A practicing obstetriciangynecologist may be faced with

a sudden patient emergency at any time. Whether it is

severe shoulder dystocia, catastrophic surgical or obstetric
hemorrhage, or an anaphylactic reaction to an injection
in the office, it will require prompt response. Preparation
for potential emergencies requires planning. Issues to
consider include advance provisioning of resources,
establishing an early warning system, designating special-
ized first responders, and holding drills to ensure that
everyone knows what to do in an emergency. Beyond
these basics, certain principles of communication and
teamwork will increase the efficiency and effectiveness of
the emergency response.
Planning
Planning for potential emergency events is challenging.
At a minimum, it should involve an assessment of the
potential or actual risks related to the practice setting or
the patient population. For example, in the outpatient
setting, are medications given or procedures performed
that may result in anaphylaxis, airway compromise, or
hemorrhage? In the inpatient setting, unit data or risk
management data may reflect common and uncommon
emergency situations that have occurred.
Advance Provision of Resources in the
Outpatient Setting
A common practice for health carerelated emergencies
is the availability of the crash cart. All physicians should
be familiar with the crash cart. Placing all necessary items
in a known, central location ensures that time is not lost
gathering supplies in an emergency. Appropriate changes
should be made to the crash cart as evidence-based
changes are made to the Advanced Cardiac Life Support
protocol. Advance provision of resources also may be
extended, for example, to the management of eclampsia
and malignant hyperthermia. Physicians in outpatient
settings may wish to create a small kit for handling allergic
reactions if they are not able to maintain a full crash cart.
As with a crash cart, the kit must be checked regularly to
ensure that perishable supplies have not been retained
beyond expiration dates. All health care providers need to
know how to use the allergic reaction kit.
Early Warning Systems in the
Inpatient Setting
Some emergencies are truly sudden and catastrophic, such
as a ruptured aneurysm, massive pulmonary embolus, or
complete abruptio placentae in the setting of trauma.
However, many emergencies are preceded by a period
of instability during which timely intervention may help
avoid disaster. The rapid response team is set up to handle
such emergencies. However, even without the use of a
rapid response team, nurses and other bedside caregivers
need to recognize that certain changes in a patients con-
dition can indicate an emergency that requires immedi-
ate intervention. These changes include some events not
usually considered to be emergencies, such as agitation or
Preparing for Clinical Emergencies in Obstetrics
and Gynecology
ABSTRACT: Patient care emergencies may periodically occur at any time in any setting, particularly the
inpatient setting. To respond to these emergencies, it is important that obstetriciangynecologists prepare them-
selves by assessing potential emergencies that might occur, creating plans that include establishing early warning
systems, designating specialized first responders, conducting emergency drills, and debriefing staff after actual
events to identify strengths and opportunities for improvement. Having such systems in place may reduce or
prevent the severity of medical emergencies.
Committee on Patient Safety and Quality Improvement
This document reflects emerging concepts on patient safety and is subject to change. The infor-
mation should not be construed as dictating an exclusive course of treatment or procedure to
be followed.
COMMITTEE OPINION
Number 487 April 2011 (Replaces No. 353, December 2006)
The American College of Obstetricians and Gynecologists
Womens Health Care Physicians
2 Committee Opinion No. 487
new onset difficulty with movement. Ideally, each service
will examine its own historical call data to determine
which events require activation of the early warning
system. It is imperative that bedside personnel be able
to request immediate help, without recrimination, when
such changes occur. For example, the nurse who calls
the rapid response team regarding the anxious postop-
erative patient with new onset shortness of breath must
not be dismissed as failing to recognize a panic attack
but instead praised for following protocol. The protocol
should provide for a full evaluation of the problem. Some
organizations have formalized the emergency communi-
cation process using a standardized communication tool,
such as SBAR (Situation, Background, Assessment, and
Recommendation); all health care providers are encour-
aged to follow it to clearly communicate the patient care
issue. Standardized responses will increase the efficiency
of care and allow a continuous quality improvement pro-
cess to assess the effectiveness of the interventions.
Rapid Response Team
Medical emergency teams, otherwise known as rapid
response teams, are designated emergency response
teams. These teams of clinicians bring critical care exper-
tise to the patients bedside or wherever it is needed.
Activation of rapid response team intervention occurs
when predefined criteria are met, although the team
intervention also may be activated for other reasons.
Rapid response team intervention should be a no-fault
process. The team is available at all times with author-
ity to summon further help as needed. By designating
criteria that define an emergency, it becomes clear when
to call for help. For example, if a maternal or postopera-
tive heart rate of more than 140 beats per minute is the
criterion, the nurse who notes such a heart rate would
immediately call the medical emergency team. This
contrasts with the common practice of calling an attend-
ing physician and awaiting a call back for orders before
intervention. Activation of rapid response team interven-
tion before a full arrest may lead to improved survival
of hospitalized patients and decreased admissions to an
intensive care unit (1). It is important to emphasize that
if there is a teaching service, calling the house officer
does not substitute for triggering rapid response team
intervention. Similarly, calling the in-house physician
in a nonteaching setting does not substitute activating
rapid response team intervention. Rapid response teams
usually have advanced practice nurses and respiratory
therapists as first responders and are expected to respond
to the problem in a standardized fashion.
The goal of standardized response and rapid effec-
tive recognition and correction of problems is better
met with a small stable group. Development of a rapid
response system is one of the patient safety initiatives
currently being promoted by the Institute for Healthcare
Improvement (2) and the Agency for Healthcare Research
and Quality. Blueprints for setting up such a system, as
well as other resources, may be found on the web sites of
these organizations.
Establishing a rapid response system involves a mul-
tistep process (35). First, key staff must be identified for
the response team. Second, the criteria for activation of
intervention by the response team should be determined.
Third, the staff involved with the rapid response system
must be educated on their respective roles. Fourth, a
means of evaluating feedback and process improvement
must be established. Finally, the effectiveness of the rapid
response system must be monitored. The rapid response
system can be divided into four components: 1) activators,
2) responders, 3) quality improvement, and 4) admin-
istration (6).
The activators are those individuals who may acti-
vate the rapid response system. Activators may be floor
staff, a patient, a family member, specialists, or anyone
concerned about the condition of a particular patient.
Team members from the nursing staff or floor staff are
trained to monitor for disturbances in any indicators of
acute distress. These indicators are determined by the
individual medical treatment facilities.
Once the rapid response system is activated, the
responders arrive at the bedside, along with the attending
physician, to treat the patient and stabilize her condition.
Responders will then determine the disposition of the
patient. Options for this can include transfer to a higher
level of care, a handoff to the primary team (nurse or
physician or both), or revision of the current treatment
plan. Activators may become responders to help aid in
stabilizing the patients condition.
When the responders arrive, the activators must be
prepared to exchange information. A communication pro-
tocol such as SBAR may be used. Using such a protocol
allows the activators to exchange information with the
responders in a clear and concise manner. This will help
ensure that expeditious care is provided to the patient.
During the response phase, other tools may be
implemented to help facilitate care for the patient. Before
initiation of the response phase, a discussion, or brief,
should be conducted to assign essential roles, establish
expectations and climate, and anticipate outcomes and
likely contingencies. The primary purpose of the commu-
nication protocol is to develop a common understanding
of the patients issues so that a consensus for the patients
treatment plan can be reached. A team huddle, designed
to reinforce plans already in place and to assess the need
to adjust the plan, also may be used to review situational
awareness and to troubleshoot and revise the current plan
of action, if needed. A check back, time out, or call out
may be used to ensure closed-loop communication.
The quality improvement team supports activators
and responders by reviewing the events surrounding the
activation of the rapid response system and evaluating the
process. An informal information exchange, or debrief, is
designed to improve team performance and effectiveness
as part of the action review. Once the review is complete,
Committee Opinion No. 487 3
the members of the rapid response team must clearly be
defined. The criteria used to activate rapid response team
intervention also must be clearly defined and dissemi-
nated among potential activators well in advance of any
emergency. It is also important for members of the rapid
response team to receive ongoing education and training
regarding important changes in the management of any
potential emergency to ensure maximal preparedness.
The exact nature of the preparation will depend on the
work environment and the resources available.
References
1. Dacey MJ, Mirza ER, Wilcox V, Doherty M, Mello J, Boyer A,
et al. The effect of a rapid response team on major clinical
outcome measures in a community hospital. Crit Care Med
2007;35:207682.
2. Institute for Healthcare Improvement. Establish a rapid
response team. Available at: http://www.ihi.org/IHI/Topics/
CriticalCare/IntensiveCare/Changes/EstablishaRapid
ResponseTeam.htm. Retrieved December 13, 2010.
3. Mahlmeister LR. Best practices in prenatal care: the role of
rapid response teams in perinatal units. Legal issues and risk
management. J Perinat Neonatal Nurs 2006;20:2879.
4. Gosman GG, Baldisseri MR, Stein KL, Nelson TA,
Pedaline SH, Waters JH, et al. Introduction of an obstetric-
specific medical emergency team for obstetric crises: imple-
mentation and experience. Am J Obstet Gynecol 2008;
198:367.e1367.e7.
5. Clements CJ, Flohr-Rincon S, Bombard AT, Catanzarite
V. OB team stat: rapid response to obstetrical emergencies.
Nurs Womens Health 2007;11:1949.
6. Agency for Healthcare Research and Quality. TeamSTEPPS
Rapid Response Systems module: instructors materials.
Available at: http://www.ahrq.gov/teamsteppstools/rrs/
rrsinstructmod.htm. Retrieved December 13, 2010.
7. Gardner R, Raemer DB. Simulation in obstetrics and gyne-
cology. Obstet Gynecol Clin N Am 2008;35:97127, ix.
8. Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Recurrent
obstetric management mistakes identified by simulation.
Obstet Gynecol 2007;109:1295300.
the administration team then provides organizational
resources to implement improvements in the process.
Emergency Drills and Simulation
The principle that standardized care can result in safe care
applies to emergencies as well as to routine care. Thus,
each service should consider a protocol for manage-
ment of common emergencies, such as emergency cesar-
ean deliveries or postpartum hemorrhage. This training
may use a sophisticated simulated environment, but it
also may use the everyday workspace in a mock event.
Protocols also can be reinforced by being prominently
displayed as posters, pocket cards, or other aids.
Using drills to train physicians to respond to emer-
gencies has several theoretical advantages. Adult learning
theory supports the importance of experiential learning.
Emergencies occur in a specific physical setting and may
involve a group of nurses, physicians, and other health
care providers attempting to respond. By conducting
a drill in a realistic simulator or in the actual patient
care setting, issues related to the physical environment
become obvious.
Emergency drills also allow physicians and others to
practice principles of effective communication in a crisis.
Many aspects of the medical environment work against
effective communication, including the often hierarchical
hospital structure, and the nature of the training, work
setting, and the different educational backgrounds and
levels of understanding of the health care team. Many
physicians are accustomed to talking to nurses. Effective
teamwork requires talking with each other. It requires
that there be a team leader coordinating the response,
but it also should empower all members of the team to
share information. By practicing together, barriers hin-
dering communication and teamwork can be overcome.
Effective drills may lead to improved standardization of
response, health care provider satisfaction, and patient
outcomes.
Simulator training also may be beneficial with respect
to identifying common clinical errors made during emer-
gencies and correcting those deficiencies (7). Although
this is promising, there are limited data to suggest that
improved proficiency with simulation models correlates
with increased proficiency during actual emergencies (8).
Conclusion
The obstetriciangynecologist practices in an environ-
ment where true emergencies will periodically occur.
Preparation for these in-hospital situations requires that
emergency supplies be placed in locations well known
to members of the rapid response team. In addition,
Copyright April 2011 by the American College of Obstetricians and
Gynecologists, 409 12th Street, SW, PO Box 96920, Washington,
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ISSN 1074-861X
Preparing for clinical emergencies in obstetrics and gynecology.
Committee Opinion No. 487. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2011;117:10324.