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Pregnancy Emergencies: When to Seek ER Care

Osher Ben Or, Certified Midwife
20 November 2024

During pregnancy, in some cases, you can to go to the obstetric emergency department, which provides care for women in various pregnancy stages (usually from week 24 onward), 24 hours a day, 7 days a week.

Reasons for obstetric emergency department admission

  • Vaginal bleeding.
  • Headaches / blurred vision / epigastric (upper abdominal) pain.
  • Decreased fetus movement.
  • Breaking of the waters.
  • Injury.
  • Referral from a gynecologist.
  • Post-term pregnancy follow-up and/or other pregnancy follow-up.
  • Early contractions.

The professional staff in the obstetric emergency department includes physicians alongside nurses who will conduct an initial assessment of the pregnant woman’s condition and decide what tests are required accordingly.

The obstetric emergency department is active 24 hours a day, 365 days a year. It belongs to the delivery room and is usually located near it. The obstetric emergency department is intended to provide assistance with a range of issues related to pregnancy including various stages of childbirth and high-risk pregnancy.
Medical centers may vary in the week in which you can be admitted at the obstetric emergency department. Usually, their service is provided to pregnant women from week 24 of pregnancy.

Who will you meet in the obstetric emergency department

The obstetric emergency department has a professional team that can perform an initial assessment of the medical condition of visiting women.

The midwife in the obstetric emergency department – will conduct a quick assessment of the urgency of the visit, will take information on the pregnancy and relevant obstetric history, relevant medical history affecting the reason for the emergency department visit. The midwife will ask you to have a urine test, will assess vital signs and perform fetal monitoring. In addition, as necessary and depending on the reason you visit, she will take a blood test, attach an infusion and perform a vaginal examination (this is done by a physician or the midwife). Sometimes a physician will perform an examination with a speculum (an instrument that is inserted into the vagina, allowing for inspection of the uterine cervix), for example to confirm or rule out suspicion of amniotic rupture.

A physician in the obstetric emergency department – will conduct an assessment that will include medical questioning (medical history), ultrasound scan, considering ordering additional imaging scans or consulting physicians of various disciplines, according to the reason for the visit and need, including deciding on suitable medication as necessary.

At the end of the emergency department inquiry and according to the findings, the physician will recommend whether you should be discharged home, be admitted to the mother and fetus department or undergo additional tests at the hospital. Later, the medical staff will decide whether the time has come to be admitted to a delivery room, whether for observation or for childbirth.

What to bring to the obstetric emergency department

When you come to the obstetric emergency department, it is important that you bring your pregnancy follow-up card and any important medical documentation that is relevant to your medical history, obstetric history or pregnancy.

Tip: it is a good idea to scan or photocopy these documents so that you have a copy on your phone to ensure their availability in any case.

Reasons for obstetric emergency department admission

  • Vaginal bleeding
  • Headaches, blurred vision and epigastric pain
  • Decreased fetus movement
  • Breaking of the waters
  • Injury
  • Referral from a gynecologist
  • Post-term or other pregnancy follow-up
  • Early contractions

Internal vaginal examination

A vaginal examination is intended to assess the uterine cervix during pregnancy and the progression of childbirth, to make a decision on your care. In most cases, you will get the information without asking, but if you do not receive it, you should ask for what it is necessary.

During the examination, you may get information on the following subjects:

The uterine cervix: dilation of the uterine cervix: measured in cm (from 0 to 10), the length of the uterine cervix ("flattening") is measure in percent, the cervix texture (soft, medium or hard), the cervix location (posterior, central or anterior).

The fetus: the presenting part, location of the head in the pelvis (head height) – estimated relative to two bony protrusions in the pelvis called the ‘spines’ – this is the narrowest part of the pelvis.

After you get an explanation and express your consent, you will be asked to lie on your back covered with a sheet. In the examination, the examiner will use sterile gloves and a lubricant to facilitate the gentle insertion of their fingers up to the opening of the cervix. If you experience difficulty with the vaginal examination or feel anxious due to the examination, share this with the examiner. If you experience a contraction during the examination, ask to wait until the contraction ends and have the examination before the next one.

Tips for a successful, less painful examination

  • In the beginning of childbirth or when you are not in labor, sometimes the cervix is in a very posterior position and lifting the pelvis (with two fists under the buttocks) helps make the examination easier to perform and less painful.
  • During the examination, it is recommended to relax your body consciously: deep inhalation and slow exhalation help achieve this relaxation.

Reasons for obstetric emergency department admission during pregnancy

There are a number of causes of vaginal bleeding or bloody discharge. The treatment for the bleeding depends on its source.

Source of bleeding: placenta

Placenta previa

A condition in which the placenta is rooted in the bottom part of the uterus, partly or fully obstructing the inner opening of the cervix. Placenta previa is diagnosed by ultrasound scan during pregnancy. The clinical symptomatology is usually painless vaginal bleeding.

In the case of the placenta partially or fully obstructing the inner opening of the cervix, cesarean section is the only option for childbirth.

In the case of a low placenta that is close to the inner opening of the cervix, you will be monitored during the pregnancy. As the pregnancy progresses, the placenta can change its relative location (due to uterine growth) and according to its location it will be decided whether vaginal delivery is feasible or whether you will have to undergo a cesarean section.

Risk factors for placenta previa: placenta previa in a previous pregnancy, past cesarean sections, past pregnancies, the age of the mother is over 35, scars in the uterus due to operations, curettage procedures or other medical procedures, multiple pregnancy, cigarette smoking or use of cocaine.

Placental abruption

Placental abruption (separation) causes about a third of uterine bleeding cases during the second half of pregnancy. Placental abruption is defined as partial or complete detachment of the placenta from the uterine wall occurring before the fetus exits the uterus, which may impair the blood supply to the fetus.

In most cases, the cause of the phenomenon is unknown but sometimes it may occur due to abdominal trauma or a traffic accident in which the body is slammed forward and backward or may develop owing to a longer chronic process such as an infection.

Risk factors: past placental abruption, preeclampsia, chronic hypertension, early amniotic rupture and intrauterine infection, smoking and use of cocaine, hypercoagulability states.

The common clinical signs characteristic of placental abruption are vaginal bleeding and increased uterine activity. The bleeding may be sudden and profuse, combined with painful contractions of the uterus. But there are cases of placental abruption in which the blood is trapped between the placenta and uterus and no vaginal bleeding is visible, in which case there will be increased uterine activity and abdominal pain. In the case of major abruption, this may affect the fetal heart rate and cause fetal distress. In chronic abruption cases, the symptoms are usually less fulminant.

Placental abruption is diagnosed clinically but an ultrasound scan will not always demonstrate it. Placental abruption cases are potentially life-threatening for the mother and fetus. Timing of induced delivery in placental abruption cases depends on the week of pregnancy and your clinical condition and that of the fetus.

Placenta accreta

A condition in which the placenta takes root in the abdominal wall and penetrates the mucosa of the uterus in varying degrees. In the worst case, the placenta may penetrate adjoining organs such as the urinary bladder or intestines.

Risk factors for placenta accreta: placenta previa, past cesarean section, IVF treatments, past pregnancies, pregnancy at advanced age. Placenta accreta is diagnosed by ultrasound in the second or third trimester. If there is suspicion of placenta accreta, it may be diagnosed by MRI too. Placenta accreta may cause bleeding during pregnancy but its most significant complication is significant bleeding during delivery, which may necessitate removal of the uterus (hysterectomy). In the case of placenta accreta, delivery will be by cesarean section only. If necessary, physicians of other disciplines will participate in the operation: urology, surgery, and so on. There are many types of operations. The aim of the operation is to reduce bleeding, thus allowing the placenta to be extracted while sparing the uterus.

Source of bleeding: the cervix

During pregnancy, the cervix has abundant blood vessels. These blood vessels are very sensitive, so they may bleed after sexual intercourse, after a vaginal examination and if there is a cervical polyp, it may bleed too.

The dilation of the cervix (as part of childbirth) itself may cause bleeding, and when the cervix dilates a little before birth, the mucus plug is detached, resulting in pinkish-brown discharge with a viscous-mucous consistency.

Source of bleeding: vagina

Bleeding coming from a wound or lesion in the vagina that bleeds after scratching, sexual intercourse or injury.

For any fresh bleeding of a quantity similar to that of menstruation, it is important to seek immediate assessment by a physician.
In general, it is recommended to seek physician assessment when there is vaginal bleeding in pregnancy in order to evaluate its source and its effect on the fetus.

Inquiry in the emergency department: clinical assessment for you and the fetus, blood tests as necessary. When the blood type is Rh negative, the medical staff will make a decision on the need to administer antibodies (anti-D) to the mother and more.

In any case of suspicion of amniotic rupture, such as sudden wetness or in the form of dripping, irrespective of the pregnancy week, it is important to go to the obstetric emergency department, where they will perform tests for ruling out or verifying the condition.

The assessment is done by a speculum or a test strip that changes color when it interacts with amniotic fluid. The treatment will be provided according to your condition, the week of pregnancy you are at and the vitality of the fetus. In any case of amniotic rupture, you must be admitted to a hospital.

Fetal movements in the uterus are an important measure of the fetus’ health. Usually, you will begin to feel the fetus’ movements in week 16 to 24, but you should know that women in their first pregnancy report feeling movements later relative to those who have been pregnant.

Initially, the movements will feel like "fluttering" and as the pregnancy progresses, they become more apparent. You will also feel when your fetus is awake and asleep during the day, and you may learn to identify the fetus' sleep cycles, which range from 20 to 40 minutes during which the fetus will not move.

The number of movements varies during the hours of day and each fetus has his or her own activity patterns. Over time you will get to know the activity patterns of your fetus and learn to identify when he or she is more active and less active, whether he or she moves more in the day or in the evening.

If you feel a change in the movement patterns or reduced movements, or you do not feel any movements at all – it is important to seek medical assessment immediately.

From week 26-28 of pregnancy, it is recommended to start monitoring fetal movements.

How to count fetal movements

There are a number of methods for counting fetal movements. We will discuss the most common one here. Consult a pregnancy nurse or your physician about the method they recommend:

To count fetal movements, you should spare some time, about half an hour at least, and be in a quiet place (to avoid background noise and distractions) and after a light meal.

Lie down on your left side and concentrate on your breathing. Place your hands on your abdomen, count the fetus movements for 30 minutes. During this time you are supposed to feel 3 to 5 movements. If after 30 minutes you feel fewer than 3 movements, do not stop. Continue to count for another 30 minutes, after which you should count 6 movements in an hour. If you do not reach this number, it is important to seek medical assessment immediately.

Examination in the obstetric emergency department: lengthy fetal monitoring with guidance on marking of fetal movements (using an indicator that records movements on the monitor page). Later, biophysical profiling by a physician.

Biophysical profiling is a noninvasive ultrasound scan that evaluates the condition of the fetus in the uterus by recording each tested parameter: body movements, breathing movements, body tone, quantity of amniotic fluid and fetal monitoring.

There are many factors that affect the number of movements you report, most of which are common, such as lack of concentration or inattention during a busy day, change in the normal pattern of movements due to fetal growth in the uterus and more. But conditions and illnesses that may result in fetal suffering may also manifest in reduced or weakened fetal movements.

Daily tracking of fetal movements allows you to monitor the condition of your fetus in the uterus.

In any case of injury, fall or involvement in a traffic accident, even without direct abdominal trauma, it is important to be examined in an emergency room. In this condition, there is concern of early detachment of the placenta due to the injury. Sometimes evaluation by an orthopedist or surgeon is also necessary, depending on the injury mechanism or the complaints you have as a result.

If you are injured, whether there was direct abdominal impact or not, the physician will consider admitting you for approximately 24 hours, depending on your condition.

You may stay for inpatient observation during which the fetus will be monitored, an ultrasound scan will be done to assess his or her condition and you will be asked to pay attention to fetal movements and report the onset of uterine activity. If you have Rh factor blood type, they will consider giving you anti-D antibodies.

Headache, worsening edema, high blood pressure, blurred vision or epigastric pain may be signs of a developing preeclampsia. In the emergency room, they will evaluate you, including blood tests, maternal and fetal assessment, urine test for protein and blood pressure measurements.

Read more on pre-eclampsia

Many women describe the pain of labor at the beginning of childbirth like "menstrual pain", manifesting in lower abdominal pain and back pain occurring intermittently. In any case of labor, contractions or pressure before week 37, which do not resolve, it is important for you to seek consultation and examination by your physician in the community (HMO) or an obstetric emergency department.

In the obstetric emergency department: when you are connected to a fetal monitor, the midwife will connect the transducer to you for evaluating uterine activity (recording of contractions) too, allowing to check for labor and the regularity, frequency and duration of contractions. Also, the midwife will place her hands over your uterus to check for hardening.

Vaginal examination – it may be necessary to perform an internal vaginal examination for contractions that promote delivery, which cause changes in the uterine cavity (dilation, flattening, location and consistency).

Full term contractions: it is very difficult to say exactly when to go to the obstetric emergency department, but the most important thing is to listen to your body. If you feel intensifying labor pain, pain which you have difficulty coping with at home, you should go to the obstetric emergency department for assessment.

In principle, the more regular the contractions are (two or more in ten minutes) and the greater their intensity and duration is, the greater is the chance that the woman is starting childbirth.

As a rule, regular contractions that intensify in pain, every 5 minutes for an hour or two (two hours for a first pregnancy, or even less in the case of a second or later pregnancy), require going to the obstetric emergency department.

When you consider whether to go to the obstetric emergency department, take into account other data such as traffic on the way at the time of your journey, travel distance and more.

More on the stages of childbirth

A state of loss of fluids as a result of diarrhea and vomiting may cause early contractions. Diarrhea and vomiting may be caused by bad or contaminated food and cause viral or bacterial infection. If you also have a fever, it is important to rule out listeria infection and according to the medical discretion of the attending staff, they may provide you antibiotics to rule out listeria infection.

The physician will provide you, during your last appointment (around week 38), with a letter containing details on the course of the pregnancy. If you have reached week 40, it means you are in a post-term state. From week 40, pregnancy monitoring is done as necessary and according to medical recommendations.

Sometimes, the physician monitoring you during pregnancy will refer you to the obstetric emergency department due to a finding in an examination.

Note

Note

There are many other possible reasons women may come or be referred by their physicians to the emergency room. Every case has a different treatment and additional tests according to the condition of the woman and fetus and the week of pregnancy. With any question you may have, it is always important to contact your physician. If you feel unsure, stressed or if it is late, it may be a good time to go to the closest obstetric emergency department.

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