Overview
Obstetric assessment in the Emergency Department focuses on the safety of both mother and fetus. Time-critical conditions include ectopic pregnancy, placental abruption, placenta praevia, severe pre-eclampsia/eclampsia, preterm labour, ruptured membranes, uterine rupture and maternal trauma.
The approach combines ABC stabilisation, rapid obstetric history, focussed examination, fetal assessment and early consultation with OBGYN according to local protocols.
Key History & Red Flags
- Gestation and obstetric history: gravidity, parity, LMP/EDD, multiple pregnancy, previous caesarean, prior complications (e.g. pre-eclampsia, haemorrhage, ectopic, IUFD).
- Presenting complaint: abdominal pain, PV bleeding, reduced fetal movements, contractions, leaking fluid, headache, visual changes, dyspnoea or chest pain.
- Bleeding: onset, amount, clots, associated pain, relation to trauma or intercourse.
- Fluid loss: gush vs trickle, colour (clear, bloodstained, meconium), odour, time of onset.
- Fetal movements: normal, reduced or absent; time since last felt.
- Medical history: hypertension, diabetes, cardiac disease, epilepsy, HIV, renal disease.
- Medication and allergies: antihypertensives, anticoagulants, antiepileptics, ART, supplements.
Red flags: severe or sudden abdominal pain, heavy PV bleeding, reduced/absent fetal movements, seizures, severe headache with visual disturbance, RUQ/epigastric pain, dyspnoea, chest pain, hypotension, tachycardia, features of sepsis, or maternal trauma.
Obstetric Assessment
During obstetric assessment in the Emergency Department, clinicians will typically:
- Take a thorough obstetric and medical history, including pregnancy details, prenatal care and complications. This may include due date, number of previous pregnancies and deliveries, prior complications, and current medications or supplements. Click to open the Parity & Gravidity Calculator .
- Perform a focused physical examination, including abdominal examination (fundal height, lie, presentation, engagement, tenderness, contractions) and, when indicated and safe, a pelvic examination to assess cervical dilation/effacement and PV bleeding or fluid.
- Monitor fetal heart rate and uterine contractions. Fetal heart rate monitoring helps assess fetal wellbeing; contraction pattern helps determine labour status.
- Assess for signs of preterm labour (contractions, cervical change, ruptured membranes) and term labour.
- Check maternal vital signs: blood pressure, heart rate, respiratory rate, oxygen saturation and temperature.
- Order diagnostic tests such as blood work, urine tests and ultrasound imaging as needed to assess maternal and fetal status and identify complications.
- Determine gestational age and estimate fetal weight to guide management decisions, where possible.
- Assess for signs of fetal compromise or serious complications such as placental abruption, placenta praevia, uterine rupture or eclampsia, and escalate urgently where indicated.
Differential Diagnosis
Common conditions that may present with obstetric symptoms in the Emergency Department include:
| Condition | Common Symptoms | Diagnostic Tests | Treatment (Principles) | Danger Signs | Grading / Notes |
|---|---|---|---|---|---|
| Preterm labour | Uterine contractions, pelvic pressure, backache, PV discharge or bleeding before 37 weeks. | CTG, cervical examination, cervical length (ultrasound), fetal fibronectin test, ultrasound for presentation and fluid. | Tocolytics (where appropriate), corticosteroids for fetal lung maturity, magnesium sulphate for neuroprotection as per protocol, admission/transfer. | Increasing contraction frequency/intensity, PV bleeding, ruptured membranes, fetal distress. | Risk stratified by gestational age, cervical length and clinical course. |
| Placental abruption | Vaginal bleeding, abdominal/back pain, uterine tenderness, frequent contractions, fetal distress or IUFD. | Clinical diagnosis, CTG, ultrasound (may not show all abruptions), blood tests (FBC, coagulation, crossmatch). | Resuscitation (IV access, fluids, blood products), urgent OBGYN review, consideration of immediate delivery depending on severity and gestation. | Severe PV bleeding, maternal shock, rigid “woody” uterus, non-reassuring CTG, coagulopathy. | Severity based on extent of separation, maternal and fetal status (mild to severe). |
| Pre-eclampsia | Hypertension, proteinuria, headache, visual disturbances, oedema, RUQ/epigastric pain. | BP monitoring, urinalysis for protein, blood tests (renal, liver, platelets, LDH), CTG, ultrasound for growth and Dopplers. | Blood pressure control, magnesium sulphate for severe features/eclampsia prophylaxis, close monitoring, timing of delivery in consultation with OBGYN. | Severe headache, visual changes, chest pain, dyspnoea, seizures, oliguria, HELLP syndrome, pulmonary oedema. | Mild to severe pre-eclampsia based on BP, organ involvement and laboratory results. |
| Gestational diabetes | Often asymptomatic; sometimes increased thirst, polyuria, fatigue, blurred vision. | Glucose tolerance test, capillary blood glucose, HbA1c (baseline), fetal ultrasound for growth and liquor. | Dietary modification, glucose monitoring, insulin or oral agents as per protocol, fetal surveillance; ED focus on acute complications. | Uncontrolled hyperglycaemia, DKA, large-for-gestational-age fetus, polyhydramnios, pre-eclampsia. | Severity guided by control of blood glucose and presence of complications. |
| Placenta praevia | Painless PV bleeding in the second half of pregnancy; uterus usually soft, non-tender. | Ultrasound to localise placenta (transabdominal and often transvaginal), CTG. | Avoid digital vaginal examination, stabilise mother, anti-D if indicated, admission and planning for caesarean delivery in major praevia. | Heavy PV bleeding, maternal instability, fetal distress. | Partial/complete, major/minor – based on proximity to internal os. |
| Breech presentation | Palpation suggests breech, fetal head in fundus, sometimes decreased fetal movements near term. | Abdominal examination, ultrasound confirmation, CTG. | Consider external cephalic version (ECV) where appropriate, planned caesarean or vaginal breech delivery as per local policy and expertise. | Labour with undiagnosed breech, cord prolapse, fetal distress. | Frank, complete or footling breech; management based on gestation, type and maternal/fetal conditions. |
Management of Eclampsia
Eclampsia is the occurrence of seizures in a patient with pre-eclampsia and is an obstetric emergency. Priorities are maternal stabilisation, seizure control, blood pressure management and planning for delivery. Always follow your local OBGYN protocols for exact dosing and indications.
| Step | Description | Example Dose / Notes |
|---|---|---|
| Stabilise the patient | Ensure airway patency, breathing and circulation. Place the patient in left lateral position, administer oxygen, secure IV access and monitor vital signs. Prevent injury during seizures. | N/A |
| Control seizures | Magnesium sulphate is first-line to control seizures and prevent recurrence. Benzodiazepines may be used for ongoing seizures or if magnesium is not immediately available. |
Example: MgSO4 4–6 g IV loading dose over 15–20 min, then 1–2 g/hour infusion.
Diazepam 5–10 mg IV or lorazepam 2–4 mg IV can be used cautiously if needed. (Use exact local protocol doses.) |
| Lower blood pressure | Administer antihypertensives (e.g. labetalol, hydralazine) to reduce BP to a safe range while maintaining uteroplacental perfusion. | Examples: Hydralazine 5–10 mg IV, repeated as needed; labetalol 20–80 mg IV in incremental doses as per protocol. |
| Plan/induce delivery | Delivery is the definitive treatment. Timing and mode depend on gestation, maternal stability and fetal condition. In severe or refractory cases, urgent delivery may be required once the mother is stabilised. | N/A |
| Postpartum management | Continue magnesium sulphate for at least 24 hours postpartum or 24 hours after last seizure (whichever is later). Monitor for recurrent seizures, BP, urine output and complications such as pulmonary oedema, HELLP and postpartum haemorrhage. | Example: MgSO4 1–2 g/hour infusion for ≥24 hours, adjust according to local guidelines and renal function. |
Maternal Trauma & ED Caesarean Section
Maternal trauma can result from motor vehicle collisions, falls, assault or other mechanisms. Management follows standard trauma principles with modifications for pregnancy (left lateral tilt, attention to uterine displacement, and fetal assessment where possible).
In the Emergency Department, priorities include rapid assessment of maternal vital signs, primary and secondary survey, appropriate imaging (balancing maternal benefit and fetal risk), and continuous fetal monitoring when feasible. Rh-negative mothers may require anti-D as per protocol.
In rare situations, an emergency caesarean section may be required in the ED to save the mother and/or fetus. Indications for perimortem/ED caesarean section include:
- Maternal cardiac arrest (particularly ≥ 20–24 weeks gestation) where resuscitation is ongoing.
- Maternal instability with inability to resuscitate adequately due to gravid uterus.
- Severe maternal trauma with fetal compromise and no time for theatre transfer.
- Catastrophic obstetric events such as uterine rupture or massive placental abruption with fetal compromise.
ED caesarean is a last resort, performed only in extreme emergencies by trained staff, with immediate involvement of OBGYN, anaesthesia and neonatal teams where available. Close monitoring for haemorrhage, infection and other complications is required post-delivery.
OBGYN Guidelines
For detailed obstetric emergency pathways, medication regimens and referral criteria, refer to: