What are the top 3 intrapartum delivery obstetrics (OB) emergencies that physician assistant (PA) students should learn about?

Top 3 Intrapartum Delivery OB Emergencies for PA Student Education

The three most critical intrapartum emergencies that PA students must master are: (1) postpartum hemorrhage, (2) shoulder dystocia, and (3) maternal cardiac arrest with perimortem cesarean delivery. These represent the highest-impact emergencies in terms of maternal and fetal morbidity and mortality that require immediate recognition and intervention.

1. Postpartum Hemorrhage (PPH)

PPH is the leading preventable cause of maternal mortality worldwide and demands immediate recognition with protocol-driven management. 1, 2

Prevention and Initial Management

• Administer oxytocin 5-10 IU via slow IV or IM injection at shoulder release or immediately postpartum as first-line prophylaxis 1, 2, 3
• If bleeding occurs despite oxytocin, give tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT: 276 to prevent one maternal death) 1, 2, 3
• Critical pitfall: Delaying tranexamic acid beyond 3 hours significantly reduces effectiveness 1, 2

Essential Resources and Equipment

• Have large-bore IV catheters (14-16 gauge), fluid warmers, and forced-air body warmers immediately available 4, 1
• Establish massive transfusion protocol with 1:1:1 ratio of packed red blood cells:fresh frozen plasma:platelets 1
• Maintain maternal temperature >36°C as clotting factors function poorly at lower temperatures 1

Why This Emergency Matters

PPH creates physiological challenges where the pregnant uterus becomes a vital source of blood volume during hypovolemic events, and intrinsic maternal compensatory mechanisms may trigger delivery 5. The combination of high frequency and preventable mortality makes this essential teaching content.

2. Shoulder Dystocia

Shoulder dystocia represents a time-critical emergency requiring systematic manual maneuvers to prevent permanent brachial plexus injury and neonatal hypoxic injury.

Predictive Assessment

• Systematically assess for multiparity, history of previous rapid delivery, regular painful uterine contractions, and urge to push when evaluating imminent delivery 4, 2, 3
• Position patient for McRoberts maneuver if shoulder dystocia is anticipated 2, 3
• Perform cervical examination before contacting the receiving obstetric team to optimize triage decisions 4, 3

Clinical Decision-Making

• Assess for cephalopelvic disproportion before proceeding with augmentation, which occurs in 25-30% of active phase arrest cases 2, 3
• Oxytocin augmentation is first-line treatment with 92% success rate for vaginal delivery when cephalopelvic disproportion is absent 2, 3

Why This Emergency Matters

Modern high-fidelity simulation training for shoulder dystocia has demonstrated measurable benefits in maternal and perinatal outcomes 6. The technical skills required—including classical manual maneuvers—are fundamental competencies for any provider managing deliveries 6.

3. Maternal Cardiac Arrest with Perimortem Cesarean Delivery (PMCD)

Maternal cardiac arrest requires immediate CPR with pregnancy-specific modifications and preparation for PMCD within 4 minutes to optimize both maternal and fetal outcomes. 4, 1, 2

The 4-Minute Rule

• If ROSC is not achieved after approximately 4 minutes of resuscitative efforts, PMCD should be strongly considered 4
• PMCD should be performed at bedside—do not transport to operating room during maternal cardiac arrest 4
• Shorter arrest-to-delivery time is associated with better outcomes for both mother and infant 4

Pregnancy-Specific Resuscitation Modifications

• Initiate standard ACLS protocols with continuous left uterine displacement to relieve aortocaval compression 4, 3
• Manual uterine displacement should continue throughout PMCD until fetus is delivered 4
• Critical pitfall: Failing to maintain left uterine displacement perpetuates aortocaval compression and compromises resuscitation efforts 2

Surgical Considerations

• Only a scalpel is required to begin PMCD—do not wait for surgical equipment 4
• Do not spend time on lengthy antiseptic procedures; either perform abbreviated antiseptic pour or eliminate entirely 4
• If maternal viability is not possible through fatal injury or prolonged pulselessness, begin PMCD immediately without waiting 4

Vaginal Delivery Alternative

• If cervix is fully dilated and fetal head is at appropriately low station during cardiac arrest, immediate assisted vaginal delivery can be considered 4
• This facilitates both fetal resuscitation and maternal resuscitation by relieving aortocaval compression 4

System-Level Preparedness

• Educate all staff about pregnancy-specific resuscitation modifications 1
• Ensure basic and advanced life-support equipment is immediately available in labor and delivery units 4
• Designate neonatal resuscitation team including personnel skilled in emergency neonatal endotracheal intubation 4

Why This Emergency Matters

Failure to recognize the 4-minute window for PMCD leads to poor maternal and fetal outcomes 2. Despite being rare, maternal cardiac arrest represents a catastrophic emergency where knowledge of the specific protocol directly impacts survival 4, 1. The counterintuitive nature of performing emergency cesarean delivery during active CPR makes this essential didactic content that cannot be learned adequately through clinical exposure alone.

Common Pitfalls Across All Three Emergencies

• Not having hemorrhage management resources immediately available delays critical interventions 2
• Underestimating physiological changes of pregnancy complicates airway management during emergencies 2
• Lack of standardized approaches to emergency obstetric care contributes to poor maternal outcomes 2
• Emergency obstetric training for all personnel managing deliveries is essential, as not all training is clinically effective 7