1. Bleeding. By bleeding, I mean bleeding that is similar in character or heaviness to a menstrual period.  Bleeding to this degree may indicate that something has happened to the placenta. For example, a condition known as placental abruption involves the separation of the placenta from the uterine wall and may lead to heavy bleeding and the sudden onset of abdominal or pelvic pain.
The placenta is the connection between mother and baby, supplying the baby with oxygen while inside the uterus. Abruption of the placenta may represent a small degree of separation in which only a portion of the placenta tears away from the uterus, or in catastrophic cases, the entire placenta may separate.
Another condition known as placenta previa is a life-threatening condition in which the placenta implants or attaches to the area overlying the cervical opening. It may partially obscure the opening (known as a partial previa) or it may completely occlude the opening (known as a complete previa). When the cervix begins to open during labor the placenta becomes detached from the uterus leading to a potentially life-threatening hemorrhage. Placenta previa is usually diagnosed early in the pregnancy via ultrasound and patients are cautioned to come to the hospital immediately at the first sign of bleeding. A cesarean section is usually required to manage a placenta previa.
There are other less serious causes of bleeding near the end of pregnancy, but placental abruption and placental previa are always first to mind as the most serious causes of significant bleeding near term. For instance, a harmless condition known as “bloody show” results from the cervix softening in advance of labor. Typically this results in a bloody discharge, but the bleeding may be prominent, resembling that seen with a menstrual period. It is also common for a woman to experience some degree of bleeding or spotting after sexual intercourse, particularly in the last few weeks of pregnancy. If you are experiencing bleeding in pregnancy that resembles menstrual bleeding it is always appropriate to contact us.
2. Rupture of Membranes. The baby exists within a sac or bag that is filled with amniotic fluid. As a normal part of the labor process this bag breaks or ruptures, occurring most commonly as the cervix dilates or opens. It is also common for physicians or nurse-midwives to manually “break” the sac in an effort to induce or augment the labor process. Spontaneous rupture or breaking can occur, however, well in advance of labor, even well in advance of the due date in a condition known as preterm premature rupture of the membranes (PPROM). When rupture of the membranes occurs spontaneously, women most commonly report feeling a sudden “gush” of fluid from the vagina. After this initial release of fluid it is common to experience a continued sense of “wetness,” and/or repeated, “gushes” of fluid.
It can be difficult to know if spontaneous rupture of membranes has occurred. If you experience an initial release of fluid and are uncertain, I suggest lying down for 30-60 minutes and then return to the standing position. With rupture of the membranes, women will typically experience another “gush” when standing. Rupture of membranes near your due date should not cause alarm. If you are certain your membranes have ruptured you should come to the hospital. If you are uncertain, it is always good to give us a call.
3. Absent or Decreased Fetal Movement. Happy, healthy babies move. They move a lot.  Near the end of pregnancy there is less room for movement so the character of movements may change. Many women n ear the end of pregnancy report fetal 
movements becoming less strong, resembling more of a “roll” than a “kick.” Most importantly, decreased fetal movement is not a sign of labor. Rather, it can be a sign that something is wrong causing the baby to conserve energy by remaining still. Over the course of a day you should feel at least twelve distinct fetal movements. If ever you have a sense that your baby is not moving or is moving less than usual, perform the following “kick test.” Eat or drink something and then lie down on your left side, counting the number of fetal movements you experience over one hour. Keep in mind that babies near term also sleep for extended periods and you may want to nudge the baby with your hand and/or play music in order to awake the baby. In an hour of paying attention you should feel at least four (4) separate movements. If you perform this “kick test” and do not feel four (4) separate movements you should contact us immediately.
- Labor Contractions. This is by far the most difficult sign to explain (and often recognize) as most all pregnant women experience contractions near their due date. In this case, I’m describing labor contractions as opposed to false labor contractions. Contractions associated with true labor are typically painful, often taking one’s breath away. They are regular and organized, occurring at fixed intervals and lasting 40-60 seconds. Each contraction has a definite start, builds to a peak, and then diminishes. I advise women to call or come to the hospital after an hour of painful, regular contractions that are approximately five (5) minutes apart. A word about false labor…it can be surprisingly difficult to differentiate between true and false labor. The reality is, you will likely make at least one trip to the hospital only to be told you are not in labor–that’s alright. It happens to everyone!.
One way to differentiate between false and true labor contractions is the response to exercise such as walking. False labor tends to diminish, while true labor tends to intensify with light exercise. Keep in mind, I’m describing contractions near your due date. If you experience contractions at a frequency of more than four (4) per hour and you are not at least thirty-four (34) weeks pregnant you should always call us.
So as you begin the last stages of your pregnancy remember these four (4) important reasons to call and/or come to the hospital: bleeding, rupture of membranes, absent or decreased fetal movement, and labor contractions. Most importantly, if you are unsure, contact us. It is always better to call if you have a question about your pregnancy. During regular business hours and after hours call 260-222-7401 and follow the prompts to be connected to the provider on call.
As always, if you have additional questions or comments you may e-mail me directly at DrStroud@fertilityandmidwifery.com.