2010, 11(1):17-24 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719272
  3. CACCIATORE A, RAPITI S, CARRARA S, CAVALIERE A, ERMITO S, DINATALE A, IMBRUGLIA L, RECUPERO S, LA GALIA T, PAPPALARDO EM, ACCARDI MC. Obstetric management in Rh alloimmunizated pregnancy J Prenat Med [online] 2009, 3(2):25-27 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279102

Investigations - Followup

Fact Explanation
Doppler studies [1] There can be placental insufficiency that can cause fetal compromise. Blood flow velocity waveforms are recorded from the umbilical arteries, the middle cerebral artery, and the descending thoracic aorta. Resistance index and pulsatility index is also measured. Absent or reverse end-diastolic flow in the umbilical artery is an indicator of fetal compromise. [2] Doppler studies are repeated at intervals not less than 2 weeks.
Cardiactocography (CTG) Is done when there is suspicion about the fetal well being. Absence of accelerations, presence of decelerations, and reduced variability are found in fetal distress. [3]
References
  1. WHITWORTH M, BRICKER L, NEILSON JP, DOWSWELL T. Ultrasound for fetal assessment in early pregnancy Cochrane Database Syst Rev [online] :CD007058 [viewed 20 August 2014] Available from: doi:10.1002/14651858.CD007058.pub2
  2. HECHER K., CAMPBELL S., DOYLE P., HARRINGTON K., NICOLAIDES K.. Assessment of Fetal Compromise by Doppler Ultrasound Investigation of the Fetal Circulation : Arterial, Intracardiac, and Venous Blood Flow Velocity Studies. Circulation [online] 1995 January, 91(1):129-138 [viewed 26 July 2014] Available from: doi:10.1161/01.CIR.91.1.129
  3. CHERN CJ, BEUTLER E. Biochemical and electrophoretic studies of erythrocyte pyridoxine kinase in white and black Americans. Am J Hum Genet [online] 1976 Jan, 28(1):9-17 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2009

Investigations - Screening/Staging

Fact Explanation
Modifiec biophysical profile (nonstress test and amniotic fluid volume ) Monitoring the fetuses with retarded growth, macrosomia and post term pragnancies etc may need assessing the amniotic fluid volume. A nonstress test and amniotic fluid volume assessment is usually sufficient. [1,2]
References
  1. WHITWORTH M, BRICKER L, NEILSON JP, DOWSWELL T. Ultrasound for fetal assessment in early pregnancy Cochrane Database Syst Rev [online] :CD007058 [viewed 20 August 2014] Available from: doi:10.1002/14651858.CD007058.pub2
  2. CZERESNIA JM, ARAUJO JúNIOR E, CORDIOLI E, MARTINS WP, NARDOZZA LM, MORON AF. Applicability of the Rapid Biophysical Profile in Antepartum Fetal Well-Being Assessment in High-Risk Pregnancies from a University Hospital in S?o Paulo, Brazil: Preliminary Results ISRN Obstet Gynecol [online] :329542 [viewed 20 August 2014] Available from: doi:10.1155/2013/329542

Management - General Measures

Fact Explanation
Management of high risk pregnancies Grandmulty parity, elderly primi, teenage pregnancies, mothers with co morbid disorders [3] , past history of poor progression, vaginal birth after caesarian section, anaemia, are some of the high risk pregnancies that needs specific management.
Vaginal Birth After Cesarean section Requirement for induction, need for the of caesarean delivery and risk of uterine rupture is increased in VBAC compared with similar women with spontaneous labour. Perinatal mortality is significantly increased in VBAC than in elective repeat cesarean delivery (ERCD). [1] Mothers presenting for VBAC should be carefully councelled regarding the rare risk of uterine rupture and informed written consent should be taken.
Correction of risk factors before the delivery Anaemia [5] causes worsening of postpartum haemorrhage. Therefore it has to be corrected and blood should be reserved in an case of emergency.
Management of Rh negative mothers Rhesus negative [6] previously unsensitized mothers should be planned to be given rhogum within 72 hours of delivery.
Psychological support Reassurance and education of the labour done in antenatal period is important in alleviating fear during the labour. Allowing a guardian to be with the mother during the labour is new concept that will improve the outcome. [2]
Pelvic assessment Pelvic assessment should be done to see the adequacy of the pelvis [4] for the normal vaginal delivery.
References
  1. GUISE JM, EDEN K, EMEIS C, DENMAN MA, MARSHALL N, FU RR, JANIK R, NYGREN P, WALKER M, MCDONAGH M. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep) [online] 2010 Mar:1-397 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20629481
  2. SMITH VALERIE, BEGLEY CECILY M, CLARKE MIKE, DEVANE DECLAN. Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis. Array [online] 2012 December [viewed 22 August 2014] Available from: doi:10.1186/1471-2393-12-166
  3. UZAN J, CARBONNEL M, PICONNE O, ASMAR R, AYOUBI JM. Pre-eclampsia: pathophysiology, diagnosis, and management Vasc Health Risk Manag [online] 2011:467-474 [viewed 19 September 2014] Available from: doi:10.2147/VHRM.S20181
  4. BANCROFT-LIVINGSTON G, GORDON H. Unstable lie in pregnancy and in labour. Postgrad Med J [online] 1967 Feb, 43(496):92-96 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466233
  5. BAROOTI E, REZAZADEHKERMANI M, SADEGHIRAD B, MOTAGHIPISHEH S, TAYERI S, ARABI M, SALAHI S, HAGHDOOST AA. Prevalence of Iron Deficiency Anemia among Iranian Pregnant Women; a Systematic Review and Meta-analysis J Reprod Infertil [online] 2010, 11(1):17-24 [viewed 27 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719272
  6. CACCIATORE A, RAPITI S, CARRARA S, CAVALIERE A, ERMITO S, DINATALE A, IMBRUGLIA L, RECUPERO S, LA GALIA T, PAPPALARDO EM, ACCARDI MC. Obstetric management in Rh alloimmunizated pregnancy J Prenat Med [online] 2009, 3(2):25-27 [viewed 18 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279102

Management - Specific Treatments

Fact Explanation
Induction of labour In unfavorable cervices, there is slight advantage of labour induction using cervical-ripening agents. Cervical ripening is done using either surgical or medical methods. Arteficial separation of the membranes, foley catheters, prostaglandins are used for the ripening of the cervix. Prostaglandins should be used carefully in low doses as there is an increased risk of uterine tachysystole and hyperstimulation. When prostaglandin is used, fetal heart rate monitoring is important to detect the fetal compromise. [2]
Assess the progression of the labour Labour progression is usually assessed with the bishop score. [1] First stage and second stage has to be monitored to detect complications such as poor progression of labour. Partogram has to be carefully maintainedfrom the onset of first cervical dialatation to detect poor progression.
Augmentation of the labour [4] Duration of 1st stage of labor is significantly reduced with use of oxytocin. [6] Usually 2U for multi and 5U for nulliparous women may be adequate. High dose oxytocin regimen (starting dose at 4 mU/min. and increment of 4 mU/min.) is usually used. Nulliparas women may require more dose than and multiparas. [4] The maternal complications of oxytocin includes intrapartum placental abruption, postpartum hemorrhage, intrapartum and postpartum blood transfusion and hysterectomy. The neonatal complications includes asphyxia, hypoxia-ischemic encephalopathy, neonatal seizure, neonatal death, respiratory distress syndrome. [4]
Management of the first and second stage of labour Mother should be asked to empty the bladder, taken into the labour room with the onset of labour. First stage progression of labour shoud be monitored with partogram. Maternal heart rate, blood pressure, respiratory rate and temperature needs to be monitored. Fetal welbeing is checked with fetal heart rate, CTG monitoring, and colour of amniotic fluid. Diameter of cervix is monitored 4 hourly and pain relief, maintaining the hydration has to be considered. With the onset of crowning [5] , delivery has to be done under sterile conditions and episiotomy [5] is done needed.
Normal vaginal delivery Experienced persons should attend the delivery. Sterile techniques should be employed. Apgar score [7] shoul be checked after delivery of the baby. If it is more than 7, no resuscitation needed and , if less than 7, resuscitation may needed.
Management of third stage of labour Active management of third stage of labour is important to prevent postpartum haemorrhage. [3] Third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Oxytocin [6] used at 5–10 IU after delivery, controlled cord traction, uterine massage[3] are the components in this active management. Pssive management without any interventions also can be done waitng for the spontaneous delivery of the placenta. Other third stage interventions include squeezing the uterus from the fundus to expel the placenta (Credé maneuver) , placental cord drainage, umbilical vein injection. [3]
Postpartum care Breast feeding has to be initiated within 1/2 hour of delivery. Mother is monitored for 2 hours in the labour room and then send to the ward. Neonate has to be examined for any abnormalities. Vitamin K [8] is given to the baby immediately after delivery and BCG before discharge from the hospital. Previously unsensitized rhesus negative mothers should be given rhogum. Follow up visit should be arranged to Induction of labourost natal clinic.
References
  1. STEER P, FLINT C. Physiology and management of normal labour BMJ [online] 1999 Mar 20, 318(7186):793-796 [viewed 21 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115220
  2. GALAL M, SYMONDS I, MURRAY H, PETRAGLIA F, SMITH R. Postterm pregnancy Facts Views Vis Obgyn [online] 2012, 4(3):175-187 [viewed 20 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991404
  3. GüLMEZOGLU AM, WIDMER M, MERIALDI M, QURESHI Z, PIAGGIO G, ELBOURNE D, ABDEL-ALEEM H, CARROLI G, HOFMEYR GJ, LUMBIGANON P, DERMAN R, OKONG P, GOUDAR S, FESTIN M, ALTHABE F, ARMBRUSTER D. Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial Reprod Health [online] :2 [viewed 22 August 2014] Available from: doi:10.1186/1742-4755-6-2
  4. ZHANG J, BRANCH DW, RAMIREZ MM, LAUGHON SK, REDDY U, HOFFMAN M, BAILIT J, KOMINIAREK M, CHEN Z, HIBBARD JU. Oxytocin Regimen for Labor Augmentation, Labor Progression, Perinatal Outcomes Obstet Gynecol [online] 2011 Aug, 118(2 0 1):249-256 [viewed 22 August 2014] Available from: doi:10.1097/AOG.0b013e3182220192
  5. ALBERS LL, SEDLER KD, BEDRICK EJ, TEAF D, PERALTA P. Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial J Midwifery Womens Health [online] 2005, 50(5):365-372 [viewed 19 September 2014] Available from: doi:10.1016/j.jmwh.2005.05.012
  6. SOSA CG, ALTHABE F, BELIZAN JM, BUEKENS P. Use of oxytocin during early stages of labor and its effect on active management of third stage of labor Am J Obstet Gynecol [online] 2011 Mar, 204(3):238.e1-238.e5 [viewed 19 September 2014] Available from: doi:10.1016/j.ajog.2010.10.005
  7. CHADHA IA. Neonatal resuscitation: Current issues Indian J Anaesth [online] 2010, 54(5):428-438 [viewed 19 September 2014] Available from: doi:10.4103/0019-5049.71042
  8. RENNIE JM, KELSALL AW. Vitamin K prophylaxis in the newborn--again. Arch Dis Child [online] 1994 Mar, 70(3):248-251 [viewed 19 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029755