What are the new guidelines for managing obstetric emergencies during the golden hour?

Golden Hour Management in Obstetric Emergencies

The "golden hour" in obstetric emergencies refers to the critical first 60 minutes requiring immediate, systematic interventions focused on maternal stabilization, with specific protocols for cardiopulmonary resuscitation, hemorrhage control, and emergency delivery when indicated.

Maternal Cardiac Arrest: The 4-Minute Rule

If maternal cardiac arrest occurs, circulation must be restored within 4 minutes before proceeding to perimortem cesarean delivery. 1

• Initiate standard ACLS protocols immediately upon cardiac arrest 1
• Maintain continuous left uterine displacement throughout resuscitation to relieve aortocaval compression 1
• Begin hysterotomy if maternal circulation is not restored within 4 minutes of arrest 1
• Do not delay perimortem cesarean delivery beyond this 4-minute window, as maternal and fetal outcomes deteriorate rapidly 1

Critical pitfall: The most common error is delaying perimortem cesarean delivery beyond 4 minutes while continuing futile resuscitation efforts 1

Postpartum Hemorrhage Management

Prevention (First-Line)

• Administer 5-10 IU of oxytocin via slow IV or intramuscular injection at the time of shoulder release or immediately postpartum to reduce hemorrhage incidence 2
• This applies to all deliveries, including those occurring outside specialized maternity facilities 2

Active Treatment

Administer 1 gram of tranexamic acid intravenously within 1-3 hours of bleeding onset to reduce maternal mortality. 2

• The WOMAN trial demonstrated reduced bleeding-related mortality (1.5% vs 1.9%, RR 0.81) when tranexamic acid was given within 3 hours of diagnosis, with a number needed to treat of 276 2
• Manual removal of the placenta should NOT be performed routinely to prevent hemorrhage, except in cases of severe, uncontrollable bleeding 2

Amniotic Fluid Embolism: Checklist-Based Approach

Use a cognitive aid checklist for AFE management, as this rare emergency (1.9-6.1 per 100,000 births) has a case fatality rate exceeding 50% in classic presentations. 2

• Focus on the "ABC" principle: airway, breathing, and circulation support 2
• The differential diagnosis includes pulmonary embolism, myocardial infarction, air embolism, high spinal block, and sepsis—all requiring similar initial stabilization 2
• Keep the checklist concise and immediately accessible in the labor and delivery unit 2

Imminent Delivery Assessment

Predictive Clinical Signs

When evaluating for imminent delivery, systematically assess: 2

• Multiparity (previous pregnancies)
• History of previous rapid or non-hospital delivery
• Regular, painful uterine contractions
• Urge to push

Pre-Hospital Management

• If qualified medical staff (physician or midwife) are present and imminent delivery is suspected, perform cervical examination before contacting the receiving obstetric team to optimize patient triage (transfer vs. on-site delivery) 2
• Keep the option available to rapidly position the patient supine for the McRoberts maneuver: hyperflexion of the mother's legs tightly to her abdomen, allowing lowering of the fetal head in the umbilical-coccygeal axis 2
• Do NOT perform routine episiotomy outside specialized structures solely to reduce anal sphincter injury risk 2

Severe Pre-Eclampsia in the Golden Hour

Coordinate immediately with emergency services to discuss antihypertensive treatment and magnesium sulfate administration. 3

• Maintain strict fluid balance limited to 60-80 mL/hour during labor in preeclamptic patients to prevent pulmonary edema 1
• Direct contact should be established between the on-call obstetrician and emergency medical services team with clear documentation 3

Anesthetic Management During Emergencies

Neuraxial Catheter Placement

Insert a neuraxial catheter early for anticipated difficult deliveries or obstructed labor to avoid the need for general anesthesia during a crisis. 1, 4

• Neuraxial techniques should be selected over general anesthesia for most cesarean deliveries, including urgent cases, unless specific contraindications exist (profound fetal bradycardia, ruptured uterus) 1, 4
• Use dilute concentrations of local anesthetics with opioids to produce minimal motor block 4

Aspiration Prophylaxis

• Administer non-particulate antacids, H₂ receptor antagonists, and/or metoclopramide before all surgical procedures 1
• Uncomplicated laboring patients may consume modest amounts of clear liquids, but solid foods must be avoided 1
• Clear liquids are permitted up to 2 hours before anesthesia induction for elective cesarean delivery 1

Vasopressor Management

• Phenylephrine is the first-line vasopressor for neuraxial anesthesia-induced hypotension, unless maternal bradycardia is present 1

Airway Management: Critical Pitfalls

Do not underestimate the physiological changes of pregnancy that complicate airway management during emergency cesarean delivery. 1, 4

• Have a preformulated difficult airway strategy in place: immediate mask ventilation with cricoid pressure or supraglottic airway device if intubation fails 1
• Create a surgical airway if ventilation is impossible 1
• Basic and advanced life-support equipment must be immediately available in the operative area, including pulse oximeter, qualitative carbon dioxide detector, and basic airway management equipment 1, 4

Obstructed Labor Management

Initial Assessment

• Assess for cephalopelvic disproportion (CPD) before proceeding with augmentation, which occurs in 25-30% of active phase arrest cases 4
• For active phase arrest without CPD evidence, oxytocin augmentation should be first-line treatment (92% success rate for vaginal delivery) 4

Impacted Fetal Head During Cesarean

• Consider reverse breech extraction for impacted fetal head during cesarean delivery, which may be associated with improved Apgar scores and reduced NICU admissions 4

Communication and Coordination Protocols

Establish direct contact between the on-call obstetrician and emergency medical services team for all potential obstetric emergencies. 3

• Provide clear communication and documentation of all advice given 3
• For threatened premature labor, make medicalization of inter-hospital transfers on a case-by-case basis rather than as routine protocol 3
• Perform immediate evaluation and systematic obstetrical examination for patients reporting imminent delivery, severe pre-eclampsia symptoms, or trauma to identify signs predictive of fetal morbidity 3

Common pitfall: Underestimating the urgency of obstetric complaints results in delayed care for time-sensitive conditions—prioritize thorough evaluation and documentation 3