Initial Assessment at Onset of Labour

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Initial Assessment at Onset of Normal Labour — History, Examination & Planning

When a woman arrives in labour, the first assessment should find danger early, confirm whether she is in labour, check mother and baby, and set the plan. It is best done in six steps: triage, history, the mother, the abdomen and the baby, a vaginal examination when needed, and a clear decision about risk and place of care.

🎯 AT A GLANCE — WHY THE FIRST ASSESSMENT MATTERS

The initial assessment answers five questions: Is she in labour? How far on? Are mother and baby well? Is she low-risk or high-risk? What is the plan?

It combines history, observations, abdominal examination, fetal assessment, and — when safe and needed — a vaginal examination

A structured, unhurried, respectful assessment finds the 10–20% of women who need a higher level of care, and avoids unnecessary admission or intervention for those who do not

Look for danger first, then for labour. A quick safety check in the first minutes decides whether she needs immediate help or time to talk.

🚨 FIRST MINUTES — ANY OF THESE NEEDS IMMEDIATE SENIOR HELP

Heavy or fresh vaginal bleeding, severe constant abdominal pain, or a hard tender uterus — do not do a vaginal examination until praevia is excluded

Convulsions, severe headache with visual symptoms, or BP ≥ 160/110; fever, shock, or breathlessness

Fetal heart below 110 or above 160 bpm, absent or reduced movements, thick meconium, or a prolapsed cord

Imminent birth (urge to push, bulging perineum, crowning), transverse or oblique lie, breech in advanced labour, or preterm labour

🗺️ THE ASSESSMENT AT A GLANCE

1 · Greet and triageWelcome her and her companion, check for red flags, and note the time of arrival

2 · HistoryLabour symptoms, membranes, fetal movement, and the antenatal record

3 · Maternal observationsPulse, BP, temperature, respiratory rate, urine

4 · Abdomen and babyFundal height, lie, presentation, engagement, contractions, and fetal heart

5 · Vaginal examination (if indicated)Cervix, station, position, membranes, liquor, and pelvis

6 · Decide and documentIn labour or not, stage, risk level, place of care, monitoring, and a clear plan

STEP 1 · HISTORY — listen first, examine second

📝 HISTORY — THE LABOUR AND THE PREGNANCY

Current Labour

Contractions: onset, frequency, duration, strength, and where the pain is felt

Show or bleeding? Amount and colour

Membranes: did the waters break, when, and what colour (clear, meconium, blood)?

Fetal movements in the last 24 hours

Headache, visual change, upper abdominal pain, fever, or other symptoms

Pregnancy and Past History

Age, parity, gestation (scan-confirmed EDD)

Booking record: BP, Hb, blood group and Rh, HIV, HBsAg, VDRL, GBS result, glucose tolerance

Scan findings: placental site, growth, liquor, and presentation

Previous caesarean or uterine surgery; past labours, birth weights, PPH, shoulder dystocia

Medical and drug history, allergies, last meal

Ask about preferences: her birth plan, who will support her, pain-relief choices, and anything that worries her.

STEP 2 · THE MOTHER — observations and general examination

🌡️ OBSERVATIONS AND WHAT TO DO ABOUT THEM

Measure	Concern if	Action
Blood pressure	≥ 140/90 (raised); ≥ 160/110 (severe)	Repeat after 15 min; check urine protein; pre-eclampsia pathway and senior review
Pulse	≥ 120 bpm, or 100–119 on repeat	Look for fever, bleeding, pain, anxiety, or dehydration
Temperature	≥ 38.0 °C once, or ≥ 37.5 °C twice, 1 hour apart	Treat as possible infection or sepsis; blood tests and antibiotics
Respiratory rate / SpO₂	> 24 per minute, or SpO₂ < 95%	Examine chest and heart; senior review
Urinalysis	Protein ≥ 1+, glucose, or ketones	Pre-eclampsia, diabetes, or dehydration work-up
General	Pallor, oedema, jaundice, or poor hydration	Check Hb; correct as needed

STEP 3 · THE ABDOMEN AND THE BABY — Leopold's manoeuvres and the fetal heart

🤰 ABDOMINAL EXAMINATION

Check	How	Findings that need action
Inspection	Scars, shape, striae, movements	Previous caesarean scar → plan for TOLAC or repeat section; transverse shape → malpresentation
Fundal height	Measure from the pubic symphysis	Much larger → twins, polyhydramnios, macrosomia; much smaller → FGR, oligohydramnios
Lie and presentation	Fundal and lateral grips; pelvic grip	Breech, transverse, or oblique lie → senior review
Engagement	Fifths of the head palpable above the brim	Head not engaged in a first labour may suggest disproportion, praevia, or a full bladder
Contractions	Palpate for 10 minutes; note frequency, length, strength	More than 5 in 10 minutes (tachysystole) → review; weak, infrequent → latent phase or dehydration
Uterine tone	Relaxes between contractions?	Constant hardness and tenderness → abruption or scar rupture
Fetal size	Estimate small, average, or large	Suspected macrosomia or FGR → scan and plan

💓 FETAL ASSESSMENT ON ADMISSION

Listen to the fetal heart with a Pinard or hand-held Doppler for at least one full minute, immediately after a contraction; feel the mother's pulse at the same time to avoid confusion

Normal baseline: 110–160 bpm, with accelerations or normal variability; abnormal rate, decelerations, or reduced movements → CTG and senior review

Admission CTG is not recommended for low-risk women with a normal fetal heart on auscultation — it increases interventions without improving outcomes

Use CTG when there are risk factors, meconium, abnormal auscultation, bleeding, reduced movements, or a high-risk indication — see our FHR Monitoring guides

Meconium-stained liquor needs continuous monitoring and an obstetric unit

STEP 4 · THE VAGINAL EXAMINATION — only when it will change management

🧤 VAGINAL EXAMINATION — BEFORE YOU START

1

Is it indicated? Do it to diagnose labour or decide care — not as a routine

2

Exclude praevia and bleeding: check the placental site on the latest scan; if bleeding, do a speculum look, not a digital exam

3

Check the membranes: in preterm rupture, use a sterile speculum and avoid digital exams unless labour is established

4

Prepare: explain, obtain consent, offer privacy and a chaperone, empty the bladder, and wash hands

5

Use strict asepsis with sterile gloves and antiseptic; limit repeat examinations — about every 4 hours unless there is a clinical reason

🔬 WHAT TO ASSESS AND RECORD

Feature	What to note
Cervix	Dilatation (cm), effacement (%), consistency (firm, medium, soft), and position (posterior, mid, anterior)
Membranes and liquor	Intact or ruptured; colour (clear, meconium-stained, blood-stained), smell, and amount
Presentation and position	Vertex, face, brow, or breech; sutures and fontanelles to define the position (for example, OA, OP, OT)
Station	Relation of the presenting part to the ischial spines (−3 to +3, or −5 to +5 in cm)
Caput and moulding	Caput present or absent; moulding 0 to +++ (bones touching, overlapping and reducible, overlapping and irreducible)
Cord or limbs	Any cord or small parts felt below the presenting part (cord prolapse → emergency)
Pelvis	Adequacy: sacral curve, ischial spines, subpubic arch, and cervical findings (see Bishop score in our Prolonged Pregnancy guide)

STEP 5 · TESTS — only what changes care

🧪 INVESTIGATIONS ON ADMISSION

All women: urinalysis; haemoglobin if not done recently; blood group and Rh if unknown; HIV, hepatitis B, and VDRL if never tested; malaria test in endemic areas

High-risk women (previous caesarean, APH, pre-eclampsia, multiple pregnancy, anaemia, obesity, previous PPH): group and save or cross-match; IV access

Diabetes: capillary glucose on arrival, then hourly; suspected infection: blood culture, CRP, full count

Rh-negative women: record for later anti-D; group B streptococcus: check the screening result (taken at 36–37 weeks) and plan prophylaxis

STEP 6 · DECIDE AND PLAN — is she in labour, and how risky is it?

🧭 IS SHE IN LABOUR? — DECIDING WHAT TO DO

Finding	Interpretation	Plan
Irregular contractions, no cervical change	Not in labour (false labour)	Reassure, support, give analgesia, and discharge with clear advice
Regular painful contractions, early cervical change, less than 4–6 cm	Latent phase	Encourage rest, mobilisation, and fluids at home or in a calm room; review in 2–4 hours
Progressive dilatation, active contractions	Established (active) labour	Admit; start partograph or Labour Care Guide; continue assessment
Ruptured membranes, no contractions, term	Prelabour rupture of membranes	Induction or expectant care up to 24 hours; immediate induction and antibiotics if GBS-positive
Any red flag or risk factor	Higher-risk labour	Admit to an obstetric unit with senior care

Send-home advice: return for regular strong contractions, waters breaking, bleeding, reduced movements, or if she is worried or unable to cope.

⚖️ RISK STRATIFICATION — WHERE AND HOW TO MONITOR

Low Risk

Spontaneous labour at 37–42 weeks

Singleton, cephalic presentation

No medical or obstetric complications

Normal observations and a normal fetal heart

Care: intermittent auscultation, partograph, and mobility; midwife-led unit possible

High Risk

Preterm or post-term, multiple pregnancy, or malpresentation

Hypertension, diabetes, heart disease, anaemia, or epilepsy

Previous caesarean, APH, FGR, polyhydramnios or oligohydramnios, meconium, BMI ≥ 35

Abnormal fetal heart or reduced movements; HIV; Rh disease

Care: obstetric unit, continuous CTG as indicated, IV access, bloods, and senior review

🔍 SPECIAL SITUATIONS AT ADMISSION

Previous Caesarean

Counsel on TOLAC versus repeat caesarean

Continuous fetal monitoring, IV access, and group and save

Anaesthetic and theatre team aware; watch for scar pain, bleeding, or fetal heart changes

GBS Positive or Unknown

Penicillin G 5 million units IV, then 2.5–3 million units every 4 hours until birth

Start at admission in labour or with ruptured membranes

Allergy: cefazolin or clindamycin as per protocol

Term Rupture of Membranes

Confirm with speculum or test; check liquor colour

Offer induction soon, or expectant care up to 24 hours with monitoring

Check temperature every 4 hours; avoid repeated digital exams

Preterm Labour

Transfer to a unit with NICU

Steroids, magnesium, antibiotics, and tocolysis as appropriate

See our Preterm Labour & PPROM guide

🗂️ DOCUMENT, COMMUNICATE AND SUPPORT

Record everything with times: arrival, history, observations, examination findings, assessment, and plan — and who was informed

Start a partograph or Labour Care Guide as active labour begins — see our Partograph guide

Explain findings and options in plain language and obtain consent for each procedure

Encourage a companion of her choice, mobility, a quiet environment, light food, and oral fluids in low-risk labour

Discuss pain relief early and check she knows how to call for help

⛔ COMMON PITFALLS

Vaginal examination with bleeding before praevia is excluded

Admitting every woman with contractions — latent labour is usually best managed with support at home

Skipping the antenatal record — missing a scar, a diabetes result, or a GBS status

Routine admission CTG in low-risk women, or listening to the heart during rather than after a contraction

Routine enema, shaving, or restricting fluids

Forgetting to document or to tell the team about a risk factor

Memory Aid

TRIAGE

Six steps for the first assessment of a woman in labour.

T

Time the contractions, and confirm dates and gestation

R

Red flags first — bleeding, BP, fits, fever, fetal heart, imminent birth

I

Infant — fetal heart after a contraction, lie, presentation, engagement, and movements

A

Assess the mother — pulse, BP, temperature, urine, and abdomen

G

Gentle vaginal examination — only if indicated and safe; aseptic technique

E

Establish the plan — stage, risk level, place of care, monitoring, and documentation

Remember: a calm, thorough first assessment sets the direction of the whole labour — it finds the women who need help, and protects those who do not need intervention.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on NICE, ACOG and WHO guidance; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.