Warning Signs
Part of Midwifery and Childbirth
The danger signs during pregnancy, labor, and the postpartum period that require immediate action — and what that action should be.
Why This Matters
The majority of maternal deaths are preventable — not because they require sophisticated treatment, but because they follow a recognizable pattern of warning signs that, if identified early, allow time to act before the situation becomes irreversible. The three most common killers of mothers — hemorrhage, infection, and hypertensive crisis — all announce themselves with early signals. A birth attendant who recognizes those signals and responds appropriately saves lives; one who misses them or delays action loses them.
Warning signs are not rare exotic presentations. They are the early phases of conditions that occur in a predictable proportion of all pregnancies and deliveries. In any community where births are attended, warning signs will appear regularly. The goal of this article is to make the recognition of warning signs automatic — so that when the situation is unfolding, the response is already forming before full assessment is complete.
The format used here is direct: sign → significance → immediate action. Some of these situations can be managed in the field; others cannot. Knowing the difference is itself lifesaving.
Warning Signs During Pregnancy
Vaginal bleeding before 28 weeks:
Significance: Bleeding in the first half of pregnancy may indicate miscarriage, ectopic pregnancy (life-threatening), or implantation bleeding (normal). Volume and associated symptoms differentiate these.
Action:
- Light spotting without pain, no clots: monitor; reassure; recheck if continues or worsens
- Any bleeding with significant pain: assess for ectopic pregnancy — pain typically one-sided, may radiate to shoulder; internal bleeding causes faintness, shoulder pain from blood under diaphragm
- Ectopic pregnancy is a surgical emergency — mortality without intervention is high; evacuate urgently
Vaginal bleeding after 28 weeks:
Significance: In the third trimester, bleeding may indicate placenta previa (placenta covering the cervical opening) or placental abruption (placenta detaching prematurely). Both are emergencies.
- Placenta previa: bright red, painless bleeding; first episode often not life-threatening but may herald catastrophic re-bleeding
- Placental abruption: may be little external blood, but severe abdominal pain, uterus that feels hard and rigid between contractions, fetal distress
Action:
- All significant third-trimester bleeding: immediate referral if possible; prepare for hemorrhage
- Do not perform internal examination — in placenta previa, this can trigger catastrophic hemorrhage
- Placental abruption with fetal distress: needs urgent delivery by any means available
Severe headache, visual changes, or right upper abdominal pain in the second half of pregnancy:
Significance: These symptoms, especially combined with elevated blood pressure, indicate severe preeclampsia — or worse, impending eclampsia. The headache is severe and not relieved by rest or simple analgesia. Visual changes include flashing lights, blurring, or loss of peripheral vision. Right upper abdominal pain indicates liver capsule distension.
Action:
- Immediately check blood pressure
- If BP ≥160/110: this is a hypertensive emergency; give antihypertensive if available (nifedipine 10 mg orally or sublingual)
- Magnesium sulfate 4g IV/IM if available — prevents eclamptic seizure
- Urgent delivery is the only definitive treatment; refer immediately
No fetal movement for 12+ hours after 28 weeks:
Significance: Decreased or absent fetal movement can indicate fetal distress or fetal death.
Action:
- Have the mother lie on her left side, drink something sweet, and focus on movement for 2 hours
- 10 movements in 2 hours: reassuring; continue daily counting
- Fewer than 10 movements or no movement: assess fetal heart rate; if abnormal or undetectable, urgent assessment for fetal wellbeing
- Confirmed fetal death (no heart sounds): the baby will require delivery; labor will usually begin spontaneously within 2 weeks, or induction may be necessary
High fever (>38°C) during pregnancy:
Significance: Fever in pregnancy is dangerous because some infections cause fetal damage (rubella, toxoplasmosis, listeria) and all systemic infections can trigger premature labor.
Action:
- Identify source: urinary tract infection is the most common cause (painful urination, frequency); pneumonia; malaria (in endemic areas)
- Antipyretics (paracetamol is safe in pregnancy) to reduce fever
- Antibiotics for confirmed or suspected infection (amoxicillin is safe; avoid tetracyclines, fluoroquinolones)
- Antimalarials for confirmed or suspected malaria — this is a leading cause of maternal mortality in endemic regions and must not be undertreated in pregnancy
Warning Signs During Labor
Prolonged latent phase:
Significance: Latent phase (irregular contractions, cervix not yet in active labor) lasting more than 20 hours in a first-time mother or more than 14 hours in subsequent births.
Action:
- Assess hydration and encourage oral fluids
- Encourage rest — walking in latent phase is often counterproductive when contractions are irregular
- Reassess — ensure you are distinguishing latent labor from false labor (prodromal labor that doesn’t progress)
- If mother is exhausted: consider allowing rest (labor will often resume after sleep)
Failure of progress in active labor:
Significance: Less than 1 cm dilation per hour during active labor (cervix beyond 6 cm, contractions regular and strong) for 2+ consecutive hours indicates arrested labor. Causes: inefficient contractions, malposition, cephalopelvic disproportion.
Action:
- Reposition the mother — upright positions, walking, rocking
- Encourage the mother’s pushing if in second stage
- Assess baby’s position: if malposition suspected (baby facing forward rather than back), position changes (hands-and-knees) may correct
- If no progress after 2 hours of repositioning and adequate contractions: this baby likely needs delivery assistance that cannot be provided at home; urgently refer
Fetal heart rate abnormalities:
| Pattern | Significance | Action |
|---|---|---|
| Below 100 bpm after a contraction | Hypoxia | Reposition left lateral; check cord position; urgent delivery |
| Above 180 bpm sustained | Fetal distress or infection | Same as above |
| Absent heart sounds | Fetal compromise or death | Urgent assessment |
| Sudden absence after previously heard | Cord accident | Urgent delivery |
Umbilical cord prolapse:
Significance: The umbilical cord delivers before the baby, slipping through the cervix. If the baby’s head then presses the cord against the pelvis, blood flow to the baby ceases. Death or brain damage within minutes.
Signs: Cord visible at the vaginal opening, or palpable on internal examination below the presenting part. Sudden severe fetal heart rate drop.
Action: This is a rare but catastrophic emergency.
- Call for all available help immediately
- Elevate the presenting part — push the baby’s head up and back with a hand inside the vagina to take pressure off the cord. This hand must stay in position until delivery.
- Position the mother in knee-chest position (face down, knees drawn up to chest) — gravity helps take pressure off the cord
- Do not push the cord back in
- Deliver as rapidly as possible by any means available
- Keep the cord moist with clean wet cloth if it is external
Rupture of uterus:
Significance: The uterine wall tears, usually during prolonged obstructed labor (especially with a previous uterine scar). The mother bleeds internally and goes into shock; the baby is typically compromised or dies.
Signs: Sudden severe abdominal pain, then paradoxical relief of contractions as the uterus loses tone; abdomen becomes rigid; fetal parts become palpable through the abdominal wall; fetal heart disappears; mother rapidly deteriorates into shock.
Action: Surgical emergency — there is no field treatment. Keep the mother in shock position (flat, legs elevated), manage IV fluids if available, and evacuate urgently. Mortality without surgery approaches 100%.
Heavy bleeding during labor (antepartum hemorrhage):
Action: Heavy bleeding at any point during labor requires urgent assessment — determine source (placenta previa, abruption, other), maintain the mother’s blood volume with fluids, and prepare for emergency delivery.
Warning Signs After Delivery
Postpartum hemorrhage:
Definition: Blood loss exceeding 500 mL (1 pint) after delivery, OR any bleeding that compromises the mother’s condition.
Signs: Heavy ongoing bleeding soaking multiple thick cloths, soft uterus (failed contraction), falling blood pressure, rising pulse, pallor, faintness, confusion.
Action:
- Massage the uterus firmly until firm
- Give oxytocin (10 units IM) or misoprostol (600 mcg sublingual) if available
- Ensure the bladder is empty
- If placenta retained: manual removal
- Bimanual compression if bleeding continues
- Tranexamic acid 1g if available
- Evacuate urgently — this is a leading cause of maternal death and requires blood transfusion to survive major hemorrhage
Fever after delivery (puerperal fever):
Definition: Temperature ≥38°C on any 2 of the first 10 postpartum days (excluding the first 24 hours).
Causes: Uterine infection (most common), wound infection, urinary tract infection, mastitis, DVT.
Signs of uterine infection: Foul-smelling lochia, uterine tenderness, subinvolution (uterus not descending as expected).
Action:
- Begin broad-spectrum antibiotics immediately without waiting for confirmation
- Encourage uterine drainage: massage, breastfeeding
- Ensure adequate hydration
- If no improvement in 24-48 hours or deterioration: evacuate
Severe headache, visual changes, or seizure after delivery:
Significance: Postpartum eclampsia — the majority of eclamptic seizures occur in the first 24-48 hours after delivery. Blood pressure can spike dangerously even after a delivery that appeared uncomplicated.
Action:
- Measure blood pressure
- If seizure is occurring: protect from injury; position on left side to prevent aspiration
- Magnesium sulfate 4g IV/IM if available — treatment of choice for eclamptic seizure
- After seizure: urgent delivery (already delivered) or stabilization and referral
Newborn warning signs:
| Sign | Significance | Action |
|---|---|---|
| Not breathing/weak cry at 1 min | Asphyxia | Resuscitate immediately |
| Temperature below 36°C | Hypothermia | Warm immediately, skin-to-skin |
| Yellow jaundice first 24 hours | Hemolytic disease | Urgent referral |
| Cord redness spreading onto abdomen | Omphalitis | Antibiotics, urgent care |
| Not feeding in 8 hours | Multiple causes | Assess for illness, hypothermia |
| Seizures | Meningitis, asphyxia, metabolic | Urgent referral |
| Labored breathing at rest | Respiratory distress | Monitor; refer if worsening |
Making the Decision to Refer
The hardest decision in field midwifery is often whether to refer. Transport may be dangerous, distant, or unavailable. The mother may refuse. The family may be frightened by the suggestion.
The framework for referral decisions:
- Is the situation beyond your skills? Be honest. A ruptured uterus cannot be treated without surgery.
- Is the situation deteriorating despite your best intervention? If hemorrhage continues after massage, oxytocin, and bimanual compression, blood transfusion is the only remaining option.
- Does the delay in referral increase risk? In hemorrhage and eclampsia, every minute matters.
Having the referral conversation in advance — during prenatal care — is far easier than during a crisis. Every pregnant woman should know the warning signs, know who to call, and know how she would reach medical care if needed. This is not pessimism — it is preparation.