What is the initial workup for a 38-week pregnant female presenting to the Emergency Room (ER) with contractions?

From the Guidelines

The initial workup for a 38-week pregnant female presenting to the ER with contractions should include a comprehensive maternal and fetal assessment, prioritizing vital signs, focused history, physical examination, laboratory tests, and continuous electronic fetal monitoring, as outlined in the most recent guidelines 1. The assessment should begin with obtaining vital signs, including blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation.

• A focused history should be performed to determine contraction frequency, duration, and intensity, as well as presence of rupture of membranes, vaginal bleeding, fetal movement, and any other concerning symptoms.
• Review of the patient's prenatal records is crucial for identifying risk factors, previous pregnancy complications, and Group B Streptococcus status.
• Physical examination should include abdominal palpation to assess fetal position and a sterile speculum and digital cervical exam to determine cervical dilation, effacement, and fetal station.
• Laboratory tests, such as complete blood count, basic metabolic panel, urinalysis, and possibly a urine drug screen if indicated, should be conducted.
• Continuous electronic fetal monitoring should be initiated to assess fetal heart rate and contraction pattern, following the guidelines for intrapartum fetal monitoring 1.
• Ultrasound may be performed to confirm fetal position, estimate fetal weight, and assess amniotic fluid volume.
• The patient's labor progression should be closely monitored, and if she is in active labor (typically defined as cervical dilation ≥6 cm with regular contractions), she should be admitted to the labor and delivery unit 1.
• If not in active labor but contractions are regular, she may be observed for several hours to determine labor progression. This comprehensive initial assessment is crucial for determining whether the patient is in true labor and guiding appropriate management to ensure optimal maternal and fetal outcomes, considering the potential complications and the need for careful fluid management, as highlighted in the guidelines for managing preterm labor 1.

From the Research

Initial Workup for a 38-Week Pregnant Female with Contractions

The initial workup for a 38-week pregnant female presenting to the Emergency Room (ER) with contractions involves several key steps:

• Assessment of fetal well-being through fetal heart rate monitoring, as the onset of regular, strong, and progressive uterine contractions may result in mechanical and hypoxic stresses to the fetus 2
• Evaluation of the progress of labor, fetal size, and reserves, as well as the presence of meconium staining of amniotic fluid and intrauterine inflammation 2
• Consideration of the clinical context, including the speed of onset of intrapartum hypoxia and preexisting uteroplacental insufficiency, to improve perinatal outcomes 2

Fetal Heart Rate Monitoring

Fetal heart rate monitoring is a crucial component of the initial workup, as it provides valuable information about fetal well-being:

• Fetal heart rate variability is a reflection of autonomic nervous system activity and a useful marker for fetal well-being 3, 4
• The use of corticosteroids and tocolytic drugs can affect fetal heart rate variability, and their effects should be taken into account when monitoring fetal heart rate 3, 4, 5

Individualization of Care

Individualization of care is essential to optimize outcomes for the fetus:

• Clinicians should move away from "pattern recognition" guidelines and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation 6
• The clinical context, including the presence of non-hypoxic pathways of neurological damage, should be considered when making decisions about fetal monitoring and intervention 6