I am a duty doctor. One patient is coming with water break what questions should i ask. What should be done

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I now have excellent content from authoritative textbooks. Let me compile the full clinical answer.

Water Break (PROM) - Duty Doctor Assessment & Management Guide

"Water break" = Premature Rupture of Membranes (PROM) - rupture of amniotic and chorionic membranes before the onset of labor.

PART 1: HISTORY QUESTIONS TO ASK

Confirm the Rupture

Question	Why It Matters
Describe what happened - was it a sudden gush or slow leak?	Classic PROM: spontaneous gush followed by persistent mild seepage. Differentiate from urinary incontinence or excess vaginal discharge.
When did it start?	Determines duration of rupture - longer latency = higher infection risk
What color/smell was the fluid? (clear, green, bloody, foul-smelling)	Green/meconium-stained = fetal distress. Foul smell = possible chorioamnionitis.

Gestational Age & Obstetric Details

Question	Why It Matters
Last menstrual period (LMP)? / Gestational age?	Calculates estimated due date - term vs preterm PROM has very different management
Gravida/Para status? Prior pregnancies, deliveries?	Prior preterm deliveries = higher risk
Did you have any prenatal visits / ultrasounds?	Confirms gestational age; checks for prior anomalies
Is this a singleton or multiple pregnancy?	Higher risk with multiples

Labor Status

Question	Why It Matters
Are you having contractions? How frequent, how strong?	Determines if active labor is in progress
Any urge to push or pressure in the pelvis?	Suggests advanced labor or cord prolapse

Infection Warning Signs

Question	Why It Matters
Do you have a fever or feel feverish/chills?	Fever + PROM = chorioamnionitis until proven otherwise
Any abdominal pain or uterine tenderness?	Sign of intrauterine infection
Any recent vaginal infections, STIs, or vaginal discharge?	GBS, Chlamydia, GC, BV increase complications
Have you had any recent vaginal exams or procedures (e.g., amniocentesis)?	Risks for ascending infection

Bleeding & Other Concerns

Question	Why It Matters
Any vaginal bleeding?	Raises concern for placenta previa or abruption
Recent sexual intercourse?	Can mimic PROM; can also trigger labor
Any prior cervical cerclage?	Requires special management
Any known fetal anomalies?	Affects resuscitation and management decisions

Fetal Movement

Question	Why It Matters
Is the baby still moving? Any change in movements?	Decreased fetal movement = possible fetal compromise

PART 2: PHYSICAL EXAMINATION

Vitals First

Temperature (fever = chorioamnionitis flag)
Pulse, BP, SpO2, RR
Fetal heart rate by Doppler/CTG

Obstetric Exam

Fundal height - correlates with gestational age
Fetal lie & presentation - vertex, breech, transverse
Uterine tenderness - key sign of chorioamnionitis or abruption

STERILE SPECULUM EXAM (mandatory - do NOT do digital exam first)

Look for: pooling of fluid in the posterior fornix
Visually assess cervical dilatation and effacement
Ask patient to cough or perform Valsalva maneuver - look for gush of fluid from the cervix
Check for prolapsed cord or visible fetal part - emergency if present

CRITICAL: Avoid digital cervical examination until speculum exam is done. Digital exam reduces the latent period and increases infection risk.

PART 3: BEDSIDE DIAGNOSTIC TESTS

Test	Method	Positive =
Nitrazine paper	Swab posterior vaginal vault, apply to paper	Turns blue if pH >6.5 (amniotic fluid). Normal vaginal pH is <5.5. False positives: blood, semen, BV, Trichomonas, antiseptics
Fern test	Dry vaginal fluid swab on glass slide, microscope	Crystalline fern pattern = amniotic fluid. Blood may obscure it.
Smear combustion	Flame fluid on slide	Amniotic fluid turns white/crystallizes; vaginal secretions caramelize to brown

The combination of history + nitrazine + ferning diagnoses ~90% of PROM cases.

Additional Investigations

Ultrasound - assess amniotic fluid volume (AFI). Low AFI (<5 cm) suggests significant leak and may predict imminent delivery. Not diagnostic alone.
CTG (cardiotocography) - continuous fetal heart rate monitoring for fetal well-being and to identify occult contractions
Cultures: Swab for Group B Streptococcus (GBS), Chlamydia trachomatis, Neisseria gonorrhoeae
CBC, CRP - leucocytosis and elevated CRP support chorioamnionitis
Blood cultures if sepsis suspected

PART 4: MANAGEMENT (Based on Gestational Age)

All Patients With PROM:

IV access + baseline bloods (FBC, CRP, blood cultures if febrile)
Continuous CTG monitoring
Obstetric consultation - always
Admission - all PROM patients require inpatient management
Screen and treat for intraamniotic infection

By Gestational Age:

Gestational Age	Management
≥37 weeks (Term PROM)	Induce labor - oxytocin infusion preferred. Reduces chorioamnionitis risk. No benefit from expectant management. Minimize digital exams until active labor phase.
34-36 weeks (Late preterm)	Usually deliver - conservative management significantly increases chorioamnionitis risk (16% vs 2%) with minimal benefit
32-33 weeks	Expectant management; consider corticosteroids for lung maturity
24-31 weeks (Preterm PROM)	Expectant management. Corticosteroids (betamethasone) for lung maturity. Consider magnesium sulfate for neuroprotection (<32 wks). Antibiotics to prolong latency.

Antibiotics for Preterm PROM:

Ampicillin 2g IV + Azithromycin 1g PO (initial dose)
Followed by Ampicillin 2g IV Q6h x 48h + Amoxicillin 875mg PO BD for 5 days

Corticosteroids:

Betamethasone 12mg IM x 2 doses 24 hours apart (for fetal lung maturity in preterm PROM <34 weeks)

If Chorioamnionitis Confirmed:

Broad-spectrum antibiotics immediately (e.g., ampicillin + gentamicin)
Delivery is indicated - chorioamnionitis is an absolute contraindication to tocolysis

PART 5: RED FLAGS - CALL FOR HELP IMMEDIATELY

Visible/palpable prolapsed cord - emergency cesarean
Meconium-stained fluid - fetal distress, prepare NICU team
Fever + uterine tenderness - chorioamnionitis, deliver regardless of gestational age
Significant vaginal bleeding - rule out placenta previa/abruption
Non-reassuring CTG - fetal compromise, prepare for emergency delivery
Active labor + preterm - notify senior obstetrician immediately

Sources: Tintinalli's Emergency Medicine, 9e | Rosen's Emergency Medicine, 10e | Creasy & Resnik's Maternal-Fetal Medicine, 9e

Her admission date was tomorrow. How to write admission sheet and how to admit her

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obstetric admission sheet documentation PROM unplanned admission before scheduled date

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The library doesn't have a dedicated section on admission documentation, so I'll answer from clinical knowledge directly - this is a standard procedural topic well within established practice.

Admitting a PROM Patient Who Was Scheduled for Tomorrow

The key point: her scheduled admission date is irrelevant. PROM is an emergency obstetric indication. She must be admitted today, right now, regardless of what was planned. Water break = admit immediately.

STEP 1: DECISION TO ADMIT

Document or verbally state the indication for emergency/unplanned admission:

"Patient presents with spontaneous rupture of membranes (PROM) at [X] weeks gestation. Patient was previously scheduled for elective admission on [tomorrow's date] but has presented as an emergency today. Admission indicated for PROM management."

This protects you legally and clinically. The prior scheduled date does not override the current clinical situation.

STEP 2: HOW TO WRITE THE ADMISSION SHEET

An obstetric admission sheet (also called the Admission Note or Clerking Sheet) follows a structured format. Here is what to fill in for this patient:

🔷 SECTION A - PATIENT IDENTIFICATION

Name:
Age:
MRD No. / IP No.:
Ward:
Date & Time of Admission: [TODAY's date and time - NOT tomorrow]
Admitting Doctor:
Referred by: (self / GP / OPD / Emergency)
Type of Admission: EMERGENCY  ← mark this clearly

🔷 SECTION B - CHIEF COMPLAINT

Presenting Complaint:
"Leaking per vaginum since [time] on [date]"
Duration: [e.g., 3 hours]

🔷 SECTION C - OBSTETRIC HISTORY (OB History)

Current Pregnancy:

LMP (Last Menstrual Period): DD/MM/YYYY
EDD (Expected Date of Delivery): DD/MM/YYYY
Gestational Age: __ weeks __ days
ANC (Antenatal Care): Booked / Unbooked
No. of ANC visits:
Last USG date & findings:
Blood group & Rh type:

Past Obstetric History (GPLA formula):

G: (Gravida - total pregnancies including this one)
P: (Para - deliveries after 28 weeks)
L: (Living children)
A: (Abortions)

Previous deliveries:
- Date | Gestation | Mode (NVD/LSCS) | Baby weight | Outcome

🔷 SECTION D - HISTORY OF PRESENT ILLNESS

Write a short paragraph:

"Mrs. [Name], G_P_L_A_, [gestational age] weeks gestation, presented to casualty/OPD at [time] on [date] with complaints of sudden leaking of clear fluid per vaginum since [time]. The fluid was [color], [odor]. She complains of [contractions / no contractions]. She denies fever, vaginal bleeding, decreased fetal movement. She was previously scheduled for planned admission on [tomorrow's date] for [reason, e.g., elective LSCS / IOL]. However, due to spontaneous membrane rupture, she is being admitted today as an emergency."

🔷 SECTION E - MENSTRUAL & CONTRACEPTIVE HISTORY

Menarche: age ___
Cycle: Regular / Irregular, every ___ days
Flow: Normal / Heavy / Scanty, for ___ days
Contraception: None / IUD / Pills (document if prior use)

🔷 SECTION F - MEDICAL & SURGICAL HISTORY

Known hypertension: Yes / No
Known diabetes: Yes / No
Thyroid disorders: Yes / No
Previous surgeries: Yes / No (specify)
Drug allergies: Yes / No (specify)
Current medications:

🔷 SECTION G - GENERAL & SYSTEMIC EXAMINATION

General condition: Conscious / Oriented / Cooperative
Built & nutrition: Normal / Thin / Obese
Pallor: Present / Absent
Jaundice: Absent
Edema: Absent / Present (site)
Cyanosis: Absent
Lymphadenopathy: Absent

Vitals:
- BP: ___/___  mmHg
- Pulse: ___ bpm
- Temperature: ___°F / °C
- RR: ___ /min
- SpO2: ___%

Systemic Exam:
- CVS: S1 S2 heard, no murmur
- RS: Clear air entry bilateral
- Abdomen: (see obstetric exam below)
- CNS: No focal deficits

🔷 SECTION H - OBSTETRIC EXAMINATION

Uterus:
  - Size corresponds to ___ weeks gestation
  - Fundal height: ___ cm
  - Uterus: Relaxed / Tender (tenderness = chorioamnionitis flag)

Fetal:
  - Lie: Longitudinal / Transverse / Oblique
  - Presentation: Cephalic / Breech / Shoulder
  - Engagement: Engaged / Not engaged
  - FHS (Fetal Heart Sounds): Present, regular, ___ bpm

Sterile Speculum Examination:
  - Liquor pooling in posterior fornix: Present / Absent
  - Cervical os: Dilated / Closed (___ cm)
  - Effacement: ____%
  - Show: Present / Absent
  - Nitrazine test: Positive (blue) / Negative
  - Fern test: Positive / Negative
  - Cord prolapse: Absent (MUST check)

Digital Vaginal Exam: Deferred / Performed (only if needed after speculum)

🔷 SECTION I - INVESTIGATIONS ORDERED

On Admission:
- CBP / CBC
- Blood group & Rh type (if not known)
- Random blood sugar
- Urine routine
- CRP (if infection suspected)
- HVS (High Vaginal Swab) for culture - GBS, GC, Chlamydia
- USG Obstetric: AFI, fetal well-being, presentation
- CTG (Cardiotocograph): Start immediately

🔷 SECTION J - DIAGNOSIS

Provisional Diagnosis:
"G_P_L_A_ at [gestational age] weeks with Premature Rupture of Membranes (PROM)"

OR if preterm:
"G_P_L_A_ at [X] weeks with Preterm Premature Rupture of Membranes (PPROM)"

🔷 SECTION K - PLAN OF MANAGEMENT

1. Admit in labour ward / antenatal ward
2. Continuous CTG monitoring
3. IV access - 18G cannula, send bloods
4. IV fluids: [e.g., DNS / RL at TKO rate unless in labour]
5. Antibiotics: [e.g., Inj. Ampicillin 2g IV stat + Azithromycin 1g PO]
6. Steroids if preterm: [Inj. Betamethasone 12mg IM if <34 weeks]
7. Nil by mouth (if delivery anticipated)
8. Inform senior obstetrician / consultant on call
9. Obstetric consent obtained: Yes / No
10. Inform NICU team if preterm

Signature: _____________
Name: _____________
Designation: Duty Doctor / RMO
Date & Time: [TODAY]

STEP 3: NURSING ADMISSION ORDERS (Tell the ward nurse)

Give verbal or written orders:

Bed rest - preferably left lateral position
NPO (nil by mouth) if labour active or delivery imminent
Monitor vitals every 30 min - 1 hour (BP, pulse, temp)
CTG - start immediately and report any decelerations
Pad count - monitor amount and character of leaking (colour, smell)
Fetal movement chart - ask patient to report decreased movements
Do NOT give any vaginal examination without doctor order
IV line - maintain patent, run fluids as ordered
Call doctor immediately if: fever, bleeding, severe pain, cord visible, CTG changes, urge to push

STEP 4: KEY THINGS TO NOTE IN THE FILE

Write today's actual date and time - not tomorrow's scheduled date
Write "Emergency Admission" clearly
Mention the previous scheduled admission date and state why patient is being admitted today instead
Get informed consent for treatment and possible delivery
Inform the consultant / senior doctor - do not manage alone as duty doctor

Bottom line: Scheduled dates get cancelled the moment a clinical emergency occurs. PROM is always an emergency admission. Document thoroughly, start CTG, call your senior, and don't delay.

How should I approach this patient and ask the details

Great practical question. This is about the clinical communication approach - how to actually talk to the patient, in what order, and what tone to use.

How to Approach a PROM Patient - The Doctor's Workflow

THE MINDSET FIRST

This patient is:

Anxious and scared (water broke unexpectedly)
In possible discomfort or early labour pain
May have come alone or in a panic
Was mentally prepared for tomorrow, not today

Your job in the first 60 seconds is: calm her, make her feel safe, then gather information.

PHASE 1 - FIRST 2 MINUTES (Rapid Visual Assessment + Rapport)

Before asking anything, look at her as she walks/is wheeled in:

Is she in pain / distress?
Is she bleeding?
Is she holding her abdomen?
Can she speak in full sentences? (if not - emergency, act first)

Then introduce yourself:

"Hello, I'm Dr. [Name], the duty doctor. You're in safe hands. Can you tell me briefly what happened?"

Let her speak first - don't interrupt. In 30-60 seconds she will tell you the most important thing herself.

PHASE 2 - CONFIRM THE EMERGENCY STATUS

Ask 3 rapid screening questions before anything else:

Question	What You're Ruling Out
"Are you feeling the baby moving right now?"	Fetal distress / stillbirth
"Is there any heavy bleeding?"	Placenta previa / abruption
"Do you feel like you need to push?"	Imminent delivery / cord prolapse

If any answer is alarming - stop history, act immediately. Call senior, put on CTG, do speculum.

If all clear - proceed calmly with full history.

PHASE 3 - HISTORY IN CONVERSATION (Not an Interrogation)

How to Ask - Tone & Style

Sit down if possible (or bend to her level if she's on the bed)
Speak slowly and clearly
One question at a time - don't bombard
Acknowledge her answers before moving on
Use simple, non-medical language

The Actual Conversation Flow

Start with the chief complaint - open ended:

"Tell me - when did you notice the leaking? Did it come suddenly or gradually?"

Then follow up:

"What did the fluid look like - was it clear, was there any colour to it, any smell?"

"Is it still leaking or did it stop?"

"Have you had any contractions - like tightening or cramping in your tummy?"

Move to gestational age:

"How many weeks pregnant are you? When is your due date?"

"When was your last period - do you remember the date?"

"When was your last scan? Do you have your reports with you?"

Check for infection signs:

"Do you have any fever? Have you been feeling hot or shivery?"

"Any pain in your tummy - not contractions, but a constant pain or tenderness?"

"Has the fluid had any bad smell?"

Ask about bleeding carefully:

"Have you noticed any blood - even a little - along with the fluid?"

(If yes - this becomes urgent immediately)

Obstetric background:

"Is this your first pregnancy or have you been pregnant before?"

"Any previous deliveries - normal delivery or C-section?"

"Any miscarriages in the past?"

Antenatal care:

"Have you been coming for your regular checkups? Where are you booked?"

"Any complications during this pregnancy - high BP, diabetes, any problems with the baby?"

"We see you were scheduled for admission tomorrow - can you tell me what that was for?"

(This is important - she may have been scheduled for LSCS, IOL, or monitoring. Knowing why changes your management.)

Fetal movement:

"Is the baby moving well? Have you felt movement today?"

Medical history (brief):

"Any medical conditions - blood pressure, diabetes, thyroid, heart problems?"

"Any allergies to medicines?"

"What medicines are you currently taking?"

Social / support:

"Is anyone with you today - your husband, family?"

"Did you come far? Is transport available if we need to shift you?"

(Relevant if this is a secondary centre with no NICU)

PHASE 4 - EXAMINATION APPROACH (How to Handle the Patient)

After history, explain before you touch:

"I need to examine you now. First I'll check your tummy and the baby's heartbeat, and then I'll need to do an internal examination with a speculum - that's a small instrument. I'll be gentle. Is that okay?"

Always:

Ask for permission before examination
Have a female nurse/chaperone present
Explain each step as you do it
Tell her what you find in simple terms after

PHASE 5 - AFTER EXAMINATION - WHAT TO TELL HER

Don't leave her hanging. Once you've assessed, explain clearly:

"Your water has broken - this is what we call rupture of membranes. This means we need to admit you today and monitor you and the baby closely. We will check the baby's heartbeat, run some tests, and I will inform the senior doctor. You are in the right place."

Avoid:

Using scary jargon without explanation ("your cervix is dilated 4cm" means nothing to her)
Saying "don't worry" without giving a reason
Giving too much information all at once
Making promises about the mode of delivery before senior review

QUICK REFERENCE - ORDER OF APPROACH

1. Walk in → Rapid visual assessment (15 sec)
2. Introduce yourself → Let her speak (30-60 sec)
3. Ask 3 emergency screening questions (1 min)
4. Sit, calm her, take structured history (5-7 min)
5. Explain examination → Examine (5 min)
6. Reassure and explain the plan (2 min)
7. Start admission, call senior

Total time target: 15-20 minutes from arrival to admission orders written.

LANGUAGE TIPS (If Patient Speaks Local Language)

If she doesn't understand medical English, use simple phrases:

Medical Term	Simple Phrase
Rupture of membranes	"Your water bag has broken"
Gestational age	"How many months pregnant are you?"
Contractions	"Tightening pains in your tummy?"
Fetal heart	"Baby's heartbeat"
Speculum exam	"Examination inside with a small instrument"
Admission	"We need to keep you in the hospital today"

The whole approach is: Assess quickly → Ask calmly → Examine gently → Explain clearly → Admit promptly. Never rush the patient's story - she will give you the diagnosis herself most of the time.

How to assess the feral heart rate and and check the tummy

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The library doesn't have a dedicated obstetric examination chapter in indexed headings, but this is a well-established core clinical skill. I'll give you a thorough, accurate answer from standard obstetric training knowledge.

Obstetric Abdominal Examination + Fetal Heart Rate Assessment

BEFORE YOU START

Position the patient correctly:

Lie her flat on her back, one pillow under her head
Ask her to empty her bladder first (a full bladder distorts findings)
Expose the abdomen from the xiphisternum to the pubic symphysis
Keep her legs slightly bent (relaxes abdominal muscles)
Keep a sheet over the lower limbs for dignity
Stand on her right side
Warm your hands before touching

PART 1 - INSPECTION (Just Look First)

Before touching, stand back and look at the abdomen:

What to Look For	What It Means
Size of the uterus - does it look term-sized?	Correlates with gestational age
Shape - ovoid (normal) or transverse bulge?	Suggests lie of the baby
Fetal movements visible on the surface	Good sign - baby is active
Skin changes - linea nigra, striae gravidarum	Normal pregnancy signs
Scars - previous LSCS scar (Pfannenstiel scar low on abdomen)?	Important for planning delivery
Asymmetry or unusual bulges	May suggest abnormal lie

PART 2 - FUNDAL HEIGHT MEASUREMENT

Step 1 - Find the fundus (top of the uterus):

Start from the xiphisternum, press gently downward with the ulnar border of your left hand until you feel the firm top of the uterus
That is the fundus

Step 2 - Measure:

Place the zero end of the tape measure at the upper edge of the pubic symphysis
Run the tape up along the midline of the abdomen (do not follow curves - straight line)
Measure to the top of the fundus
Read in centimetres

Normal rule:

From 20 weeks onward, fundal height in cm ≈ gestational age in weeks (±2 cm)

Fundal Height Level	Approximate Weeks
At pubic symphysis	12 weeks
Halfway between pubis and umbilicus	16 weeks
At the umbilicus	20 weeks
Halfway between umbilicus and xiphisternum	28 weeks
At xiphisternum	36 weeks
Slightly below xiphisternum	40 weeks (head engages, fundus drops)

PART 3 - LEOPOLD'S MANEUVERS (The 4 Grips)

These 4 systematic hand maneuvers tell you: what is in the fundus, where the baby's back is, what is at the pelvis, and how far the head has descended.

GRIP 1 - FUNDAL GRIP

What you find: What is in the top of the uterus

How to do it:

Face the patient's head
Place both hands on the upper abdomen, fingers curling around the fundus
Feel gently - bounce the part between your hands

Feeling	What It Means
Soft, irregular, not ballotable	Breech (buttocks) in the fundus → head is down (cephalic presentation) - NORMAL
Hard, round, smooth, ballotable	Head in the fundus → baby is breech
Nothing firm	Transverse lie

GRIP 2 - LATERAL / UMBILICAL GRIP

What you find: Position of the baby's back and limbs

How to do it:

Keep facing the patient's head
Place both palms flat on each side of the abdomen at the level of the umbilicus
Apply gentle but firm pressure alternately with each hand
One side will feel: smooth, firm, continuous resistance = baby's back
Other side will feel: irregular, nodular, softer = baby's limbs (hands, feet, knees)

Why it matters: Tells you which side the back is on - you will listen for the fetal heart on the same side as the back, below the umbilicus (in cephalic presentation).

GRIP 3 - PAWLIK'S GRIP (First Pelvic Grip)

What you find: What is in the pelvis (presenting part) and if it is engaged

How to do it:

Face the patient's feet
Use your right hand only
Place thumb and fingers on either side of the lower abdomen just above the pubic symphysis
Grasp gently and try to move the presenting part from side to side

Feeling	What It Means
Round, hard, smooth, can be moved sideways (ballotable)	Head - NOT engaged (floating)
Round, hard, cannot be moved - fixed	Head - engaged
Soft, irregular	Breech presenting

Caution: This grip can be uncomfortable for the patient. Be gentle. Skip if patient is in pain.

GRIP 4 - SECOND PELVIC GRIP (Deep Pelvic Grip)

What you find: How far the head has descended into the pelvis

How to do it:

Now face the patient's feet
Place both hands flat on the lower abdomen, fingers pointing downward toward the pelvis
Slide fingers gently downward on both sides toward the pubic symphysis
Press inward and downward

Feeling	What It Means
Fingers can go deep, tips converge below the head	Head not engaged - you can feel most of the head
Fingers diverge - can't reach below the head	Head is engaged in the pelvis
Fingers cannot go down at all	Head deeply engaged

Engagement = the widest diameter of the head (biparietal diameter) has passed through the pelvic inlet. In primigravida, engagement normally occurs at 36-38 weeks. In multigravida, may not engage until labour begins.

PART 4 - UTERINE TENDERNESS

After the Leopold maneuvers, gently palpate the entire uterus:

Is the uterus soft and relaxed between contractions? (Normal)
Is there constant, board-like hardness? → Abruption
Is there focal tenderness on pressing? → Chorioamnionitis, abruption
Does the patient wince or pull away when you press? → Always document this

PART 5 - FETAL HEART RATE ASSESSMENT

Method 1 - Pinard's Fetoscope (Ear Trumpet - Traditional)

How to use:

Place the wide open end of the Pinard on the mother's abdomen
Press your ear firmly to the other (narrow) end
Remove your hands completely from the fetoscope - let it balance between your ear and the abdomen
Listen carefully - count the beats

Where to place it:

In cephalic presentation (head down) - place over the fetal back, just below the umbilicus
In breech - place above the umbilicus
The back position (from Grip 2) tells you exactly where to listen

Count:

Count beats for 1 full minute (or 15 seconds × 4)
Normal FHR: 110-160 bpm

Method 2 - Hand-Held Doppler (Sonicaid) - Most Common Now

How to use:

Apply ultrasound gel to the probe tip
Place the probe on the abdomen where you expect the fetal back (same rule as above)
Angle the probe at 45 degrees and apply gentle pressure
Move slowly until you hear the fast, rhythmic "whoosh-whoosh" sound of the fetal heart
The machine displays the heart rate digitally
Count / read for at least 1 minute

Tips to find the fetal heart faster:

Start just below and to one side of the umbilicus (depending on where the back is)
If not found, move in small circles
You may first hear the maternal pulse (~70-80 bpm) - this is slower, don't confuse it
Fetal heart sounds like a fast ticking watch or galloping horse

Normal: 110-160 bpm

Finding	What It Suggests
110-160 bpm, regular	Normal
>160 bpm (tachycardia)	Fetal distress, maternal fever, infection, drugs
<110 bpm (bradycardia)	Cord compression, severe fetal distress - EMERGENCY
Irregular rhythm	Possible arrhythmia - needs CTG
Cannot find heart beat	Reposition, try different area - if still absent, urgent ultrasound

Method 3 - CTG (Cardiotocography) - Best for PROM Patients

For a PROM patient specifically, CTG is the gold standard and should be started immediately on admission.

How to apply CTG:

Two transducers are placed on the abdomen with elastic belts:
- Tocometer (flat disc) - placed at the fundus - records contractions
- Ultrasound transducer (dome-shaped) - placed over the fetal back - records fetal heart
Apply gel under the ultrasound transducer
Ask the patient to press the button each time she feels the baby move
Run the trace for minimum 20 minutes

What to look for on the CTG trace:

Feature	Normal (Reassuring)	Non-Reassuring	Abnormal
Baseline FHR	110-160 bpm	100-109 or 161-180	<100 or >180
Variability	5-25 bpm	<5 bpm for 40-90 min	<5 bpm for >90 min
Accelerations	≥2 in 20 min (each ≥15 bpm for ≥15 sec)	No accelerations	-
Decelerations	None / early only	Late or variable	Prolonged

A normal (reactive) CTG:

Baseline 110-160
Variability ≥5 bpm
At least 2 accelerations in 20 minutes
No significant decelerations

COMPLETE SEQUENCE - WHAT TO WRITE IN NOTES

After your examination, document exactly like this:

Abdominal Examination:
- Abdomen: soft, uterus relaxed / tender
- Fundal height: ___ cm (corresponds to ___ weeks)
- Lie: Longitudinal / Transverse / Oblique
- Presentation: Cephalic / Breech
- Presenting part: Head / Breech
- Engagement: Engaged (2/5 palpable) / Not engaged (5/5 palpable)
- Fetal back: Right side / Left side
- Fetal movements: Felt / Not felt on palpation
- FHR: ___ bpm, regular, by Doppler / Pinard / CTG
- Contractions: Present (frequency ___, duration ___) / Absent

MEMORY AID - THE 4 THINGS ABDOMINAL EXAM TELLS YOU

1. SIZE     → Fundal height → gestational age
2. SITUATION → Lie (longitudinal / transverse / oblique)
3. POSITION  → Where is the back? (right / left)
4. STATION   → How far is the head down? (engaged / not engaged)

And then always finish with the fetal heart - it is never optional.

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