Precipitous and difficult deliveries

Emergency Delivery

Despite the majority of US births occurring in hospitals and under the direct care of obstetricians, there is a subset of patients who will deliver imminently in the emergency department (ED). ED physicians must be skillfully trained to manage both uncomplicated and complicated delivery scenarios. An ED delivery may require resuscitation of both mother and infant, so supplies should be readily available and all necessary consultants and support staff should be involved to ensure the best outcome. Most births are uncomplicated and require no significant additional interventions but ED staff must be prepared for these more complicated scenarios.

Precipitous Delivery Masquerading as Biliary Colic in the Setting of Depo-Provera® Failure

Precipitous delivery in the emergency department is a high-acuity, low-occurrence event that requires rapid recognition and interdepartment cooperation to prevent fetal and maternal morbidity and mortality. Prompt recognition of the peripartum state can be delayed by reported usage of long-acting contraception and concurrent distracting complaints. In this case report, a young female presented to the emergency department with epigastric abdominal pain in the setting of recent workup for biliary colic and multiple doses of long-acting, depot contraceptive agents. Early utilization of bedside ultrasound confirmed a full-term, intrauterine pregnancy as well as an impacted gallbladder stone, followed by a precipitous footling breech presentation that required an emergent cesarean section.

Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States

IMPORTANCE

Hospital-based obstetric services have decreased in rural US counties, but whether this has been associated with changes in birth location and outcomes is unknown.

OBJECTIVE

To examine the relationship between loss of hospital-based obstetric services and location of childbirth and birth outcomes in rural counties.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study, using county-level regression models in an annual interrupted time series approach. Births occurring from 2004 to 2014 in rural US counties were identified using birth certificates linked to American Hospital Association Annual Surveys. Participants included 4 941 387 births in all 1086 rural counties with hospital-based obstetric services in 2004.

EXPOSURES

Loss of hospital-based obstetric services in the county of maternal residence, stratified by adjacency to urban areas.

MAIN OUTCOMES AND MEASURES

Primary outcomes were county rates of (1) out-of-hospital births; (2) births in hospitals without obstetric units; and (3) preterm births (<37 weeks' gestation).

RESULTS

Between 2004 and 2014, 179 rural counties lost hospital-based obstetric services. Of the 4 941 387 births studied, the mean (SD) maternal age was 26.2 (5.8) years. A mean (SD) of 75.9% (23.2%) of women who gave birth were non-Hispanic white, and 49.7% (15.6%) were college graduates. Rural counties not adjacent to urban areas that lost hospital-based obstetric services had significant increases in out-of-hospital births (0.70 percentage points [95% CI, 0.30 to 1.10]); births in a hospital without an obstetric unit (3.06 percentage points [95% CI, 2.66 to 3.46]); and preterm births (0.67 percentage points [95% CI, 0.02 to 1.33]), in the year after loss of services, compared with those with continual obstetric services. Rural counties adjacent to urban areas that lost hospital-based obstetric services also had significant increases in births in a hospital without obstetric services (1.80 percentage points [95% CI, 1.55 to 2.05]) in the year after loss of services, compared with those with continual obstetric services, and this was followed by a decreasing trend (-0.19 percentage points per year [95% CI, -0.25 to -0.14]).

CONCLUSIONS AND RELEVANCE

In rural US counties not adjacent to urban areas, loss of hospital-based obstetric services, compared with counties with continual services, was associated with increases in out-of-hospital and preterm births and births in hospitals without obstetric units in the following year; the latter also occurred in urban-adjacent counties. These findings may inform planning and policy regarding rural obstetric services.

Clinical significance of precipitous labor

Background

Precipitous labor is defined as expulsion of the fetus within less than 3 hours of commencement of regular contractions. We retrospectively examined our cases of precipitous labor to identify the clinical significance and perinatal outcomes following precipitous labor in singleton vertex deliveries.

Methods

A retrospective population-based study was conducted comparing women with singleton precipitous labor and those with labor of normal duration. We examined the clinical characteristics and outcomes by comparing patients with precipitous labor and those with labor of normal duration in 0 and two-parous singleton pregnant women.

Results

Using a multivariate analysis, precipitous labor in nulliparous women was independently associated with teenagers (adjusted OR: 1.71, 95% CI: 0.99 - 2.95, P = 0.049), preterm delivery (adjusted OR: 1.77, 95% CI: 1.16 - 2.70, P < 0.01) and hypertensive disorders (adjusted OR: 1.77, 95% CI: 1.19 - 2.65, P < 0.01), while in two-parous women, it was independently associated with hypertensive disorders (adjusted OR: 2.64, 95% CI: 1.33 - 5.24, P < 0.01). No significant differences were noted between the two groups regarding maternal or neonatal complications on both nulliparous and two-parous women.

Conclusion

Although precipitous labor was associated with hypertensive disorders in singleton vertex deliveries, it was not associated with maternal or neonatal outcomes.