Obstetric Examination in the ED
A focused, structured approach to assess the pregnant patient and fetus in the emergency setting – identify red flags, stabilise, and involve obstetrics early.
Always check BP + fetal heart
Any bleeding in late pregnancy → exclude placenta praevia before PV exam
Think ectopic in 1st trimester pain/bleeding
Call obstetrics early, not late
ED Priorities
Overview
Key concept: Obstetric examination in ED is not a full antenatal visit – it is a rapid, structured
assessment to rule out life-threatening conditions for mother and fetus, and to decide who needs urgent obstetric care.
- Confirm pregnancy and estimated gestational age (EDD / GA).
- Rapidly screen for maternal red flags:
- Severe abdominal pain, heavy vaginal bleeding, collapse or hypotension.
- Headache, visual disturbance, RUQ pain, seizures (think pre-eclampsia/eclampsia).
- Shortness of breath, chest pain, signs of sepsis.
- Rapidly screen for fetal red flags:
- Absent or reduced fetal movements (after quickening).
- Abnormal or absent fetal heart on Doppler/CTG (if available).
- Preterm contractions or rupture of membranes.
- Stabilise ABC, then perform focused obstetric history, exam, and bedside tests.
Quick ED Exam Flow
Sequence- Assess ABC, position in left lateral tilt if ≥ 20 weeks to avoid supine hypotension; connect basic monitoring.
- Check vital signs (BP in both arms if hypertensive, HR, RR, SpO₂, temperature).
- Confirm pregnancy and gestational age (LMP, antenatal card, prior scans).
- Focused history: chief complaint, bleeding, pain, contractions, fluid leak, fetal movements, previous obstetric history.
- Focused physical exam: general appearance, abdomen (fundal height, lie, presentation, tenderness, contractions), consider speculum exam where appropriate.
- Bedside tests: urine dipstick (protein, glucose, nitrites), finger-prick glucose, β-hCG for early pregnancy, fetal heart Doppler if GA allows.
- Escalate to obstetrics for red flags, abnormal fetal assessment, or uncertainty.
Focused Obstetric History
History- Presenting complaint: bleeding, pain, contractions, fluid leakage, decreased fetal movements, trauma, collapse, headache/visual symptoms.
- Gestational age & pregnancy details:
- LMP, EDD, number of fetuses (singleton/multiple).
- Any previous ultrasound and dating information.
- Obstetric history (GTPAL):
- Number of previous pregnancies, deliveries, miscarriages, ectopics, terminations.
- History of pre-eclampsia, gestational diabetes, preterm labour, stillbirth, postpartum haemorrhage.
- Previous caesarean section or uterine surgery (important for VBAC/rupture risk).
- Current pregnancy:
- Booked vs unbooked, antenatal clinic attended, known complications (placenta praevia, IUGR, HT, DM).
- Medications (including antihypertensives, insulin, anticoagulants) and allergies.
- Symptom-specific questions:
- Bleeding: onset, volume, clots/tissue, associated pain, trauma or intercourse, gestational age.
- Pain: site, onset, character, radiation, relation to movements or contractions.
- Fluid leak: sudden gush vs trickle, colour, odour (clear, blood-stained, meconium-like).
- Movements: normal, reduced, or absent compared to usual.
- Medical history: hypertension, diabetes, epilepsy, cardiac disease, asthma, thrombophilia, infections (HIV status if known), etc.
- Social history & safeguarding: support at home, intimate partner violence, substance use, mental health concerns.
Physical Examination
Exam- General: level of distress, pallor, diaphoresis, confusion, respiratory effort.
- Vital signs:
- HR, BP (repeat if high/low), RR, SpO₂, temperature.
- Look for hypertension (≥ 140/90), tachycardia, tachypnoea, fever, hypotension or shock.
- Cardiorespiratory: auscultate heart and lungs (PE, pulmonary oedema, pneumonia, cardiomyopathy).
- Abdominal examination:
- Inspect: scars, distension, obvious uterine size vs gestational age.
- Palpate:
- Fundal height (cm from symphysis – approximate GA after 20 weeks).
- Uterine tone and tenderness (abruption, chorioamnionitis, uterine rupture risk).
- Fetal lie (longitudinal, transverse, oblique) and presentation (cephalic, breech, other).
- Engagement of presenting part in late pregnancy.
- Assess contractions: frequency (per 10 min), duration, intensity, maternal response.
- Fetal heart:
- Use handheld Doppler from ~12–14 weeks; normal range ~110–160 bpm.
- If CTG available and appropriate gestation, attach and interpret with obstetric support.
- Lower limbs & reflexes: oedema, calf tenderness (DVT), hyperreflexia or clonus (pre-eclampsia).
Do not perform a digital vaginal exam in the presence of unexplained third-trimester bleeding
until placenta praevia has been excluded (by ultrasound or obstetric decision). A gentle speculum exam may be done
if indicated and deemed safe.
Pelvic & Vaginal Examination
When & How- Speculum exam:
- Useful for assessing source of bleeding, cervical dilatation (visually), rupture of membranes, infection.
- Avoid if placenta praevia is suspected and not yet excluded – discuss with obstetrics.
- Digital vaginal exam:
- For labour assessment (cervical dilatation/effacement/station) – best done by or with obstetric team.
- Avoid in:
- Unexplained heavy bleeding in 2nd/3rd trimester.
- Known placenta praevia or vasa praevia.
- Preterm prelabour rupture of membranes unless specifically indicated.
Bedside Tests & Investigations
Tests- Urine dipstick: protein (pre-eclampsia), glucose (diabetes), nitrites/leukocytes (UTI), ketones (hyperemesis/dehydration).
- Finger-prick glucose: for all unwell patients, diabetics, or reduced consciousness.
- β-hCG: in early pregnancy or when pregnancy status/viability is uncertain; correlate with ultrasound.
- Blood tests:
- FBC, U&E, LFTs, coagulation profile in significant bleeding or suspected pre-eclampsia/HELLP.
- Group & save / crossmatch if bleeding or surgical intervention likely.
- Ultrasound: if available and trained operator:
- Confirm intrauterine vs ectopic pregnancy in early gestation.
- Fetal heartbeat, presentation, placental location, amniotic fluid volume in later gestation.
Fetal Assessment & Monitoring
Fetus- Intermittent auscultation:
- Handheld Doppler; normal baseline 110–160 bpm.
- Listen before, during, and after a contraction if in labour.
- CTG (if available and ≥ ~26–28 weeks):
- Assess baseline rate, variability, accelerations, and decelerations.
- Concerning features: persistent tachycardia or bradycardia, absent variability, recurrent late or variable decelerations – escalate to obstetrics urgently.
- Document all fetal heart findings clearly and include time, method, and any concerning changes.
High-Risk Presentations
Red Flags- Vaginal bleeding:
- 1st trimester – think ectopic pregnancy, miscarriage, molar pregnancy.
- 2nd/3rd trimester – think placenta praevia, placental abruption, labour, vasa praevia.
- Assess haemodynamic status, resuscitate, avoid digital PV exam until praevia excluded.
- Abdominal pain / contractions:
- Preterm labour, abruption, uterine rupture (especially with previous CS), appendicitis, other non-obstetric causes.
- Rupture of membranes:
- Confirm history; check colour of fluid (clear, blood, meconium).
- Risk of chorioamnionitis and cord prolapse – urgent obstetric review.
- Decreased/absent fetal movements: requires urgent assessment, fetal heart check and CTG if available.
- Hypertensive emergencies: severe BP elevation, headache, visual disturbance, epigastric pain, seizures – treat as severe pre-eclampsia/eclampsia.
- Trauma in pregnancy: manage per ATLS with modifications (left tilt, fetal assessment, Rh prophylaxis where indicated).
Bleeding + pain + shock → think ectopic or abruption
Headache + HT + visual symptoms → PET
Decreased FM → urgent fetal assessment
Collaboration, Documentation & Handover
Teamwork- Involve obstetrics early for any:
- Abnormal maternal observations or red flags.
- Abnormal fetal heart or CTG.
- Bleeding, suspected labour, rupture of membranes, or uncertain diagnosis.
- Document:
- Gestational age, gravidity/parity, key history points.
- Vital signs trends, exam findings (fundal height, lie, presentation), fetal heart results.
- Bedside tests, medications given, fluids, and response.
- Give structured handover (e.g. SBAR) to obstetric team, including concerns and what you want from them.
- Provide clear safety-net advice on discharge (when to return: bleeding, pain, fluid leak, reduced movements, headache, visual disturbance, etc.).