The document describes the procedures for admission, history taking, physical examination, abdominal examination, and vaginal examination during the first stage of labor. Key steps include checking vital signs, medical history, performing Leopold's maneuvers to determine fetal position and presentation, measuring fundal height and symphysio-fundal height. A vaginal exam is done to assess cervical dilation, rupture of membranes, presentation and descent of the fetus. The goal is to monitor labor progress and the condition of the mother and fetus safely.

1. FIRST STAGE OF LABOR
MUKESH SAH
POST GRADUATE MEDICAL INTERN

2. Admission
Receiving a pregnant women to the hospital for the delivery of baby and care
of women and neonate is called admission.
Purpose:
• To assist in a safe delivery of the baby.
• To provide immediate care, safety and comfort of the mother and child.
• To monitor closely a women with history of complication.
• To manage and prevent complication .
• To observe and report sign and symptoms and general condition of women.

3. Admission procedure
• Welcome the women and observe her gait, position and general
conditions
• Check the women’s antenatal card or ask for the following
information and record responses
-Age
-Any disease and surgery
-Allergies
- Number of previous pregnancy/deliveries
- Type of previous delivery

4. • General medical problems
• Any medications used
• If she has pain, ask for onset, length, strength and frequency
• Check women for temperature, BP, pulse, respiration rate, weight etc.
• Help her to go to bed
• Record all the information thoroughly

5. History taking
1. Vital statistics:
• Name:
• Address:
• Age:
• Gravida, Parity:
• Duration of marriage: This is relevant to note the fertility or fecundity. A
pregnancy long after marriage without taking course of any method of
contraceptive is called low fecundity and soon after marriage is called high
fecundity. An women with low fecundity is unlikely to conceive frequently.

6. Vital statistics continue….......
• Religion
• Occupation: it is helpful in interpreting symptoms of fatigue due to excess
physical work or stress or occupational hazards.
• Occupation of the husband: A fair idea about the socioeconomic status of
the patient
• Period of gestation:
2. Chief complaints: Chief complaints to be noted.
3. History of present of illness: Elaboration of the chief complaints as
regard their onset, duration, severity, use of medications and progress is to
be noted.

7. 4. History of present pregnancy:
• The important complications In different trimesters of the present
pregnancy are to be noted carefully. These are hyperemesis and
threatened abortion in first trimester; features of urinary tract infection In
second trimester and anemia, pre-eclampsia and antepartum hemorrhage
in the last trimester.
• Number of previous antenatal visit, immunization status, immunization
status, has to be noted. Any medication or radiation exposure in early
pregnancy, or medical-surgical event during pregnancy should be
enquired.

8. 5. Obstetric history:
• This is only related with multigravida. The previous obstetric
events are to be recorded such as status of gravida, parity,
number of delivery (term and preterm), miscarriage, pregnancy
termination (MTP) etc.
• Enquiry is to made whether she had antenatal and intranatal care
before

9. 6. Menstrual history: age of menarche, duration of menarche,
intervals in days, regularity of cycle, pain during period, amount of
bleeding, clot and last date of menstruation
7. Past medical history: Relevant history of past medical illness like
urinary tract infections and tuberculosis etc.
8. Past surgical history : Previous surgery-general or gynecological,
if any, is to be enquired

10. 9. Family history: Family history of hypertension, diabetes,
tuberculosis, known hereditary disease, if any, or twinning is to
be enquired
10. Personal history: Contraceptive practice prior to pregnancy,
smoking or alcohol habits are to be enquired. Previous history of
blood transfusion, corticosteroid therapy, any drug allergy and
immunization against tetanus or prophylactic administration are
to be enquired

11. Physical Examination
• Build: obese/ Average/Thin
• Height: Average/Short stature/tall stature. Short stature is likely to be associated with a
small pelvis
• Weight: weight should be taken to assess overweight or thin/underweight
• Edema: write as present or absent. Pitting edema and non pitting. Primary site of
examination is just above the medial malleolus elicited by pressing the tip of thumb ,
anterior site of the lower third of the shine bones (tibia), the dorsum of foot

12. • Anemia: present or absent-mild, moderate and severe. The primary site to see is:
Lower palpebral conjunctiva-Retracted both the lower eyelids at a time and tell the
patient to look upwards
Other sites:
Dorsum and tips of the tongue
Soft palate
Nail beds
Palm and soles
skin

13. • Cyanosis : Absent/present. Types: peripheral/central
Sites to detect cyanosis:
Peripheral-
Tip of nose
Ear lobe
Outer surface of lips, cheek and chin
Tips of fingers and nose
Nail beds
Central-
Tongue
Inner surface of lips
Gum, soft palate, cheeks
All sites of peripheral cyanosis

14. • Jaundice: Expressed as present/ absent
Site to detect:
Upper bulbar conjunctiva- The patient is asked to look downwards and upper eyelids
are retracted to see the bulbar conjunctiva well
Undersurface of tongue
Soft palate
Sole and palm
Skin
Jaundice is always checked in sunlight near an open window

15. • Tongue, teeth, gum and tonsils: Write healthy or any specific lesion
present. The mouth is examined for features of malnutrition like
glossitis, stomatitis, presence of any septic focus like tonsillitis and
caries teeth
• Neck veins: Generally examined to see whether these are engorged
or not
• Neck Glands: The neck is examined for presence of any enlarged
gland. Thyroid gland is also inspected and palpated for any
enlargement or any other pathology

16. • Cardiovascular system: palpation and auscultation of heart are done.
Palpation: No abnormality
Auscultation: Normal heart sounds, if any abnormality is detected or
suspected detailed examination is done and noted
• Respiratory system:
Position of trachea
Palpation, percussion and auscultation done on both sides
• G.I. System: Liver and spleen are palpated routinely for any enlargement
and tenderness

17. • Other systems:
Neurological systems-
Higher function
Cranial nerves
Sensory function
Urinary system:
Kidney
Renal angle tenderness

18. • Leg veins: Note the presence of tortuosities of veins varicose vein or
presence of any pigmentation or ulcer
• Pulse: rate, volume, rhythm any special character, other pulses and any
different of different pulses
• Respiration : rate, rhythm, any special variety
• Temperature: write body temperature
• Blood Pressure: write Blood pressure

19. • Examination of breast: Examination of breasts helps to note the
presence of pregnancy changes and also note the nipples (cracked or
depressed) and skin condition of the areola. The purpose is to correct
the abnormality, if any, so that there will be no difficulty in
breastfeeding immediately following delivery

20. Abdominal Examination
Abdominal examination can reasonably diagnose the lie, presentation,
position, and attitude of the fetus. Before abdominal examination the
following preparatory procedures are done:
• Verbal consent for examination is taken
• Ask the patient to evacuate her bladder
• Always keep one female attendant
• Stand on right side of the patient
• Explain the patient what you are going to do
• Make dorsal position-thighs and knees both partially flexed
• Abdominal is exposed fully and other parts are covered well

21.  Inspection: To note
• Whether the uterine ovoid is longitudinal or transverse or oblique
• Undue enlargement of the uterus
• Skin condition of abdomen for evidence of ringworm or scabies and
• Any incision scar mark on the abdomen

22. Scabies Ringworm

23. Palpation:
General principles:
• Palpate should be done very gently
• Don’t try to palpate during contraction. It is done in relaxed phase of
uterus
• All grips are palpated facing towards the mother’s face except the pelvic
grip which is done facing towards the patient’s legs

24. Measurement of the height of the fundus:
• The uterus is to be centralized if it is deviated. The ulnar border of the
left hand is place on the upper most level of the fundus and an
approximate duration of pregnancy is ascertained in terms of weeks of
gestation.
• Normally, height of the fundus at 24 weeks lies at the level of
umbilicus. The level of junction between the lower third and middle
third of the distance between umbilicus and ensiform cartilage (Xiphoid
process) corresponds to 28th week of pregnancy, the junction of middle
third and upper third to 32nd week and at the level of ensiform cartilage
pregnancy corresponds to 36th week. At 40th week fundal height drops
down again to the level of 32nd week

26. • Also measure the Symphysio-fundal height (SFH) with a measuring tape.
SFH is the distance between the upper border of symphysis pubis to
highest level of fundus as detected by ulnar border of left hand. Bladder
should be empty 30 minutes before examination.
• SFH is measured in supine position with legs extended. Zero mark of the
tape is placed over the uppermost border of symphysis pubis. Tape is run
along the midline of the women’s abdomen upto the fundus in cm
approximates the fetal gestational age until 36 weeks of pregnancy.

28. Finger methods to measure fundal height

29. Obstetric grips (Leopold Manoeuvers):
There are four grips which will be performed sequentially.
A. Fundal grip (First Leopold)
B. Lateral grip (Second Leopold)
C. Pawlik’s grip (Third Leopold)
D. Pelvic grip (Fourth Leopold)

30. A. Fundal grip (First Leopold):
• The palpation is done facing the patient’s face. The whole of the fundus
area is palpated using both hands laid flat on it to find out which pole of
the fetus is lying in the fundus
• Broad, soft and irregular mass suggestive of breech or
• Smooth, hard and globular mass suggestive of head. In transverse lie,
neither of the fetal poles are palpated in the fundal area.

32. B. Lateral grip or umbilical grip (Second Leopold):
• The palpation is done facing the patient’s face. The hands are to be placed
flat on either side of the umbilicus to palpate one after the other, the sides
and front of the uterus to find out the position of the back, limbs and the
anterior shoulder.
• The back is suggested by smooth curved and resistant feel. The limb side is
comparatively empty and there are small knob like irregular parts.

34. C. Pawlik’s grip ( third Leopold):
• The examination is done facing towards the patient’s face. The
overstretched thumb and four fingers of the hand are placed over the
lower pole of the uterus keeping the ulnar boarder of the palm on the
upper boarder of the symphysis pubis, when the fingers and the thumb are
approximated, the presenting part is grasped when it is not engaged and
mobility is tested from side to side

35. Powlik’s grip

36. D. Pelvic grip (fourth Leopold):
• The examination is done facing the patient’s feet. Four fingers of both hand
are placed on either side of the midline in the lower pole of the uterus and
parallel to be inguinal ligament. The fingers are pressed downwards and
backwards in a manner of approximation of finger tips to palpate the part
occupying the lower pole of the uterus. If it is head, characteristics to note
are: presenting area, attitude and engagement

37. Pelvic grip

38. Auscultation:
Preparatory procedures-
• Ask the patient to evacuate her bladder
• Dorsal position-thigh and knee flexed
• Abdomen is exposed
• Stand on right side of the patient
Procedures:
• By lateral grip the back of the fetus is located
• Diaphragm is placed over the fetal back of the stethoscope. Alternatively, Pinard’s
fetoscope can also be used
• FHS is heard where there is maximum intensity

39. • The fetal heart sounds are best audible through the back (left
scapular region) in vertex and breech presentation where
the convex portion of the back is in contact with the uterine
wall. However, in face presentation, the heart sounds are
heard through the fetal chest

40. Vaginal Examination
• A vaginal examination is an internal examination of the vagina
and cervix
• A vaginal examination is an intimate procedure that should
only be perform when it is absolutely necessary and provide
information that will aid in decision-making process. The
examination should always be approached in a sensitive
manner that maintains the dignity of the client at all times.
• The midwife should ensure that the women is in a comfortable
position, she has emptied her bladder
• Informed consent must be obtained before the procedure is
carried out.

41. Indication of vaginal examination
• To assess the pelvic capacity whether vaginal delivery is possible or not
• Immediately after rupture of membrane especially when there is more
chance of cord prolapse e.g. Polyhydramnios
• Determine whether the head is engaged in case of doubt
• Identify the presentation and position of the fetus
• Assess progress or delay in labor
• Ascertain whether the membrane have rupture or to rupture them
artificially
• To note the dilatation of the cervical OS

42. Articles:
• One bowl with cotton swab
• Chilttle forceps
• Light
• Sterile gloves
• Antiseptic solution
Contraindication:
• Undue examination during labor as it is always chance of introducing
infection to the sterile upper genital tract after rupture of membrane
• History of Antepartum hemorrhage
• History of leaking
• Diagnosed placenta previa

43. Procedure of Vaginal Examination
Preparatory procedures:
• Ask the patient to evacuate bladder
• Explain what is going to be done and consent is taken
• A female attendant must be present
• Set up the trolley and open the vaginal examination pack
• Position- Dorsal position on thigh flexed and knee flexed
• Stand on right side of the patient and put on sterile gloves on both hands

44. Procedure:
• Swab vulva from front to back
• Gently insert clean fingers downwards and backwards into the vagina
• Observe the labia for any sign of varicosities, edema or vulval warts or
sores
• Note whether the perineum is scarred from a previous tear of episiotomy,
some culture practice female genital mutilation, scarring from the
operation would be evident
• Note discharge or bleeding from the vaginal orifice
• If the membranes have ruptured the color and odor of any amniotic fluid
or discharge are noted.
• Offensive liquor suggest infection and green fluid indicates the presence of
meconium, which may be a sign of fetal compromise or post maturity

45. • As the examining fingers reach the end of the vagina and come into contact
with the cervix
• Palpate around the fornices and sense the proximity of the presenting part
of the fetus to the examining finger
• Assess the length of the cervical canal. A long tightly closed cervix indicates
that labor has not yet started
• The cervical canal may be partially or completely obliterated depending on
the degree of effacement
• In a primigravida, the cervix may be completely effaced but still closed; in
this case, it will be closely applied to the presenting part and can easily be
confused with a completely dilated cervix.

51. • The consistency of the cervix is noted. It should be soft, elastic and applied
closely to the presenting part
• Dilatation of the cervix is estimated in cm; 10cm dilatation equates to full
dilation
• Intact membranes can be felt through the dilating OS. When felt between
contractions they are slack but will become tense when the uterus
contracts
• If the presenting part does not felt well, some of the fluid from the
hindwaters escapes into the forewaters, causing the membrane to
protrude through the cervix. This will be more exaggerated labor

53. • Building membranes are more likely to rupture early and in this case
they will not be felt at all
• Following rupture of the membranes the midwife needs to satisfy
herself that the cord has not prolapsed by listening to the fetal heart
through a contraction
• The presenting part is defined as the part of the fetus lying over the
uterine OS during labor. In order to assess the descent of the fetus in
labor, the level of the presenting part above or below the ischial
spines expressed in cm

54. After Care:
• Wash the gloved hand on decontamination solution and remove
gloves
• Discard the used swab and pad
• Record findings on women’s chart
• Notify the findings

55. Danger signs of 1st stage of labor
Most women, including women with disabilities, give birth safely. But when
something goes wrong during labor and birth, it is very important for a
women to get the care to save her life.
1. Waters break but labor does not start within 24 hours:
• When the waters have broken, the risk is much higher that mother and
baby could get a serious infection

57. Management:
• If the patient is not in labor and there is no evidence of infection or fetal
distress, she is observed carefully in the hospital .
• Generally in 90% cases spontaneous labor ensure within 24hours. If labor
does not start within 24hours or there are reason not to wait, induction of
labor with oxytocin is to be done.

58. 2. Baby lying sideways or transverse lie:
• The baby has his head one of the his mother’s sides and the bottom across
her abdomen at her other side. This is normal before 26weeks. By 29-
30weeks we expect babies to be head down or at least breech.
Management:
• Do not try to change the position of the baby once labor started. This can
be tear the womb or separate the placenta from the womb wall. A baby
lying sideway can not be born without cesarean section.

60. 3. Bleeding before baby born (Intra-partum hemorrhage)
• Intra-partum hemorrhage, which is bleeding that occurs during labor, may
be caused by premature separation of the placenta from the uterine wall,
or may arise in cases of placenta previa where the placenta lies over the
cervix.

62. • Placenta previa to cause bleeding during labor, as most cases are diagnosed
before labor and delivered by caesarean section. Heavy bleeding during
labor is more likely to be due to premature separation of the placenta or
abruption, which may also cause pain in the abdomen or fetal distress

63. • Management:
If heavy bleeding does occur during childbirth, then a blood transfusion
may be necessary.
Saline and other fluids will also be given intravenously, and blood pressure
and pulse monitored.
 The baby will often need to be delivered by caesarean section. If the
bleeding is only mild, the labor will be closely monitored, particularly the
amount of bleeding, the baby’s heart rate and how the labor progresses.

64. 4. Fever:
• Fever is usually a sign of infection. If fever is not very strong, give plenty of
water, juice .
• If fever is very high and have chills . Antibiotics like ampicillin, amoxicillin or
erythromycin is given.
5. Green or brown waters:
• When the bag of waters breaks, the water should be clear or little pink.
Brown or green waters mean the baby has probably passed stool inside the
womb.

65. • As soon as the baby’s head is out, and before it takes its first breath, suck
out the mucus from mouth and nose by using penguin suction or suction
bulb.

66. Penguin suction suction bulb

67. 6. Intra-partum Eclampsia:
• Pre-Eclampsia is a disorder of pregnancy characterized by development of
hypertension to the extent of 140/90mmhg or more with proteinuria after
the 20th week in a previously normotensive and non-proteinuria women.
• Pre-eclampsia when complicated with generalized tonic-clonic convulsions
and or coma is called eclampsia.
Management:
• Put something under patient head to protect from injury.

68. • Put patient on her left side .
• Tongue blade is inserted between teeth.
• Vomits and secretion are removed by frequent suctioning.
• Oxygenation should be maintained (8-10l/min).
• Once the patient is stabilized , a thorough but quick general, abdominal
and vaginal examination are made.
• In the absence of any contraindication to the vaginal delivery, low rupture
of membrane is done.
• Antihypertensive e.g. Nitroglycerin, lebetalol and anticonvulsion e.g.
Magnesium sulfate drug is given

69. 7. Cord prolapse:
The cord is lying inside the vagina or outside the vulva following rupture of
the membranes.
8. Unstable lie:
This is a condition where the presentation of the fetus is constantly changed
even beyond 36th week of pregnancy when it should have been stabilized.

70. 9. Compound presentation:
when a cephalic presentation is complicated by the presence of a hard or a
foot or both alongside the head or presence of one or both hands by the side
of the breech, it is called compound presentation.

73. 10. Prolonged labor:
The labor is said to be prolonged when the combined duration of the first
and second stage is more than arbitrary time limit of 18 hours.
11. Obstructed labor:
Obstructed labor is one where in spite of good uterine contractions, the
progressive descent of the presenting part is arrested.
12. Shoulder dystocia:
The term shoulder dystocia is defined to describe a wide range of difficulties
encountered in the delivery of the shoulders.

74. Preparation of women for Labor
General preparation:
Examination of the mother:
• Thorough physical examination of the patient including pulse, BP, height,
weight, etc., are done. Per abdominally uterine contraction, fetal
presentation, position, engagement and FHS are examined. Per vaginal
examination Is done

75. Psychological counsel and reassure:
• Encouragement, emotional support and assurance are given to keep up the
morale
• Mother can explained about the labor procedure and reassurance can be
given by informing that labor procedure is a physiological process

76. Cleaning and saving:
• Abdomen, perineum, vulva, and medial sides of thighs are thoroughly
cleaned. Vulva hair is shaved and mother is dressed in a clean clothe
Bowel:
• An enema with soap and water or glycerin suppository is traditionally given
in early stage
• This may be given if the rectum feels loaded on vaginal examination. But
enema neither shortens the duration of labor, nor reduces the infection
rate

77. Rest and Ambulation:
• If the membranes are intact, the patient is allowed to walk about. This
attitude prevents venacaval compression and encourages descent of head
• Ambulation can reduce the duration of labor, need of analgesia and
improves maternal comfort
• However, labor is monitored electronically or analgesic drug (epidural
analgesia) is given, she should be in bed

78. Diet:
• There is delayed emptying of the stomach in labor. Food should be
withheld during active labor
• Fluids in the form of plain water, ice chips or fruit juice may be given in
early labor
• Iv fluid with ringer solution is started where any intervention is anticipated
or the patient is under regional anesthesia

79. Bladder care:
• Patient are encouraged to pass urine by herself as full bladder often
inhibits uterine contraction and may lead to infection
• If the women cannot go to the toilet, she is given a bed pan
• If the patient fails to pass urine specially in late first stage, catheterization is
to be done with strict aseptic precautions

80. Relief of pain:
• The common analgesic drug used in Pethidine 50-100 mg intramuscularly
when the pains are well established in the active phase of labor
• If necessary, it is repeated after 4 hours. Pethidine is an effective analgesic
as well as a sedative.

81. • Metoclopramide 10mg IM is commonly given to combat vomiting due to
Pethidine. Pethidine crosses the placenta and is a respiratory depressant to
the neonate.
• The drug should not be given if delivery is anticipated within 2 hours
• Non-pharmacological methods in the form of psychological support,
hypnosis, acupuncture, etc. are employed

82. Fetal monitoring by Pinard’s
• It is stethoscope used to listen the heart rate of fetus during pregnancy. It is
often made of wood or metal
• A pinard’s stethoscope will enable the midwife to hear the fetal heart
directly

84. • The stethoscope is placed on the mother’s abdomen, at right angles to it
over the fetal back
• The ear must be in close, firm contact with the stethoscope because then
extraneous sounds are produced.
• The stethoscope should be moved about until the point of maximum
intensity is located where the fetal heart is heard most clearly

85. • The midwife should count the beats per minute, which should be in the
range of 110-160.
• The midwife should take the women’s pulse at the same time as listening
to the fetal heart to enable her to distinguish between two
• Use of the pinard’s stethoscope will enable the midwife to hear actual
heart beat

86. Fetal monitoring by Doppler
• Doppler fetal monitor (Doppler of fetal) is a hand-held ultrasound
transducer used to detect the fetal heart beat
• It uses the Doppler effect to provide an audible simulation of the heart
beat

87. Fetal Doppler

88. • Use of this monitor is sometime known as Doppler auscultation
• Doppler fetal monitors provide information about the fetus similar to that
provided by a fetal stethoscope
• On advantages of the Doppler fetal monitor over a fetal stethoscope is the
electronic audio output which allows people other than the user to hear
the heart beat

89. CTG (Cardiotocography)
• Cardiotocography is a technical means of recording the fetal heart beat and
the uterine contractions during pregnancy, the machine use to perform the
monitoring is called a cardiotocograph, more commonly known as an
electric fetal monitor (EFM)
• CTG monitoring is widely used to assess fetal well being

90. Interpretation of CTG:
• Baseline fetal heart rate
• Baseline variability
• Acceleration from the baseline rate
• Deceleration from the baseline rate

91. Baseline fetal heart rate
• This is the fetal heart rate between uterine contractions
• A rate more rapid than 160 b.p.m is termed baseline tachycardia; a rate
slower than 110 b.p.m. is baseline bradycardia. Either may be indicative of
fetal compromise due to a number of causes.

93. Baseline Variability
• Electrical activity in the fetal heart results in minute variations in the length
of each beat.
• This causes the tracing to appear as a jagged rather than a smooth line
• The baseline rate should vary by at least 5 beats over a period of 1min
• Loss of this variability may indicate feel compromise
• Reduced variability may be noted for a short period after the
administration of maternal petidine, which depress the fetal brain

95. • An acceleration is a brief rise in the fetal heart rate of at least 15 beats, for
at least 15sec.
• A deceleration is a drop from the baseline of 15 beats for >15s.
• A deceleration of the fetal heart rate lasting longer than 3min is referred to
as a bradycardia

96. Response of the fetal heart to uterine contraction
• The fetal heart rate will normally remain steady or accelerate during
uterine contraction during the first stage of labor
• In order to assess the significance of fetal heart rate decelerations
accurately, their exact relationship to uterine contractions, size, shape, and
uniformity must be noted
• Compression of the umbilical cord, or fetal head, will result in some
decelerations, particularly if the membranes are not intact
• These would be early or variable decelerations lasting <3min with good
recovery to pre-deceleration rate

97. Fetal distress
• Fetal distress refer to fetal hypoxia in uterus. This occurs when conditions
that interfere with the supply of oxygen to the fetus.
• Fetal distress is defined as depletion of oxygen and accumulation of carbon
dioxide, leading to a state of “hypoxia and acidosis” during intrauterine life
• A fetal heart rate below 100 or above 180 is a sign that the baby is in
distress
• Fetal distress is an emergency and need to treat quickly

98. Causes of fetal distress
Maternal Factors:
• Pre-eclampsia, eclampsia, chronic nephritis and diabetes. This condition
may lead to placental insufficiency
• Severe anemia in pregnancy and severe cardiac disease result in deficient
oxygen to the mother
• Hypotension: if the mother’s blood pressure decrease during labor, blood
flow to the fetus may be reduced

99. • Prolonged labor; if the membranes have been long ruptured, interfere with
placenta circulation
• Contraction: Involuntary tightening of muscles in the uterus to deliver the
baby. Contractions briefly reduce the flow to the placenta and can
compress the umbilical cord and cause nutrients to be cut off
• Infection: Amnionitis

100. Placenta and cord factors:
• Antepartum hemorrhage (abruption placenta) due to premature
separation of placenta, it causing maternal hemorrhage then reduces
placental circulation and less oxygen to the baby
• Poor blood circulation through the cord due to cord compression eg.
Presentation or prolapsed or knotting the umbilical cord

101. Fetal circulation:
• Post-maturity associated with placental insufficiency
• Congenital fetal abnormality (cardiovascular system)
• Prematurity
• Intrauterine infection of fetus

102. Pathophysiology of fetal distress
Decreased fetal oxygenation in labor
Hypoxia
Metabolic acidosis
Asphyxia
Tissue damage/ Fetal death

103. Signs and symptoms of fetal distress
• Abnormal fetal heart rate (<120 or>160) when the women is
not in labor and <100 or>180 bpm) when women in labor
• Irregular and feeble fetal heart rate
• Decreased fetal movement
• Fetal acidosis

104. Management of fetal distress
• Lateral positioning to avoids compression of vena cava and aorta by the
gravid uterus . This increases cardiac output and uteroplacental perfusion
• Oxygen is administered (6-7L/min) to the mother with mask to improve
fetal SaO2
• Correction of dehydration by IV fluids to improves intravascular volume
and uterine perfusion
• Correction of maternal hypotension (following epidural analgesia) with
immediate infusion if 1L of crystalloid (Ringer’s solution)

105. • Stoppage of oxytocin to improve fetal oxygenation. Fetal hypoxia may be
due to strong and sustained uterine contractions
• Tocolytic (inj terbutaline 0.25mg sc) is given when uterus is
hypertonus
• Amnioinfusion is the process to increase intrauterine fluid volume
with warm normal saline (500ml) to reduce cord compression,
meconium aspiration