LABOR AND BIRTH

 Antepartum care refers to the medical and nursing care

given to the pregnant woman between conception and the
onset of labor.
 Intrapartum care refers to the medical and nursing care
given to a pregnant woman and her family during labor
and delivery.
 Postpartum care refers to the 1st 6 weeks after childbirth.
LABOR AND BIRTH
 Labor is the series of events by which uterine contractions and
abdominal pressure expel a fetus and placenta from the uterus.
Regular contractions cause progressive dilatation of the cervix and
create sufficient muscular uterine force to allow a baby to be
pushed out into the extra-uterine world. Labor represents a time of
change as it is both an ending and a beginning for the woman, her
fetus, and her family.
 Labor normally begins between 37 and 42 weeks of pregnancy, when a
fetus is sufficiently mature to adapt to extrauterine life, yet not too large to
cause mechanical difficulty with birth. In some instances, labor begins
before a fetus is mature (preterm birth). In others, labor is delayed until the
fetus and the placenta have both passed beyond the optimal point for birth
(postterm birth).
Theories of Labor
Maternal factors:.
 Uterine muscle stretch , causing release of prostaglandin.
 Pressure on the cervix stimulates nerve plexus, causing release of oxytocin by
maternal posterior pituitary gland ( Ferguson complex).
 Oxytocin stimulation in circulating blood increases slowly during pregnancy,
rises dramatically during labor, and peaks during 2 nd stage. Oxytocin and
prostaglandin work together to inhibit calcium binding in muscle cells, raising
intracellular calcium and thus activating contractions.
 Estrogen/progesterone ratio shift
Fetal factors:
 Placental aging and deterioration triggers initiation of contractions.
 Fetal cortisol, produced by the fetal adrenal glands, rises and acts on the
placenta to reduce progesterone formation and increase prostaglandin.
 Prostaglandin produced by fetal membranes( amnion and chorion) and the
decidua stimulates contractions.
 Theoretically, labor is thought to result from:
a) Progesterone deprivation
b) Oxytocin stimulation
c) Fetal endocrine control
d) Uterine decidua activation
THE FOUR COMPONENTS OF
LABOR
1.THE PASSAGE (passageway)
 The passage refers to the route a fetus must travel
from the uterus through the cervix and vagina to the
external perineum.
a) Type of pelvis
b) Pelvic inlet diameters
c) Pelvic outlet diameters
d) Ability of the uterine segment to distend, the cervix to
dilate, and the vaginal canal and introitus to distend.
2.THE PASSENGER
 The passenger is the fetus. The body part of the fetus that has
the widest diameter is the head, so this is the part least likely
to be able to pass through the pelvic ring. Whether a fetal
skull can pass depends on both its structure (bones,
fontanelles, and suture lines) and its alignment with the
pelvis.
a) Size of the fetal head and capability of the head to mold to
the passageway
b) Fetal presentation
c) Fetal attitude
d) Fetal position
3. THE POWER
 This refers to the frequency, duration and strength of
uterine contractions to complete cervical effacement and
dilation.
4. THE PSYCHE
 Refers to the client’s psychological state, available
support systems, preparation for childbirth, experiences
and coping strategies.
THE
PASSAGEWAY
TYPES OF PELVIS
Pelvic Inlet
Pelvic outlet
 In most instances, if a disproportion between fetus and pelvis
occurs, the pelvis is the structure at fault. If the fetus is the cause
of the disproportion, it is often not because the fetal head is too
large but because it is presenting to the birth canal at less than its
narrowest diameter. Keep this in mind when discussing with
parents why an infant may not be able to be born vaginally. It can
be upsetting for parents to learn that a child cannot be born
vaginally because the mother’s pelvis is too small. It can be much
more upsetting to think their infant’s head is too large because it
implies something may be seriously wrong with their baby (and
that is rarely true).
THE PASSENGER
Structure of the Fetal Skull
The FETAL SKULL
 The cranium, the uppermost portion of the skull, is composed of eight
bones. The four superior bones—the frontal (actually two fused
bones), the two parietal, and the occipital—are the bones important
in childbirth. The other four bones of the skull (sphenoid, ethmoid,
and two temporal bones) lie at the base of the cranium and so are of
little significance in childbirth because they are never presenting
parts.
 Fontanelle spaces compress during birth to aid in molding of the fetal
head. Their presence can be assessed manually through the cervix
after the cervix has dilated during labor. Palpating for fontanelle
spaces during a pelvic examination helps to establish the position of
the fetal head and whether it is in a favorable position for birth.
Diameters of the Fetal Skull
 The shape of a fetal skull causes it to be wider in its anteroposterior diameter than in its
transverse diameter. To fit through the inlet of the birth canal best, a fetus must
present the smaller diameter (the transverse diameter) of the head to the smaller
diameter of the maternal pelvis (the diagonal conjugate); otherwise, progress can be
halted and vaginal birth may not be possible. The diameters of the fetal skull vary
depending on where the measurement is taken.
• The smallest diameter of the fetal skull is the bi-parietal diameter or the transverse
diameter, which measures about 9.25 cm.
• The smallest anteroposterior diameter is the suboccipitobregmatic measurement
(approximately 9.5 cm) and is measured from the inferior aspect of the occiput to the
center of the anterior fontanelle.
• The occipitofrontal diameter, measured from the occipital prominence to the
bridge of the nose, is approximately 12 cm.
• The occipitomental diameter, which is the widest anteroposterior diameter
(approximately 13.5 cm), is measured from the posterior fontanelle to the chin.
Diameters of the Fetal Skull
 The anteroposterior diameter of the pelvis, a space approximately 11
cm wide, is the narrowest diameter at the pelvic inlet, and so the
best presentation for birth is when the fetus presents a biparietal
diameter (the narrowest fetal head diameter) to this. At the outlet,
the fetus must rotate to present this narrowest fetal head
diameter(the biparietal diameter) to the maternal transverse
diameter, a space, again, approximately 11 cm wide.
• If a fetus presents one of the anteroposterior diameters of the skull to
the anteroposterior diameter of the inlet, engagement, or the settling of
the fetal head into the pelvis, may not occur.
• If the fetus does not rotate, leaving the anteroposterior diameter of
the skull presenting to the transverse diameter of the outlet, an arrest
of progress may occur.
Diameters of the Fetal Skull
 Which anteroposterior diameter that presents to the birth canal is
determined not only by rotation but also by the degree of flexion of
the fetal head.
• In full flexion, the fetal head flexes so sharply that the chin rests on
the chest, and the smallest anteroposterior diameter, the
suboccipitobregmatic, presents to the birth canal.
• If the head is held in moderate flexion, the occipitofrontal diameter
presents.
• In poor flexion (the head is hyperextended), the largest diameter (the
occipitomental) will present.
 It follows that full head flexion is an important aspect of labor
because a fetal head presenting a diameter of 9.5 cm will fit through
a pelvis much more readily than if the diameter is 12.0 or 13.5 cm.
Molding
 Molding is overlapping of skull bones along the suture
lines, which causes a change in the shape of the fetal
skull to one long and narrow, a shape that facilitates
passage through the rigid pelvis.
 Molding is caused by the force of uterine contractions as
the vertex of the head is pressed against the not yet
dilated cervix. The overlapping that occurs in the
sagittal suture line and, generally, the coronal suture
line can be easily palpated on the newborn skull.
 Parents can be reassured that molding only lasts a day
or two and will not be a permanent condition. There is
little molding when the brow is the presenting part
because frontal bones are fused. No skull molding occurs
when a fetus is breech because the buttocks, not the
head, present first. Babies born by cesarean birth when
there is no preprocedure labor also typically have no
molding.
Fetal Presentation and Position
 Fetal Attitude. Attitude describes the degree of flexion a fetus assumes during labor or
the relation of the fetal parts to each other.

 • A fetus in good attitude is in complete flexion: The spinal column is bowed forward, the
head is flexed forward so much that the chin touches the sternum, the arms are flexed and
folded on the chest, the thighs are flexed onto the abdomen, and the calves are pressed
against the posterior aspect of the thighs. This usual “fetal position” is advantageous for
birth because it helps a fetus present the smallest anteroposterior diameter of the skull to
the pelvis and also because it puts the whole body into an ovoid shape, occupying the
smallest space possible.
 • A fetus is in moderate flexion if the chin is not touching the chest but is in an alert or
“military position” . This position causes the next widest anteroposterior diameter, the
occipitofrontal diameter, to present to the birth canal. A fair number of fetuses assume a
military position early in labor. This does not usually interfere with labor, however,
because later mechanisms of labor (descent and flexion) force the fetal head to fully flex.
 • A fetus in partial extension presents the “brow” of the head to
the birth canal.
 • If a fetus is in complete extension, the back is arched and the
neck is extended, presenting the occipitomental diameter of the head
to the birth canal (a face presentation. This unusual position usually
presents too wide a skull diameter to the birth canal for vaginal birth.
Such a position may occur in an otherwise healthy fetus or may be an
indication there is less than the usual amount of amniotic fluid
present (oligohydramnios), which is not allowing the fetus adequate
movement space. It also may reflect a neurologic abnormality in the
fetus causing spasticity.
 Fetal Lie. Lie is the
relationship between the long
(cephalocaudal) axis of the fetal
body and the long (cephalocaudal)
axis of a woman’s body—in other
words, whether the fetus is lying
in a horizontal (transverse) or a
vertical (longitudinal) position.
Approximately 96% of fetuses
assume a longitudinal lie (with
their long axis parallel to the long
axis of the woman).
Fetal Presentation
 Fetal presentation denotes the body part that will
first contact the cervix or be born first and is
determined by the combination of fetal lie and the
degree of fetal flexion(attitude).
 A cephalic presentation is the most
frequent type of presentation, occurring as often as
96% of the time. With this type of presentation, the
fetal head is the body part that first contacts the
cervix. The four types of cephalic presentation are
vertex, brow, face, and mentum. The vertex is the
ideal presenting part because the skull bones are
capable of effectively molding to accommodate the
cervix. This exact fit may actually aid in cervical
dilatation as well as prevent complications such as a
prolapsed cord (a portion of the cord passes
between the presenting part and the cervix and
enters the vagina before the fetus).During labor,
the area of the fetal skull that contacts the cervix
often becomes edematous from the continued
pressure against it. This edema is called a caput
succedaneum. In the newborn, what was the point
of presentation can be analyzed from the location
of the caput.
Variations in Cephalic Fetal Presentation
Fetal Presentation
 A breech presentation
means either the buttocks or the
feet are the first body parts that
will contact the cervix.
• A good attitude brings the fetal
knees up against the fetal abdomen.
• A poor attitude means the knees
and legs are extended.
 Breech presentation can cause a
difficult birth, with the presenting
point influencing the degree of
difficulty. Three types of breech
presentation are complete, frank,
and footling(incomplete).
Fetal Presentation
 Shoulder Presentation
In a transverse lie, a fetus lies horizontally
in the pelvis so the longest fetal axis is
perpendicular to that of the mother. The
presenting part is usually one of the
shoulders (acromion process), an iliac crest,
a hand, or an elbow . The usual contour of
the mother’s abdomen at term may appear
fuller side to side rather than top to
bottom.
Fetal Position
 Fetal position is the
relationship of the presenting part
to a specific quadrant and side of a
woman’s pelvis. The maternal
pelvis is divided into four quadrants
according to the mother’s right and
left:
a) right anterior,
b) left anterior,
c) right posterior, and
d) left posterior.
 Four parts of a fetus are typically
chosen as landmarks to describe
the relationship of the presenting
part to one of the pelvic quadrants.
• In a vertex presentation, the occiput (O) is the chosen point.
• In a face presentation, it is the chin (mentum [M]).
• In a breech presentation, it is the sacrum (Sa).
• In a shoulder presentation, it is the scapula or the acromion process (A)
 Position is indicated by an abbreviation of three letters. The middle letter
denotes the fetal landmark , O for occiput, M for mentum, Sa for sacrum, and A
for acromion process. The first letter defines whether the landmark is pointing to
the mother’s right (R) or left (L). The last letter defines whether the landmark
points anteriorly (A), posteriorly (P), or transversely (T).
 If the occiput of a fetus points to the left anterior quadrant in a vertex position,
for example, this is a left occipitoanterior (LOA) position. If the occiput points to
the right posterior quadrant, the position is right occipitoposterior (ROP).
 LOA is the most common fetal position, and right occipitoanterior (ROA) is the
second most frequent.
Mechanisms of Labor
Cardinal Movements of Labor

Engagement
Descent
Flexion
Internal rotation
Extension
External rotation/ Restitution
Expulsion
 Engagement
 Engagement refers to the settling of the presenting part of
a fetus far enough into the pelvis that it rests at the level
of the ischial spines, the midpoint of the pelvis. Descent to
this point means the widest part of the fetus (the
presenting skull diameter in a cephalic presentation, or
the intertrochanteric diameter in a breech presentation)
has passed through the pelvis or the pelvic inlet has been
proven adequate for birth. In a primipara, non-engagement
of the head at the beginning of labor suggests that a
possible complication such as an abnormal presentation or
position, abnormality of the fetal head, or cephalopelvic
disproportion exists. In multiparas, engagement may or
may not present at the beginning of labor.
 The degree of engagement is established by a vaginal and
cervical examination.
 A presenting part that is not engaged is said to be
“floating.”
 One that is descending but has not yet reached the ischial
spines may be referred to as “dipping.”
Station
 Station refers to the relationship of the
presenting part of the fetus to the level of
the ischial spines.
 • When the presenting fetal part is at the
level of the ischial spines, it is at a 0
station (synonymous with engagement).
 • If the presenting part is above the
spines, the distance is measured and
described as minus stations, which range
from −1 to −4 cm.
 • If the presenting part is below the
ischial spines, the distance is stated as
plus stations (+1 to +4 cm).
 • At a +3 or +4 station, the presenting
part is at the perineum and can be seen if
the vulva is separated (i.e., it is
crowning).
 Descent
 Descent is the downward movement of the
biparietal diameter of the fetal head within the
pelvic inlet.
 Full descent occurs when the fetal head
protrudes beyond the dilated cervix and touches
the posterior vaginal floor.
 Descent occurs because of pressure on the fetus
by the uterine fundus. As the pressure of the
fetal head presses on the sacral nerves at the
pelvic floor, the mother will experience the
typical “pushing sensation,” which occurs with
labor. As a woman contracts her abdominal
muscles with pushing, this aids descent.
Flexion

 As descent is completed and the fetal head

touches the pelvic floor, the head bends
forward onto the chest, causing the smallest
anteroposterior diameter (the
suboccipitobregmatic diameter) to present
to the birth canal. Flexion is also aided by
abdominal muscle contraction during
pushing.
Internal Rotation
 During descent, the biparietal diameter of the fetal
skull was aligned to fit through the
anteroposterior diameter of the mother’s pelvis.
 As the head flexes at the end of descent,
the occiput rotates so the head is brought into the best
relationship to the outlet of the
pelvis, or the anteroposterior diameter is now in the
anteroposterior plane of the pelvis.
 This movement brings the shoulders, coming next,
into the optimal position to enter the
inlet, or puts the widest diameter of the shoulders (a
transverse one) in line with the
wide transverse diameter of the inlet.
Crowning

 As the occiput of the fetal

head is born, the back of the
neck stops beneath the pubic
arch and acts as a pivot for
the rest of the head.
 The head extends, and the
foremost parts of the head,
the face and chin, are born.
 Extension

 As the occiput of the fetal head

is born, the back of the neck
stops beneath the pubic
arch and acts as a pivot for the rest
of the head. The head extends, and
the foremost
parts of the head, the face and
chin, are born.
 External Rotation
 In external rotation, almost immediately after
the head of the infant is born, the head
rotates a final time (from the anteroposterior
position it assumed to enter the outlet)
back to the diagonal or transverse position of the
early part of labor. This brings the
after coming shoulders into an anteroposterior
position, which is best for entering the
outlet. The anterior shoulder is born first, assisted
perhaps by downward flexion of the
infant’s head.
Expulsion
 Once the shoulders are born, the rest of the baby is born easily and smoothly
because of its smaller size. This movement, called expulsion, is the end of
the pelvic division of labor.
The Powers of Labor
 The third important requirement for a successful labor is
effective powers of labor. This is the force supplied by the
fundus of the uterus and implemented by uterine
contractions, which causes cervical dilatation and then
expulsion of the fetus from the uterus. After full dilatation
of the cervix, the primary power is supplemented by use of
a secondary power source, the abdominal muscles. It is
important for women to understand that they should not
bear down with their abdominal muscles to push until the
cervix is fully dilated. Doing so impedes the primary force
and could cause fetal and cervical damage.
Uterine contractions
 During pregnancy, the uterus begins to contract and relax
periodically as if it is rehearsing for labor (Braxton Hicks
contractions, or false labor). These contractions are
usually mild but can be so strong that a woman mistakes
them for true labor.
 Effective uterine contractions have rhythmicity, a
progressive increase in length and intensity, and
accompany dilatation of the cervix.
 Contractions are assessed according to frequency,
duration, and strength.
DIFFERENTIATING BETWEEN TRUE
AND FALSE LABOR CONTRACTIONS
False Contractions True Contractions

Begin and remain irregular
Felt first abdominally and remain confined to
the abdomen and groin
Often disappear with ambulation or sleep
Do not increase in duration, frequency, or
intensity
Do not achieve cervical dilatation
Begin irregularly but become regular and
predictable
Felt first in lower back and sweep around to the
abdomen in a wave
Continue no matter what the woman’s
level of activity
Increase in duration, frequency, and
intensity
Achieve cervical dilatation
Cervical changes
 Effacement is shortening and
thinning of the cervical canal. All
during pregnancy, the canal is
approximately 1 to 2 cm long.
During labor, the longitudinal
traction from the contracting
uterus shortens the cervix so much
that the cervix virtually appears.
 Dilatation refers to the enlargement or
widening of the cervical canal from an opening a
few millimeters wide to one large enough
(approximately 10 cm) to permit passage of a fetus.
 Dilatation occurs first because uterine contractions
gradually increase the diameter of the cervical
canal lumen by pulling the cervix up over the
presenting part of the fetus.
 Secondly, the fluid-filled membranes push ahead of
the fetus and serve as an opening wedge. If they
are ruptured, the presenting part will serve this
same function, although maybe not as effectively.
As dilatation begins, there is an increase in the
amount of vaginal secretions (show) because
minute capillaries in the cervix rupture and the last
of the mucus plug that has sealed the cervix since
early pregnancy is released.
The Stages Of Labor
THE FIRST STAGE
The first stage, which takes about 12 hours to complete, is
divided into three segments:
a latent, an active, and a transition phase.
The Latent Phase
 The latent or early phase begins at the onset of regularly perceived uterine
contractions and ends when rapid cervical dilatation begins. Contractions
during this phase are mild and short, lasting 20 to 40 seconds.
 Cervical effacement occurs, and the cervix dilates minimally. A birthing parent
who is multiparous usually progresses more quickly than a nullipara. A woman
who enters labor with a “nonripe” cervix will probably have a longer than
average latent phase. If a woman wants analgesia at this point, she shouldn’t
be denied of it, but analgesia given too early in labor is a factor that tends to
prolong this phase.
 In a woman who is psychologically prepared for labor and who does not tense
at each tightening sensation in her abdomen, latent phase contractions cause
only minimal discomfort and can be managed by controlled breathing. During
this phase, encourage women to continue to walk about and make
preparations for birth, such as doing last minute packing for her stay at the
hospital or birthing center, preparing older children for her departure and the
upcoming birth, or giving instructions to the person who will take care of them
while she is away. If desired, she could begin alternative methods of pain
relief such as aromatherapy, distraction, or acupressure.
The Active Phase

 During the active phase of labor, cervical dilatation occurs

more rapidly. Contractions grow stronger, lasting 40 to 60
seconds, and occur approximately every 3 to 5 minutes.
 Show (increased vaginal secretions) and perhaps
spontaneous rupture of the membranes may occur during
this time.
 Encourage women to be active participants in labor by
keeping active and assuming whatever position is most
comfortable for them during this time, except flat on
their back.
The Transition Phase
 During the transition phase, contractions reach their peak of
intensity, occurring every 2 to 3 minutes with a duration of 60 to 70
seconds, and a maximum cervical dilatation of 8 to 10 cm occurs. If it
has not previously occurred, show will occur as the last of the mucus
plug from the cervix is released. If the membranes have not
previously ruptured, they will usually rupture at full dilatation (10
cm). By the end of this phase, both full dilatation (10 cm) and
complete cervical effacement (obliteration of the cervix) have
occurred.
 During this phase, a woman may experience intense discomfort that is
so strong, it might be accompanied by nausea and vomiting. She may
also experience a feeling of loss of control, anxiety, panic, and/or
irritability.
 As a woman reaches the end of this stage at 10 cm of dilatation,
unless she has been administered epidural anesthesia, a new
sensation, the irresistible urge to push, usually begins.
The Second Stage
 The second stage of labor is the time span from full dilatation and cervical
effacement to birth of the infant. A woman typically feels contractions
change from the characteristic crescendo–decrescendo pattern to an
uncontrollable urge to push or bear down with each contraction as if to move
her bowels. She may experience momentary nausea or vomiting because
pressure is no longer exerted on her stomach as the fetus descends into the
pelvis. She pushes with such force that she perspires and the blood vessels in
her neck become distended.
 The fetus begins descent and, as the fetal head touches the internal
perineum to begin internal rotation, her perineum begins to bulge and appear
tense. The anus may become everted, and stool may be expelled. As the fetal
head pushes against the vaginal introitus, this opens and the fetal scalp
appears at the opening to the vagina and enlarges from the size of a dime, to
a quarter, then a half-dollar. This is termed crowning.
The THIRD STAGE

The third stage of labor, the placental stage, begins with the birth of the infant
and ends with the delivery of the placenta. Two separate phases are involved:
placental separation and placental expulsion.
Placental separation
 The placenta has loosened and is ready to deliver when:
1. • There is lengthening of the umbilical cord.
2. • A sudden gush of vaginal blood occurs.
3. • The placenta is visible at the vaginal opening.
4. • The uterus contracts and feels firm again.
 If the placenta separates first at its center and lastly at its edges, it tends to
fold on itself like an umbrella and presents at the vaginal opening with the
fetal surface evident. Approximately 80% of placentas separate and present in
this way. Appearing shiny and glistening from the fetal membranes, this is
called a Schultze presentation.
 If, however, the placenta separates first at its edges, it slides along the
uterine surface and presents at the vagina with the maternal surface evident.
It looks raw, red, and irregular, with the ridges or cotyledons that separate
blood collection spaces evident; this is called a Duncan presentation.
 A simple trick of remembering the presentations is remembering that,
if the placenta appears shiny, it is a Schultze presentation. If it looks
“dirty” (the irregular maternal surface shows), it is a Duncan
presentation
 This stage can take anywhere from 1 to 30 minutes and still be
considered normal. Because bleeding occurs as the placenta
separates, before the uterus contracts sufficiently to seal maternal
capillaries, there is a blood loss of about 300 to 500 ml, not a great
amount in relation to the extra blood volume that was formed during
pregnancy.
Placental Expulsion
 Once separation has occurred, the placenta delivers either by the
natural bearing-down effort of the mother or by gentle pressure on
the contracted uterine fundus by the primary healthcare provider (a
Credé maneuver). Pressure should never be applied to a uterus in a
noncontracted state because doing so could cause the uterus to evert
(turn inside out), accompanied by massive hemorrhage .
 If the placenta does not deliver spontaneously, it can be removed
manually. It needs to be inspected after delivery to be certain it is
intact and part of it was not retained (which could prevent the uterus
from fully contracting and lead to postpartal hemorrhage).
MATERNAL DANGER SIGNS OF
LABOR
High or Low Blood Pressure. Normally, a woman’s blood pressure rises
slightly in the second (pelvic) stage of labor because of her pushing effort. A
systolic pressure greater than 140 mmHg and a diastolic pressure greater than
90 mmHg, or an increase in the systolic pressure of more than 30 mmHg or in
the diastolic pressure of more than 15 mmHg (the basic criteria for
gestational hypertension), should be reported. Just as important to report is a
falling blood pressure because it may be the first sign of intrauterine
hemorrhage, although a falling blood pressure from hemorrhage is often
associated with other clinical signs of hypovolemic shock, such as
apprehension, increased pulse rate, and pallor.
 Abnormal Pulse. Most women during pregnancy have a pulse rate of 70 to 80
beats/min. This rate normally increases slightly during the second stage of
labor because of the exertion involved. A maternal pulse rate greater than
100 beats/min during labor is unusual and should be reported because it may
be another indication of hemorrhage.
 Inadequate or Prolonged Contractions. Uterine contractions normally
become more frequent, intense, and longer as labor progresses. If they
become less frequent, less intense, or shorter in duration, this may indicate
uterine exhaustion (inertia).
 Abnormal Lower Abdominal Contour. If a woman has a full bladder during
labor, a round bulge appears on her lower anterior abdomen. This is a danger
signal for two reasons: First, the bladder may be injured by the pressure of
the fetal head pressing against it; and second, the pressure of the full bladder
may not allow the fetal head to descend. To avoid a full bladder, ask women
to try to void about every 2 hours during labor.
 Increasing Apprehension. Warnings of psychological danger during labor are
as important to consider in assessing maternal well-being as are physical
signs. As she approaches the second stage of labor, a woman who is becoming
increasingly apprehensive despite clear explanations of unfolding events may
not be “hearing” because she has a concern that has not been met. Using an
approach such as “You seem more and more concerned. Could you tell me
what is worrying you?” may be helpful. Increasing apprehension also needs to
be investigated for physical reasons because it can be a sign of oxygen
deprivation or internal hemorrhage.
FETAL DANGER SIGNS OF LABOR
 High or Low Fetal Heart Rate. As a rule, an FHR of more than 160
beats/min (fetal tachycardia) or less than 110 beats/min (fetal
bradycardia) is a sign of possible fetal distress. An equally important
sign is a late or variable deceleration pattern revealed on a fetal
monitor. Frequent monitoring by a fetoscope, Doppler, or a monitor is
necessary to detect these changes as they first occur.
 Meconium Staining. This is not always a sign of fetal distress but is
highly correlated with its occurrence. Meconium staining, a green
color in the amniotic fluid, reveals the fetus has had a loss of rectal
sphincter control, allowing meconium to pass into the amniotic fluid.
It may indicate a fetus has or is experiencing hypoxia, which
stimulates the vagal reflex and leads to increased bowel motility.
Although meconium staining may be usual in a breech presentation
because pressure on the buttocks causes meconium loss, it should
always be reported immediately even with breech presentations so its
cause can be investigated.
 Hyperactivity. Ordinarily, a fetus remains quiet and
barely moves during labor. Fetal hyperactivity may be a
subtle sign that hypoxia is occurring because frantic
motion is a common reaction to the need for oxygen.
 Low Oxygen Saturation. Oxygen saturation in a fetus is
normally 40% to 70%. A fetus can be assessed for this by a
catheter inserted next to the cheek (under 40%
oxygenation needs further assessment). If fetal blood is
obtained by scalp puncture, the finding of acidosis (blood
pH lower than 7.2) suggests fetal well-being is becoming
compromised and that further investigation is also
necessary.
The Leopold’s Maneuvers
Determining Fetal Position, Presentation, and Lie: the LEOPOLD’s
Maneuver