![]() ![]() Patients should be instructed to contact their health care provider for any of the following reasons: 1) if their contractions occur approximately every 5 minutes for at least 1 hour, 2) if there is a sudden gush of fluid or a constant leakage of vaginal fluid (suggesting rupture of membranes ), 3) if there is any significant vaginal bleeding, or 4) if there is significant decrease in fetal movement.įIGURE 8.1. Mechanism of effacement, dilation, and labor. ![]() The mechanism of effacement and dilation and the vectors of the expulsive forces are demonstrated in Figure 8.1. The cervix is often significantly effaced before the onset of labor, particularly in the nulliparous patient. Cervical effacement is common before the onset of true labor, when the internal os is slowly drawn into the lower uterine segment. This “bloody show” results as the cervix begins thinning (effacement) with the concomitant extrusion of mucus from the endocervical glands and a small amount of bleeding from small vessels in the area. ![]() Patients often report the passage of blood-tinged mucus late in pregnancy. ![]() The patient may also notice that she is breathing more easily, because there is less pressure on the diaphragm as the uterus becomes smaller. The patient may also report that the baby is “dropping.” The patient often notices that her lower abdomen is more prominent, and she may feel a need to urinate more frequently as the bladder is compressed by the fetal head. These contractions become increasingly intense and frequent.Īnother event of late pregnancy is termed “lightening,” in which the patient reports a change in the shape of her abdomen and the sensation that the baby is lighter, the result of the fetal head descending into the pelvis. True labor is associated with contractions that the patient feels over the uterine fundus, with radiation of discomfort to the low back and lower abdomen. It is not uncommon for these contractions to resolve with ambulation, hydration, or analgesia. Braxton Hicks contractions are typically shorter in duration and less intense than true labor contractions, with the discomfort being characterized as over the lower abdomen and groin areas. As a result, it is difficult for the physician to determine the true onset of labor by history alone. These Braxton Hicks contractions (false labor) are not associated with dilation of the cervix, however, and do not fit the definition of labor. It is frequently difficult for the patient to distinguish these often uncomfortable contractions from those of true labor. Late in pregnancy they become stronger and more frequent, resulting in the patient’s perception of discomfort. Spontaneous uterine contractions, which are not felt by the patient, occur throughout pregnancy. MATERNAL CHANGES BEFORE THE ONSET OF LABORĪs a patient approaches term, she experiences uterine contractions of increasing strength and frequency. What are the next steps in evaluation of this patient? If it appears she is in labor, how might you manage this patient? The fetal heart tracing is reassuring, and there do not appear to be any regular contractions. They should be able to describe how to perform a vaginal delivery and to list indications for cesarean delivery.Ī healthy, 28-year-old patient presents to labor and delivery at 39 weeks of gestation complaining of “crampiness” overnight. They should understand the options for pain management and describe deviations from normal labor as well as maternal and fetal monitoring. Students should be able to discuss the management of the laboring patient, including appropriate triage and diagnosis. This chapter deals primarily with APGO Educational Topic Area: ![]()
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