Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG) Intrapartum Care and Obstetric Emergencies Syllabus

Intrapartum Care and Obstetric Emergencies syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Intrapartum Care and Obstetric Emergencies in Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), not a summary of it.

1. 1

   Normal Labour and Delivery

   5 topics

   • Mechanisms and stages of labour
   • Assessment of labour progress and the partogram
   • Fetal monitoring in labour
     • Intermittent auscultation and CTG interpretation
     • Fetal blood sampling and adjuncts
   • Pain relief in labour
   • Care of the perineum and physiological third stage
2. 2

   Abnormal and Complicated Labour

   5 topics

   • Failure to progress and the dysfunctional labour
   • Induction and augmentation of labour
   • Malpresentation and malposition
     • Breech presentation and external cephalic version
     • Occipito-posterior and transverse lie
   • Preterm labour and prelabour rupture of membranes
   • Care of the woman with a previous caesarean (VBAC)
3. 3

   Operative Delivery

   4 topics

   • Instrumental vaginal delivery
     • Forceps and ventouse: indications and technique
   • Caesarean section: indications, classification and technique
   • Perineal trauma and obstetric anal sphincter injury
   • Anaesthesia and analgesia for operative delivery
4. 4

   Obstetric Emergencies

   6 topics

   • Major obstetric haemorrhage
     • Antepartum and postpartum haemorrhage
     • Placenta praevia and placenta accreta spectrum
   • Shoulder dystocia and manoeuvres
   • Cord prolapse and uterine inversion
   • Amniotic fluid embolism and maternal collapse
   • Eclampsia and severe pre-eclampsia management
   • Maternal resuscitation and perimortem caesarean
5. 5

   Postnatal and Neonatal Care

   5 topics

   • Routine postnatal maternal care and complications
   • Postpartum sepsis and secondary haemorrhage
   • Newborn assessment and resuscitation
     • Apgar scoring and neonatal life support
   • Breastfeeding support and lactation problems
   • Perinatal mental health

Intrapartum Care and Obstetric Emergencies flashcards for Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG)

22 of 66 cards from the Intrapartum Care and Obstetric Emergencies deck — real questions with worked answers.

1. What are the cardinal movements (mechanisms) of labour in order for a vertex presentation?

   Engagement, descent, flexion, internal rotation, extension, restitution (external rotation), and expulsion. These allow the fetal head to negotiate the maternal pelvis by presenting the smallest diameters.

2. Define the three stages of labour.

   First stage: onset of labour to full cervical dilatation (10 cm), divided into latent and active phases. Second stage: full dilatation to delivery of the baby. Third stage: delivery of the baby to delivery of the placenta and membranes.

3. According to NICE, how are the latent and active first stages of labour defined?

   Latent first stage: painful contractions with cervical change including effacement and dilatation up to about 4 cm. Active first stage: regular painful contractions with progressive cervical dilatation from about 4 cm to 10 cm.

4. What is the suboccipitobregmatic diameter of the fetal head and why is it important?

   It is approximately $9.5\ \text{cm}$, the presenting anteroposterior diameter when the head is well flexed in a vertex presentation. It is the smallest AP diameter, optimising passage through the pelvis.

5. On the partogram, what do the alert and action lines represent?

   The alert line represents expected progress (historically $1\ \text{cm/hour}$ in the active phase); crossing it signals slow progress and the need for closer observation. The action line (drawn 2–4 hours to the right) crossing indicates the need for intervention/assessment such as oxytocin or transfer.

6. What four features are assessed on vaginal examination to evaluate progress of labour?

   Cervical dilatation, cervical effacement, station of the presenting part relative to the ischial spines, and position of the presenting part (plus caput and moulding).

7. In fetal heart rate monitoring (CTG), what are the four features assessed in the DR C BRAVADO/NICE classification?

   Baseline rate, baseline variability, accelerations, and decelerations. Each is classified as reassuring, non-reassuring, or abnormal, giving an overall category of normal, suspicious, or pathological.

8. What is a normal fetal heart rate baseline and normal baseline variability on CTG?

   Normal baseline is $110$–$160\ \text{bpm}$. Normal baseline variability is $5$–$25\ \text{bpm}$.

9. Describe the difference between early, variable, and late decelerations on CTG.

   Early decelerations mirror the contraction (nadir with peak) and reflect head compression — benign. Variable decelerations are rapid onset/recovery, varying in shape/timing, reflecting cord compression. Late decelerations begin after the contraction peak with delayed recovery and suggest fetal hypoxia/uteroplacental insufficiency.

10. What fetal scalp blood pH values indicate normal, borderline, and abnormal results?

    Normal: pH $\geq 7.25$. Borderline: pH $7.21$–$7.24$ (repeat within 30 minutes). Abnormal: pH $\leq 7.20$, indicating the need for expedited delivery.

11. List the main pharmacological options for pain relief in labour and a key feature of each.

    Entonox ($\ce{N2O}$/$\ce{O2}$ 50:50) — rapid, self-administered, short-acting. Opioids (e.g. pethadine/diamorphine) — IM, may cause neonatal respiratory depression. Epidural (low-dose bupivacaine + opioid) — most effective, may prolong second stage and cause hypotension/motor block.

12. What are recognised effects/risks of epidural analgesia in labour?

    Effective analgesia but associated with hypotension, longer second stage, increased instrumental delivery, maternal pyrexia, urinary retention, and (rarely) dural puncture headache. It does not increase caesarean rates and does not increase long-term backache.

13. What are the signs of placental separation in the third stage of labour?

    Lengthening of the umbilical cord, a gush of blood, and the uterus becoming globular, firmer and rising in the abdomen.

14. Compare active versus physiological management of the third stage of labour.

    Active management: prophylactic uterotonic (e.g. oxytocin 10 IU IM), deferred cord clamping then controlled cord traction — reduces PPH risk and shortens the third stage. Physiological management: no uterotonic, cord clamped after pulsation stops, placenta delivered by maternal effort — higher PPH and longer third stage.

15. What dose of oxytocin is recommended for active management of the third stage in NICE guidance?

    Oxytocin $10\ \text{IU}$ by intramuscular injection after delivery of the anterior shoulder or soon after birth. Syntometrine (oxytocin + ergometrine) is an alternative if no hypertension.

16. Define delay (failure to progress) in the first stage of labour.

    Cervical dilatation of less than $2\ \text{cm}$ in $4$ hours (or slowing in a multiparous woman), with or without inadequate uterine contractions. The 'three Ps' contributors are Power, Passage, and Passenger.

17. Define delay in the second stage of labour for nulliparous and parous women.

    Nulliparous: delay diagnosed if birth not imminent after $2$ hours of active pushing (consider intervention at $1$ hour). Parous: delay if birth not imminent after $1$ hour of active pushing. Add 1 hour to active phase limits if epidural in situ.

18. What are the Bishop score components and what total favours successful induction?

    Cervical dilatation, effacement (or length), consistency, position, and station of the presenting part. A score $\geq 7$ (some use $\geq 8$) indicates a favourable cervix and higher likelihood of successful induction; a low score favours cervical ripening first.

19. List methods of induction of labour in order of typical use.

    Membrane sweep (offered first), vaginal prostaglandin $\ce{PGE2}$ (dinoprostone) or mechanical balloon catheter for cervical ripening, amniotomy (ARM), and intravenous oxytocin infusion. Mechanical/balloon preferred if increased risk of hyperstimulation.

20. What is uterine hyperstimulation and how is it managed during induction/augmentation?

    Hyperstimulation is excessive uterine activity: tachysystole ($\geq 5$ contractions in $10$ minutes) or contractions lasting $\geq 2$ minutes, often with abnormal CTG. Management: stop/remove prostaglandin or oxytocin, reposition, and consider tocolysis with terbutaline $0.25\ \text{mg}$ subcutaneously.

21. What is the most common malposition of the fetal head and how does it typically resolve?

    Occipitoposterior (OP) position is the most common malposition. About 90% rotate spontaneously to occipitoanterior; the remainder may deliver as persistent OP (face-to-pubes), undergo rotational instrumental/manual rotation, or require caesarean.

22. Differentiate malpresentation from malposition.

    Malposition refers to an abnormal position of the vertex relative to the maternal pelvis (e.g. occipitoposterior, occipitotransverse). Malpresentation is any presenting part other than the vertex (e.g. breech, brow, face, shoulder/transverse lie, compound).

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