eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Delivery

Author: Thomas E Benzoni, DO, Medical Director of Mercy Air Care; Consulting Staff, Department of Emergency Medicine, Mercy Medical Center; Member, Board of Directors, Iowa Medical Society
Contributor Information and Disclosures

Updated: Sep 17, 2008

Introduction

Background

Few events cause more stress for the full time emergency physician than a pregnant woman at full term who is ready to deliver in the ED.

For more information, see Medscape's specialty Ob/Gyn & Women's Health and Medscape's Pregnancy Resource Center.

Pathophysiology

Pregnancy and delivery are natural processes that have been occurring for milennia. For milennia, delivery of the pregnant woman was the province of nonmedical (such as there was) personnel. As medical care progressed, nurses began the systematic medicalization of prenatal, delivery, and postnatal care (nurse-midwifery). This transition began in Europe, eventually crossing the Atlantic.

In the United States, one of the earliest, most reputable and still active groups is Frontier Nursing Service. Physicians have become involved only in the relatively recent past. Therefore, attendance to the natural course is mandatory; interventions are indicated only in the event of deviations from the natural or expected course.

Frequency

United States

The precise incidence of ED deliveries of pregnant full-term patients is unknown. In 2005, 14 births occurred per 1000 total population. Fertility rates (births per 1000 women aged 15-44 y) decreased to 66.7. Approximately 80% received prenatal care in the first trimester.¹

Mortality/Morbidity

The infant death rate for 2004 was 6.78 per 1000 live births.¹ The maternal death rate in 1997 was 7.7 per 100,000 births (37.1 in 1960).²

Race

The numbers of members of racial groups who receive prenatal care differ and are correlated to the probability of their seeking care in the ED.

• In 2005, 57% of all mothers sought care in the first trimester.¹
• The percentage of white mothers seeking any prenatal care was 99.5%, with the percentage of black mothers close behind at 98.7%.¹

Age

Fertility rate statistics have 15 years as the lower cutoff point. However, laboratory testing should be performed to rule out pregnancy when any female capable of reproduction (potentially as young as 9 y) presents with abdominal complaints and when pregnancy cannot be ruled out at physical examination.

Clinical

History

The history often is enough to raise suspicion of pregnancy as the cause of a patient's complaints. However, seemingly virginal patients can be pregnant, and denial of the pregnancy is not uncommon. Claims of regular menstrual periods and/or lack of sexual involvement do not rule out pregnancy.

• General signs of pregnancy include the following:
  • Cessation of menses
  • Morning sickness (eg, nausea, vomiting)
  • Urinary frequency
  • Breast enlargement and/or engorgement
  • Abdominal enlargement
  • Quickening and lightening (ie, settling of the fetus)
  • Uterine consistency changes (Goodell and Hegar signs), uterine enlargement, change in uterine shape, and uterine contractions
  • Mucosal changes (Chadwick sign)
• Gestation is defined as 280 days. The estimated date of confinement (EDC), or due date, is calculated by taking the first day of the last normal menstrual period (FDLMP), subtracting 3 months, and adding 1 week. Hand-held wheels aid this calculation.
• Typically, lightening (settling of the infant, head down, into the true pelvis) occurs several weeks before labor.
• Braxton Hicks (false labor) contractions (irregular rhythmic uterine tightening) may occur. The onset of these contractions is earlier with each succeeding pregnancy.
• Labor presentation may be classic or with variations. The onset of true labor may be gradual, abrupt, or catastrophic. In the first stage of labor, regular uterine contractions cause the cervix to dilate. The second stage consists of descent of the presenting part and delivery. The third stage of labor is delivery of the placenta.
• Signs of imminent delivery should be noted.
  • Bloody show, the expulsion of the mucus plug from the cervix
  • Breakage of the amniotic sac (bag of waters).  Determine the appearance of the fluid expelled. Clear fluid is normal, thin fluid is meconium (fetal intestinal contents consisting of the remains of swallowed amniotic fluid mostly composed of sloughed digested skin cells) stained, and thick pea-soup fluid is heavy meconium .
  • The sensation of impending defecation or an urge to push
• For a patient in labor, obtain the following minimal data set:
  • Last menstrual period (LMP), EDC, and prenatal care (including plans for delivery)
  • Pregnancy history, written as "(gravida, para, X-X-X-X)," where gravida is the total number of pregnancies (including the present one), para is the number of deliveries after 20 weeks of pregnancy, and X-X-X-X is the number of full-term infants-number of preterm infants-number of abortions-number of living children
  • Problems during this or previous pregnancies
  • Prior ultrasonographic examinations and results, and bleeding during pregnancy or labor (If findings are positive, be alert for placenta previa.)
  • Past medical and surgical history, medications, and allergies

Physical

Physical examination of the abdomen and pelvis is an invaluable tool in diagnosing labor as the cause of a woman's abdominal complaints.

• Abdominal striae may be noted. They are due to the rapid expansion of the uterus.
• When the patient is seated, the epigastrium has a typical shelflike appearance that is created by settling of the fetus.
• Fetal movements may be observed.
• Dullness on percussion of the area from the pubic symphysis to several centimeters below the xiphoid is evidence of a full-term pregnancy (in the right setting).
• Careful listening with a standard stethoscope may reveal fetal cardiac activity. Fetal stethoscopes or Doppler probes are helpful but unnecessary at term. Listening in all 4 quadrants may reveal twins.
• Carefully performed, Leopold maneuvers reveal much information and prepare the attendant for complications.
  • Palpate the fundus. If the area is smooth, hard, and round, it is the head. If the tissue is irregular, it is some other part of the fetus body.
  • Palpate the sides. A smooth, long surface suggests the fetus back. If the contours are irregular, it is probably the front or side.
  • Grasp the part in the pelvis. If it is smooth, hard, and round, it is the head. If it is irregular, it is some other part of the body.
  • Rub along the back and down to the pelvis to see if the head is present. A shelf or an abrupt change in the angle of the palpated part when the head is encountered indicates that the head is in extension (face presentation, unfavorable). If the path is smooth, the head is flexed (favorable).
• The cervix effaces (thins).

Causes

Causes of pregnancy are both obvious (ie, sexual activity) and hidden (eg, lack of access to reliable birth control, low self-esteem, denial, poverty).

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