Examination

Initial examination should follow an ABCDE approach.

Examination of the pregnant abdomen should include:

• Fundal height (Measure from pubic symphysis to the fundus)
• Foetal lie (Longitudinal/Transverse/Oblique)
• Foetal position
• Presentation (Breech vs cephalic)
• Engagement (measured as fingers palpable per abdomen 5/5 – 0/5)

PV examination

For a labouring mother, PV examination can be a distressing experience (particularly in an unknown, often crowded environment in ED. For this reason PV examination in the ED should ONLY be performed if it will actively change the management plan for the patient (in other words, if we are unsure about the diagnosis OR if delivery is suspected to be imminent).^(1-3) DO NOT perform an examination is there is excessive PV bleeding (Placenta Praevia) or suspicion of PROM as this may worsen bleeding or introduce infection¹.

• When performing PV examination explain clearly to the mother why it is indicated and provide adequate analgesia (e.g. Entonox 50:50)³
• Palpate the cervix to assess effacement (0-100%) and dilatation (0-10cm)
• Determine foetal station (position of presenting part in relation to the ischial spines)

Foetal assessment

Compared to a labour unit, the ED has limited equipment available to perform this accurately (e.g. Cardiotocography, CTG). However, it is possible to perform some basic assessments by: Auscultating the foetal heart (using a handheld Doppler or Pinnard stethoscope) for a minimum of 1 minute immediately after a contraction³. Palpate the mothers pulse at the same time to differentiate the two heartbeats. Record any accelerations or decelerations heard (Normal variability 5-25bpm over 25 minutes).

Parameters for Foetal Heart Rate: Adapted from NICE guidance³.

• POCUS: In the hands of an experienced practitioner, POCUS may be beneficial in assessing foetal heartbeat, position, presentation, and, in the case of mothers with limited antenatal history will help identify the number of foetuses present¹.

Learning bites

• It is helpful to take a focussed clinical history combined with any antenatal screening notes +/- collateral history
• Priority for assessment is ABCDE, followed by examination of the pregnant abdomen and foetus
• PV examination should ONLY be performed if it will change the management plan (i.e. unclear labour or potential imminent labour)
• Normal Foetal HR ranges from 110-160bpm (5-25bpm variability is normal).