Assemble sufficient staff and supplies to care for both the mother and newborn.
When vaginal bleeding is present, defer the pelvic examination until placenta previa has been excluded.
Utilize bedside ultrasound to check fetal presentation.
Be prepared for complications such as postpartum hemorrhage, shoulder dystocia, and breech presentation.
Less than 1% of all deliveries are in the emergency department (ED) because most women in labor are quickly triaged to the labor and delivery unit. However, if a woman is going to precipitously deliver, or the hospital has no obstetric services, it is up to the emergency physician to be prepared to deliver the infant.
Moreover, deliveries in the ED are more likely to be considered high risk. Women who deliver in the ED more often have had little or no prenatal care, may have substance abuse problems, do not know they are pregnant, or have been victims of domestic violence. These women may have higher frequencies of complications such as premature rupture of membranes (PROM), preterm labor, malpresentation, umbilical cord prolapse, placenta previa, abruptio placentae, or postpartum hemorrhage. The emergency medicine physician must be prepared to manage these complications.
Past medical, surgical, gestational age, and obstetric history should be obtained, as well as history of prenatal care. It is important to inquire about vaginal bleeding during labor. Scant, mucoid bleeding is usually termed bloody show and occurs when the cervical mucus plug is expelled. Heavy vaginal bleeding is a worrisome sign and can represent placenta previa (painless vaginal bleeding from the placenta covering the cervical os) or abruptio placentae (painful bleeding owing to placental separation from the uterus). The physician should also determine whether the patient has had a spontaneous rupture of membranes (SROM). Clear, blood-tinged, or meconium-stained vaginal fluid suggests rupture of membranes.
As always, vital signs are the first step in examination. Fetal heart rate can be assessed with handheld Doppler or with electronic fetal monitoring, if available. The abdomen should be palpated for tenderness and fundal height. Gestational age can be estimated if the mother is unsure. At 20 weeks’ gestation, the uterus is at the umbilicus, and it grows approximately 1 cm every week until 36 weeks.
Pelvic examination should begin with inspection of the perineum to determine whether the delivery is imminent (crowning). If the patient reports vaginal bleeding, examination should be deferred until an ultrasound can be performed. It is important to identify placenta previa first, as the bimanual and speculum examination can exacerbate the bleeding.
The bimanual examination determines the position of the fetus and readiness of the cervix. Sterile gloves should be used to prevent infection. A normal cervix is thick, only open at the entry to fingertip, and is firm to touch. Gradually the cervix thins; this is termed effacement. Dilation of the cervix progresses from closed to fully open (10 cm). Station indicates the location of the presenting part relative to the ischial spines. A presenting part at the ischial spines is at 0 station. If the presenting part is at the introitus, it is at +3 station. Position describes the relationship of the presenting part to the birth canal. Usually the fetal occiput is anterior.
Speculum examination can help identify spontaneous rupture of membranes. Pooling vaginal secretions should be tested with Nitrazine paper to determine pH. A dark blue color correlates to a pH of 7.0-7.4 and indicates the presence of amniotic fluid. Normal vaginal secretions have a pH of 4.5-5.5. Next, the cervical os is inspected. The examiner should identify whether it is open slightly, has bulging membranes, a visible fetal head, or other presenting part. If the examiner sees a prolapsed umbilical cord, he or she should keep a hand in the vagina and elevate the presenting part to prevent cord compression, while an assistant contacts obstetric services for an emergency cesarean section.
