Threats
Airway, breathing, circulation, hemorrhage, seizure, mental status, delivery.
Chapter8
Assessment
Maternal Physical Assessment
Educational use onlyThis chapter supports certification preparation and clinical reasoning. Follow local protocols, scope of practice, medical direction, and the established transport plan.
Learning objectives
After completing this chapter, you should be able to perform a structured maternal primary and secondary assessment, interpret pregnancy-specific trends, identify early warning findings, recognize shock and cardiopulmonary deterioration, integrate basic fetal status, and communicate time-linked changes during transport.
The maternal assessment asks five questions
1
Is there an immediate threat?
Airway, oxygenation, hemorrhage, seizure, shock, or imminent birth.
2
Is position contributing?
Relieve aortocaval compression when appropriate.
3
What is changing?
Compare trends, symptoms, examination, and fetal response.
4
What mechanism fits?
Hemorrhagic, septic, cardiogenic, obstructive, or mechanical.
5
Does the plan still fit?
Continue, pause, divert, deliver, or add resources.
Opening transport scenario
A 28-year-old patient at 34 2/7 weeks is being transferred for severe-range hypertension. Blood pressure is 166/112 mm Hg. She reports persistent headache and visual “sparkles.” Her face and hands are newly swollen, patellar reflexes are brisk, and ankle clonus is present. Twenty minutes into transport, respiratory rate rises to 30/min, SpO₂ falls to 92%, and bibasilar crackles develop. The physical assessment—not the referral label—shows worsening multisystem disease and possible pulmonary edema.
Mother–fetus connectionFetal status reflects maternal oxygenation, ventilation, cardiac output, uterine perfusion, temperature, and placental function. Maternal stabilization is often the most effective fetal resuscitation.
1. Assessment priorities
Position
Relieve aortocaval compression and document the response.
Maternal trend
Vital signs, perfusion, pain, urine output, respiratory and neurologic findings.
Obstetric focus
Uterine tone, contractions, bleeding, fluid, movement, basic fetal status.
Transport decision
Continue, pause, divert, prepare to deliver, or request resources.
History and examination occur simultaneously. A complete head-to-toe examination must never delay treatment of seizure, severe respiratory distress, major hemorrhage, shock, cord prolapse, or imminent delivery.
2. First impression and position
Appearance
Distress, posture, behavior, pallor, diaphoresis, swelling, visible bleeding.
Speech and breathing
Ability to speak, respiratory pattern, accessory muscles, cough, stridor.
Neurologic status
Orientation, agitation, lethargy, seizure activity, focal deficits.
Obstetric clues
Contraction behavior, urge to push, fluid, presenting part, fetal monitor.
Transport decision pointNew nausea, pallor, dizziness, tachycardia, hypotension, or fetal deterioration after lying flat should prompt left lateral tilt or manual uterine displacement when feasible. Reassess before assuming fluid loss is the only cause.
3. Maternal vital signs and early warning findings
Blood pressure
Use the correct cuff, support the arm, and repeat unexpected results. Severe range is systolic ≥160 or diastolic ≥110 mm Hg.
Heart rate
A higher baseline may be physiologic, but persistent marked tachycardia needs an explanation.
Respirations
A rising rate is often an early warning sign. Observe effort, speech, and trajectory.
Oxygen saturation
New hypoxemia or oxygen requirement is abnormal and requires rapid evaluation.
Temperature
38°C (100.4°F) or higher is an urgent warning sign and may affect fetal heart rate.
Urine output
Low output may reflect hypoperfusion, renal injury, preeclampsia, or magnesium accumulation.
| Finding | Why it matters | Immediate response |
|---|---|---|
| SBP <90 or >160 | Shock or severe hypertension | Validate promptly; escalate and treat mechanism |
| DBP >110 | Severe hypertension | Immediate escalation per protocol |
| HR <50 or >120 | Dysrhythmia, shock, medication, infection | Reassess rhythm, perfusion, symptoms, and trend |
| RR <10 or >30 | Ventilatory failure or critical illness | Assess airway, oxygenation, ventilation, and cause |
| SpO₂ <95% | Maternal and fetal oxygen-delivery risk | Verify waveform, support oxygenation, evaluate cause |
| Confusion or unresponsiveness | Neurologic or systemic emergency | Immediate stabilization and differential diagnosis |
These are example maternal early-warning triggers used to prompt validation and escalation. They support rather than replace clinical judgment and local policy.
A 35-week patient has HR 116/min and BP 108/68 mm Hg. Does the blood pressure rule out hemorrhage?
No. Compensated hemorrhage may be present before hypotension. Interpret skin, pulse pressure, mental status, bleeding, urine output, pain, and fetal trajectory.
4. Neurologic assessment
Symptoms
- Persistent or sudden severe headache
- Visual spots, blurring, or diplopia
- Dizziness, syncope, confusion
- Speech, weakness, or sensory change
Examination
- Level of consciousness and orientation
- Pupils and speech
- Motor and sensory symmetry
- Deep tendon reflexes and clonus
Differential
- Preeclampsia/eclampsia
- Stroke or intracranial hemorrhage
- Cerebral venous thrombosis
- Hypoglycemia, infection, toxicology, epilepsy
Hyperreflexia and clonus may support neurologic irritability but do not independently diagnose preeclampsia. During magnesium therapy, decreasing or absent reflexes, respiratory depression, declining mental status, and oliguria raise concern for toxicity.
Clinical trapDo not attribute every headache or neurologic symptom to preeclampsia. Maintain a broad differential while rapidly addressing severe hypertension and seizure risk.
5. Respiratory and cardiovascular examination
Respiratory
- Rate, pattern, speech, work of breathing
- Anterior and posterior lung sounds when feasible
- Orthopnea, cough, sputum, chest pain
- SpO₂, oxygen need, capnography when indicated
Cardiovascular
- Rate, rhythm, chest pressure, palpitations
- Peripheral pulses and perfusion
- Jugular venous distention
- Edema pattern and unilateral leg findings
Crackles, hypoxemia, orthopnea, inability to speak normally, new oxygen requirement, or jugular venous distention are not explained by normal pregnancy alone. Sudden dyspnea with pleuritic pain, syncope, or unilateral leg symptoms requires consideration of pulmonary embolism.
6. Abdominal and uterine assessment
Inspect
Distention, scars, trauma, visible movement, bleeding, fluid, presenting part.
Palpate gently
Location of pain, uterine tenderness, resting tone, contractions, rigidity.
Correlate
Gestational age, fetal movement, fetal status, membrane status, prior surgery.
Avoid harm
Do not perform routine digital vaginal examination in unexplained late-pregnancy bleeding before previa is excluded.
Possible abruption
Painful bleeding, uterine tenderness, increased resting tone or rigidity, fetal deterioration; bleeding may be concealed.
Possible previa
Classically painless bright-red bleeding with a softer uterus; presentations vary and diagnosis requires imaging.
Possible rupture
Sudden severe pain, shock, abnormal fetal status, loss of station, or concerning history of uterine surgery.
7. Vaginal bleeding, fluid loss, and perineal findings
Characterize loss
Onset, amount, progression, color, clots, pain, and concealed-bleeding clues.
Characterize fluid
Clear, blood-tinged, green/brown, foul-smelling, continuous, or intermittent.
Look for immediate threats
Visible cord, presenting part, urge to push, rectal pressure, fetal deterioration.
Why should visible blood loss not be used as the sole measure of hemorrhage severity?
Placental abruption, uterine rupture, retroperitoneal bleeding, or intra-abdominal hemorrhage may be concealed. Maternal perfusion and fetal status may worsen despite limited external blood.
8. Skin, extremities, perfusion, and pain
Perfusion
Pallor, cool clammy skin, delayed refill, weak pulses, anxiety, confusion, narrowing pulse pressure.
Coagulation clues
Petechiae, bruising, or oozing from access sites may suggest thrombocytopenia or coagulopathy.
Thrombosis clues
New unilateral swelling, warmth, redness, or tenderness is more concerning than symmetric dependent edema.
High-risk pain
Persistent RUQ/epigastric pain, pleuritic chest pain, tearing back pain, flank pain with fever, or constant pain between contractions.
9. Basic fetal integration
At minimum, integrate gestational age, fetal movement, fetal heart rate or recent tracing, contractions, membrane status, placental conditions, and the response to maternal stabilization. Detailed tracing interpretation is addressed in Chapter 10.
10. Shock and critical-illness patterns
Hemorrhagic
Tachycardia, pallor, cool skin, narrowing pulse pressure, bleeding or concealed loss, fetal deterioration.
Septic/distributive
Fever or hypothermia, tachycardia, tachypnea, altered mentation, suspected infection, abnormal perfusion.
Cardiogenic
Dyspnea, orthopnea, crackles, JVD, dysrhythmia, edema, chest symptoms, poor perfusion.
Obstructive
Sudden dyspnea, chest pain, syncope, hypoxemia, hypotension, unilateral leg findings, tension physiology.
Mechanical
Supine symptoms that improve with left tilt or uterine displacement.
Paramedic knowledge bridgeDo not treat every hypotensive pregnant patient with repeated crystalloid. Identify the mechanism: volume loss, vasodilation, pump failure, pulmonary vascular obstruction, medication effect, or vena-caval compression.
11. Transport reassessment
After position change, loading, transfer, or major vibration.
After medication, infusion, oxygen, airway, or fluid adjustment.
After new pain, bleeding, fluid, contractions, dyspnea, or neurologic symptoms.
After a monitor or equipment alert—assess the patient, not only the device.
Time-link objective trends and notify the receiving system early.
12. Evolving case study
Phase 1: Departure assessment
The 34-week patient has severe-range hypertension, headache, visual symptoms, brisk reflexes, and clonus. The crew verifies the magnesium concentration and rate, confirms urine output, establishes seizure precautions, and reports the findings.
Phase 2: Respiratory change
Respiratory rate rises to 30/min, SpO₂ falls to 92%, and bibasilar crackles develop. The team recognizes possible pulmonary edema rather than attributing dyspnea to anxiety or normal pregnancy.
Phase 3: Maternal-fetal deterioration
Positioning and oxygenation are optimized, infusions and prior fluid volume are reviewed, and the receiving team is updated. Fetal status begins to deteriorate, reinforcing the urgency of correcting maternal physiology.
Phase 4: Destination decision
The original center is 30 minutes away; an obstetric-capable hospital with anesthesia, operating-room, blood-bank, and neonatal stabilization is 7 minutes away. Current physical findings support immediate diversion discussion.
13. High-yield chapter summary
- Begin with threats, position, and maternal trend.
- Repeat unexpected vital signs with correct technique.
- Severe-range blood pressure requires immediate escalation.
- A rising respiratory rate is often an early warning sign.
- Hypoxemia, crackles, orthopnea, and new oxygen need are abnormal.
- Neurologic symptoms require a broad differential.
- Reflexes and urine output matter during magnesium therapy.
- A firm tender uterus may indicate abruption; bleeding may be concealed.
- Avoid digital examination when previa has not been excluded.
- Unilateral painful leg swelling is concerning for thrombosis.
- Hypotension may be late in hemorrhage.
- Maternal stabilization is fetal resuscitation.
- Reassess after movement, intervention, or symptom change.
- Report objective, time-linked trends.
References
- International Board of Specialty Certification. Maternal Fetal Transport Microcredential Candidate Handbook. Updated April 2026.
- American College of Obstetricians and Gynecologists. Tailored Prenatal Care Delivery for Pregnant Individuals. Clinical Consensus. 2025.
- American College of Obstetricians and Gynecologists. Gestational Hypertension and Preeclampsia. Practice Bulletin No. 222; updated 2024.
- Alliance for Innovation on Maternal Health. Maternal Early Warning System Implementation Resource Kit. 2025.
- Alliance for Innovation on Maternal Health. Urgent Maternal Warning Signs.
- Society for Maternal-Fetal Medicine. Checklists for Triage and Work-up of Persons With Symptoms Suggestive of Cardiovascular Disease in Pregnancy and Postpartum. 2025.
- Society for Maternal-Fetal Medicine. A Maternal Transport Briefing Form and Checklist. Reaffirmed 2025.
- Mehta LS, et al. Cardiovascular considerations in caring for pregnant patients. Circulation. 2020;141:e884–e903.
Chapter assessment
Twenty-question maternal assessment quiz
Immediate rationales are shown in study mode, and your score is stored locally.