Braden Zoller, OMS-III¹; K. Daniel Miller, D.O.²

Affiliations:
¹Kansas City University, Kansas City, MO.
²Chief of Obstetrics, William Newton Hospital, Winfield, KS.

In 2018, visits to the emergency department (ED) related to pregnancy, childbirth, and the puerperium were the fifth most common presenting complaint for females aged 15-64, totaling over two million visits¹. Despite the frequency of obstetric complaints, a survey completed by 212 emergency medicine residents determined only 56% of residents agreed they had adequate exposure to obstetric emergencies². Therefore, a standardized and efficient method for preparing and delivering an obstetrics consult can greatly benefit both the resident physician and the overall patient care. The following are steps to take both before and during an OB/GYN consult to maximize the effectiveness of the referral. These steps are to be taken in parallel with ED standards of care and may need to be modified or deferred based on the patient’s clinical status.

Before the Consult

1. Obtain a complete set of vital signs and order necessary labs

Review vital signs to assess for fever or hemodynamic instability. Establish IV access if the patient has vaginal bleeding or moderate to severe discomfort. Obtain either a urine pregnancy test or quantitative B-hCG if the patient has an unconfirmed pregnancy. If the patient has an established pregnancy confirm the fetal heart rate with either bedside ultrasound or doppler. Important labs to order include a complete blood count, comprehensive metabolic panel, blood type and antibody screen, and coagulation panel³.

2. Gather a thorough obstetric history

All women with obstetric concerns should be asked about their prior pregnancies as well as the current pregnancy. A common way to organize this information is the GTPAL system.

• G (gravida): number of pregnancies
• T (term births): number born at >37 weeks
• P (premature births): number born at <37 weeks
• A (abortions): number of abortions or miscarriages
• L (live): number of living children⁴

In addition to the past obstetrics history, information should be obtained about what symptoms the patient may have experienced in the current pregnancy. Questions to ask include:

• Has the patient had any vaginal bleeding?
• Has the patient noticed any leakage of fluid?
• Has the patient been able to feel fetal movement?
• Have there been contractions? If so, what were the frequency and duration?
• Has the patient been ill with any gastrointestinal or genitourinary issues?³

Supplementary to the focused obstetrics history, it is important to inquire about the patient’s full past medical history (including bleeding disorders, prior episodes of excess bleeding with menses, surgery, or deliveries), the patient’s surgical history (including prior cesarean deliveries), medications, allergies, and social history including active drug or alcohol use and intimate partner violence³.

3. Perform a physical examination including a pelvic examination

Prepare for the pelvic exam by gathering all necessary equipment and ensuring a chaperone is present. Assess for vaginal bleeding, adnexal tenderness, and size of the uterus⁴. Contraindications to digital pelvic exam include suspected rupture of membranes at less than 34 weeks gestation unless the patient is in active, painful labor and evidence or prior diagnosis of placenta previa or marginal previa³.

Making the Consult

If the patient is stable, wait until a pelvic exam has been performed prior to asking the consultant for help. Additionally, ensure the obstetrics history is complete and results of pregnancy testing, imaging, and laboratory studies have resulted. Key points to include in the consult are:

• The specific reason for consult
• Obstetric history (including gestational age) and review of systems
• Vital signs and hemodynamic status
• Pelvic exam findings
• Lab findings including urine pregnancy results or quantitative B-hCG
• Ultrasound findings
• Specific clinical question for the OB/GYN⁵

After the Consult

After the consultation, be sure to thank the consultant for their time. Review both the actions to be completed before the patient’s evaluation by the consulting physician and the actions the consulting physician will complete. Continue to monitor the patient’s clinical status and update the consulting physician with any information that may change clinical decision making⁶.

Approximately 40% of all ED visits require at least one consultation by emergency medicine providers⁷.  Obstetric emergencies will likely require the emergency physician to consult their OB/GYN colleagues many times throughout their career. A thorough history and physical exam with adequate preparation for the consultation will help to ensure safer patient care and a more efficient obstetrics consultation process.

Citations

1. CDC, 2018. National Hospital Ambulatory Medical Care Survey: 2018 Emergency Department Summary Tables. CDC.
2. Janicki AJ, MacKuen C, Hauspurg A, Cohn J. Obstetric training in Emergency Medicine: Aneeds assessment. Medical Education Online. 2016;21(1). doi:10.3402/meo.v21.28930

5. Brady PC, Pilliod R. Obstetrics in the Emergency Room. In: Handbook of Consult and Inpatient Gynecology. Springer International Publishing; 2016.
6. Kossyreva EA, Aranda J. Pelvic Pain and Vaginal Bleeding. Society for Academic Emergency Medicine. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/forstudents/online-education/m3-curriculum/group-focused-chief-complaint-history-physicalexamination-and-differential-diagnosis/pelvic-pain-and-vaginal-bleeding. Published 2015. Accessed March 11, 2022.
7. Fitz V. Consult Corner OB-GYN. EMRA. https://www.emra.org/emresident/article/consult-corner-ob-gyn/. Published December 1, 2016. Accessed February 22, 2022.
8. Golden, A. and Carter, K., 2016. The Consultation Process. [online] Society for Academic Emergency Medicine. Available at: <https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/communication/the-consultation-process> [Accessed 22 February 2022].
9. Woods, R., Lee, R., Ospina, M., Blitz, S., Lari, H., Bullard, M., and Rowe, B., 2008. Consultation outcomes in the emergency department: exploring rates and complexity. CJEM, 10(01), pp.25-31.