After completing this chapter, you should be able to distinguish contractions from established labor, describe the stages and phases of labor, assess contraction patterns, explain cervical dilation, effacement, station, presentation, and position, recognize membrane rupture and imminent delivery, identify high-risk presentations, and determine when transport should continue, pause, divert, or convert to delivery preparation.
Is this established labor?
Contractions plus cervical change—not pain alone.
How advanced is it?
Stage, dilation, effacement, station, and signs of descent.
Is delivery uncomplicated?
Presentation, membranes, bleeding, prior uterine surgery, multiples.
Is the fetus tolerating labor?
Baseline, variability, decelerations, and maternal physiology.
Does the destination still fit?
Continue, divert, prepare to deliver, or request resources.
A 32-year-old G4P3 at 38 5/7 weeks is being transferred for labor because the sending facility has no obstetric service. Contractions were every 6 minutes at departure. Fifteen minutes later they occur every 2 minutes and last 70 seconds. She reports rectal pressure and says she cannot stop pushing. The perineum bulges during contractions. The closest obstetric-capable hospital is 18 minutes away. This is no longer a routine interfacility ride; the labor assessment now determines whether the safest plan is continued transport or immediate delivery preparation.
Established labor is uterine contractions that result in cervical dilation or effacement. Contractions can be painful, regular, or frequent without producing cervical change. Membranes can rupture before labor. Conversely, labor may be established before membranes rupture.
Transport clinicians should not promise that a patient is or is not in labor without the appropriate assessment. When cervical findings are unavailable, document the observable pattern and communicate uncertainty.
Onset of labor to complete cervical dilation. The latent phase precedes active labor; current ACOG guidance uses 6 cm as the start of the active phase.
Complete dilation to birth. Includes passive descent and active maternal pushing. Crowning and involuntary bearing down suggest imminent birth.
Birth of the newborn to delivery of the placenta. Monitor bleeding and uterine tone; never apply forceful cord traction.
Early recovery after placental delivery. Prioritize uterine tone, bleeding, maternal perfusion, and newborn transition.
Describe uterine activity using four components:
Beginning of one contraction to beginning of the next.
Beginning to end of the same contraction.
Patient report, palpation, or internal measurement when available.
Whether the uterus softens adequately between contractions.
Uterine tachysystole is more than five contractions in ten minutes, averaged over thirty minutes. Always report whether fetal heart-rate decelerations accompany the pattern. Tachysystole can occur spontaneously or with oxytocin, prostaglandins, or other stimulation.
Opening of the cervix. Complete dilation is 10 cm.
Thinning and shortening of the cervix.
Relationship of the presenting part to the ischial spines; 0 station is level with the spines.
Progress of the presenting part through the pelvis. Rapid change can signal imminent birth.
A digital cervical examination is not a routine transport procedure. Perform only when trained, authorized, clinically necessary, and safe. Avoid digital examination in unexplained third-trimester bleeding until placenta previa has been excluded. Repeated examinations increase infection risk after membrane rupture.
Head first. Vertex is the usual favorable presentation.
Buttocks or feet first. Higher risk for cord prolapse, head entrapment, and neonatal compromise.
Shoulder or side presents. Vaginal birth is generally not possible without change in lie.
An extremity accompanies or precedes the presenting part. Do not pull on a visible limb.
Fetal position describes the orientation of a reference point—usually the occiput in a vertex fetus—within the maternal pelvis. Exact position may be documented by the obstetric team, but transport clinicians should at minimum know presentation, whether the presenting part is engaged or descending, and whether a cord or extremity is visible.
Document the time of rupture, whether rupture was spontaneous or artificial, and the amount, color, odor, and ongoing leakage of fluid. Clear fluid may be normal. Green or brown fluid suggests meconium. Foul odor with maternal fever or uterine tenderness raises concern for infection. Blood-stained fluid requires evaluation for bleeding causes.
Visible or palpable cord, sudden fetal bradycardia, or recurrent variable decelerations after rupture.
Signals fetal stool passage and need for neonatal readiness; it does not by itself prove acidemia.
Fever, foul fluid, uterine tenderness, maternal or fetal tachycardia.
Requires gestational-age-specific obstetric and neonatal capability.
Prepare for delivery before the final sign appears. Establish a warm environment, newborn resuscitation readiness, maternal hemorrhage supplies, suction, oxygen, clamps, towels, and additional help.
Sudden constant pain, fetal deterioration, bleeding, shock, or loss of station may indicate rupture.
Requires immediate obstetric capability and careful cord assessment.
Identify each fetus, anticipate malpresentation and more than one newborn, and prepare for hemorrhage.
Gestational age changes medication, neonatal, destination, and delivery decisions.
Painful bleeding, uterine tenderness, or shock may indicate abruption or rupture.
Hypotension can reduce uteroplacental perfusion and trigger fetal deterioration.
Stable maternal and fetal status, no imminent birth, appropriate destination and resources, adequate travel margin.
Unsecured equipment, incomplete assessment, active resuscitation, uncontrolled hemorrhage, uncertain presentation, or absent delivery readiness.
Crowning, involuntary pushing, visible presenting part, rapidly advancing second stage, or unsafe remaining travel time.
Fetal deterioration, maternal instability, abnormal presentation, uterine rupture concern, cord prolapse, or need for immediate surgical/neonatal capability.
The G4P3 patient has contractions every 6 minutes, reassuring fetal status, intact membranes, and no urge to push. The original obstetric destination is appropriate.
Contractions become every 2 minutes and last 70 seconds. The uterus softens between contractions, but the patient reports strong rectal pressure. The team reassesses the perineum, confirms fetal status, and notifies the receiving center.
Crowning and involuntary pushing develop. The team stops in the safest feasible location, warms the compartment, opens delivery and neonatal equipment, assigns maternal and newborn roles, and prepares for birth.
After birth, the newborn is dried, warmed, assessed, and supported. The mother is monitored for placental delivery, uterine tone, and hemorrhage. The team avoids forceful cord traction and continues to the appropriate receiving facility.
Immediate rationales are shown in study mode, and your score is stored locally.