Grand Rounds: Ob Team Stat: Developing a better L&D rapid response team

Key Points

It's every obstetrician's nightmare: Everything is going smoothly during labor, with normal progress, a reassuring fetal heart rate (FHR) tracing, and a dilated cervix. Suddenly there's profound bradycardia, with deceleration of the FHR to the 60s. The bedside nurse administers oxygen and IV fluids, but bradycardia persists.

A pelvic exam is performed; the cervix is unchanged, the baby is in vertex presentation and cord prolapse is ruled out. A fetal scalp electrode is placed; the monitor is picking up fetal, not maternal heart rate, and the baby has been "down" for over 5 minutes.

The charge nurse calls to the ob's answering service and the ward clerk "beeps" her as well. The ob calls back within 5 minutes, and the patient is moved to the operating room. The in-house ob physician, the OR team, and the ob anesthesiologist are paged "Stat" to the OR, and the baby is delivered by cesarean section, about 8 minutes after the move to the operating room-and 20 to 25 minutes after the onset of bradycardia. The placenta shows a partial abruption. The baby has depressed Apgar scores and cord blood gas studies show metabolic acidosis with pH less than 7.00.

Dealing with obstetric emergencies

Although the vast majority of pregnancies proceed smoothly and with minimal obstetric intervention, serious obstetric emergencies occur in 1% to 2%. Situations that typically require urgent, if not emergent, medical intervention include eclampsia, hypertensive crisis, diabetic ketoacidosis, and severe asthma. Conditions prompting surgical intervention include acute fetal distress, antepartum and intrapartum hemorrhage, umbilical cord prolapse, shoulder dystocia, and uterine rupture. Both medical and surgical interventions are often needed in cases of postpartum hemorrhage and maternal cardiac arrest. Planning for obstetric emergencies is an integral part of the function of every obstetric service. Responses to these emergencies are a measure of the effectiveness of an ob unit as well. They also help determine how effective the pediatric team will be in achieving optimal neonatal outcomes.

As our opening scenario shows, the traditional response includes a series of activation steps (Table 1), beginning with recognition of the emergency situation by the bedside nurse, communication with the attending obstetrician, evaluation of the patient by the obstetrician, and then sequential recruiting/activating of the required resources for intervention.

ACOG recommends that surgery be started within 30 minutes of decision for cesarean.¹ For an institution such as ours, with an in-house obstetrician, ob anesthesiologist, and neonatal team, it's usually possible to deliver within 30 minutes using the usual "sequential activation" approach. But this response may be inadequate to prevent adverse outcomes for some types of emergencies. When fetal distress is due to acute uterine rupture and/or lacerated vasa previa, for instance, delivery must be accomplished as rapidly as possible, preferably within a few minutes.^2,3 Adverse perinatal outcomes may occur even when the baby is delivered well within 30 minutes of the event.² And during maternal cardiac arrest, delivery is recommended within 4 minutes for both maternal and fetal indications.⁴

Even the 30-minute "decision-to-incision" goal is described as being an "elusive target," with institutional series showing up to half of emergency C/S not meeting that goal.^5-7 A recent publication included "decision-to-incision" times among 2,808 C/S performed for emergency indications at 13 university medical centers of the Maternal-Fetal Medicine Units Network; 17% of these started within 10 minutes of decision, 44% within 20 minutes, and 62% within 30 minutes.⁸