eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Delivery: Follow-up

Author: Thomas E Benzoni, DO, Medical Director of Mercy Air Care; Consulting Staff, Department of Emergency Medicine, Mercy Medical Center; Member, Board of Directors, Iowa Medical Society
Contributor Information and Disclosures

Updated: Oct 21, 2009

Follow-up

Transfer

• A specific body of law governs transfer of patients in labor. It is too large to review here. Please see the article on COBRA Laws and EMTALA. The original statute was passed as a part of a much larger bill, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Consequently, the acronym COBRA was used frequently in medical literature when referring to the statute. This statute is also titled the Emergency Medical Treatment and Active Labor Act (EMTALA). Since the latter name is more specific and descriptive, it has become the preferred acronym for referring to the statute. The full text of the statute can be found in any public library's reference section under 42 U.S.C.A. Section 1395dd et seq.³
• When it is deemed necessary to transfer a patient in labor because of anticipated risks to the neonate, it is generally best to transport her before delivery. This will normally give the neonate the optimal environment pending arrival at the facility that has the needed equipment and personnel available.
• Stabilization must be achieved. Labor should usually be arrested (eg, terbutaline, magnesium sulfate, ritodrine). Care is coordinated with the receiving facility and physician.

Complications

• Several items, including the umbilical cord and placenta previa, can be felt at initial vaginal examination.
  • Umbilical cord compression: Have someone insert a sterile gloved hand into the vagina, into the cervix, and against the pelvic wall, while maintaining space between the index and middle fingers for the cord to pass uncompressed. This individual should accompany the patient and stay in this position until the operating surgeon or obstetrician directs otherwise.
  • Placenta previa: Copious vaginal bleeding usually heralds placenta previa. The mother may be aware of this condition prior to admittance to the ED. Do not perform a vaginal examination in a patient who is bleeding vaginally and in labor. Order an immediate ultrasonography, type and cross-match blood, and alert a surgeon and an obstetrician.
• Stillbirth may occasionally occur; despite everyone's best efforts, a child may be born without signs of life.
  • Psychological support for the parents is mandatory. Grieving occurs, with all of its potential for pathologic processes.
  • If available, a clergyperson should visit the parents.
  • Recommend a support group to the parents.

Prognosis

Childbirth is a natural process.

Patient Education

• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Labor Signs.

Miscellaneous

Medicolegal Pitfalls

• Volumes have been written about the legal problems of those in obstetrics. However, the vast majority of this information does not apply to the emergency department. The emergency physician only should be concerned with delivering care commensurate with that of any reasonable emergency physician.
• As emergency medicine has become a national asset, it is likely that those who hold themselves out as emergency care providers (regardless of their degree or training) will likely be held to the standard of care of an emergency physician.
• Much concern is expressed regarding the use and interpretation of fetal monitor strips. Be aware of the following issues:
  • If sufficient time exists to use a fetal monitor, enough time exists to transport the mother to the obstetrics ward and/or to administer a tocolytic.
  • The use of fetal monitoring is a classic example of the application of technology based on an absolute dearth of information or proof that it makes any difference. Therefore, the American College of Obstetrics and Gynecology does not recommend the routine use of fetal monitoring.⁴

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