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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

Section 2 - Symptoms

Fetal distress in labour


  • Abnormal fetal heart rate (less than 100 or more than 180 beats per minute).

  • Thick meconium-stained amniotic fluid.



  • Prop up the woman or place her on her left side.

  • Stop oxytocin if it is being administered.



BOX S-7   Abnormal fetal heart rate 

  • A normal fetal heart rate may slow during a contraction but usually recovers to normal as soon as the uterus relaxes.

  • A very slow fetal heart rate in the absence of contractions or persisting after contractions is suggestive of fetal distress. 

  • A rapid fetal heart rate may be a response to maternal fever, drugs causing rapid maternal heart rate (e.g. tocolytic drugs), hypertension or amnionitis. In the absence of a rapid maternal heart rate, a rapid fetal heart rate should be considered a sign of fetal distress.

  • If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate management.

  • If a maternal cause is not identified and the fetal heart rate remains abnormal throughout at least three contractions, perform a vaginal examination to check for explanatory signs  of distress:

- If there is bleeding with intermittent or constant pain, suspect abruptio placentae;

- If there are signs of infection (fever, foul-smelling vaginal discharge) give antibiotics as for amnionitis;

- If the cord is below the presenting part or in the vagina, manage as prolapsed cord.

  • If fetal heart rate abnormalities persist or there are additional signs of distress (thick meconium-stained fluid), plan delivery:

- If the cervix is fully dilated and the fetal head is not more than 1/5 above the symphysis pubis or the leading bony edge of the head is at 0 station, deliver by vacuum extraction or forceps;

- If the cervix is not fully dilated or the fetal head is more than 1/5 above the symphysis pubis or the leading bony edge of the head is above 0 station, deliver by caesarean section.


  • Meconium staining of amniotic fluid is seen frequently as the fetus matures and by itself is not an indicator of fetal distress. A slight degree of meconium without fetal heart rate abnormalities is a warning of the need for vigilance.

  • Thick meconium suggests passage of meconium in reduced amniotic fluid and may indicate the need for expedited delivery and meconium management of the neonatal upper airway at birth to prevent meconium aspiration (page S-143).

  • In breech presentation, meconium is passed in labour because of compression of the fetal abdomen during delivery. This is not a sign of distress unless it occurs in early labour.

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Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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