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Objective To describe doctors' and specialist physicians' availability to manage obstetric complications in hospitals in six provinces of Indonesia. Methods Data from a nonrandomized, quasi-experimental pre-post evaluation study were used to describe the distribution of providers by each cadre of worker and assess the availability of doctors and obstetrician/gynecologists (ob/gyns) for consultations for women experiencing postpartum hemorrhage or pre-eclampsia/eclampsia, disaggregated by hospital type, province, referral status, and by time of day of provider consultation. Results Among hospitals that should have comprehensive emergency obstetric and newborn care (CEmONC) services available 24 hours a day, 7 days a week, many did not have a doctor available to manage obstetric complications as they presented, despite there being an average of seven ob/gyns and four doctors registered for service across all facilities. Slightly over 50% of obstetric emergency cases admitted with postpartum hemorrhage and severe pre-eclampsia/eclampsia did not receive a consultation from an ob/gyn. Among the patients who received consultations, about 70% received consultations by phone or SMS. Conclusion Findings from this study indicate that persistent issues of maldistribution of maternal and newborn specialists and high absence rates of both doctors and ob/gyns at CEmONC hospitals during obstetric emergencies undermines Indonesia's efforts to reduce high maternal mortality rates.

Background Obstetric emergencies contribute significantly to maternal morbidity and mortality. Current training in the management of obstetric emergencies in Australia and internationally focusses on utilising a multidisciplinary simulation-based model. Arguments for and against this type of training exist, using both economic and clinical reasoning. Aims To identify the evidence base for the clinical impact of simulation training in obstetric emergencies and to address some of the concerns regarding appropriate delivery of obstetric emergency training in the Australian setting. Methods A literature search was performed to identify research undertaken in the area of obstetric emergency training. The initial literature search using broad search terms identified 887 articles which were then reviewed and considered for inclusion if they provided original research with a specific emphasis on the impact of training on clinical outcomes. Results Ninety-two articles were identified, comprising evidence in the following clinical situations: eclampsia, shoulder dystocia, postpartum haemorrhage, maternal collapse, cord prolapse and teamwork training. Evidence exists for a benefit in knowledge or skills gained from simulation training and for the benefit of training in small units without access to high-fidelity equipment or facilities. Conclusions Evidence exists for a positive impact of training in obstetric emergencies, although the majority of the available evidence applies to evaluation at the level of participants’ confidence, knowledge or skills rather than at the level of impact on clinical outcomes. The model of simulation-based training is an appropriate one for the Australian setting and should be further utilised in rural and remote settings.

Background The Advanced Life Support in Obstetrics (ALSO) course is an internationally recognised interprofessional course to support health professionals to develop and maintain the knowledge and skills to manage obstetric emergencies. Aims This study investigated changes in confidence and perceived changes in the knowledge of doctors and midwives to manage specific obstetric emergency situations following completion of an ALSO course in Australia. Methods A prospective repeated-measures survey design was used to survey 165 course attendees from four Australian states pre- and postcourse and at six weeks (n = 101). Data were analysed using a Friedman two-way repeated-measures analysis of variance and the Wilcoxon signed rank test. Results There was a significant improvement in confidence and perceived knowledge of the recommended management of all 17 emergency situations immediately postcourse (P < 0.001) and at six weeks postcourse (P < 0.001) when compared to precourse levels for both groups of health professionals. However, a significant decrease in knowledge and confidence for many emergency situations from immediately postcourse to six weeks postcourse (P < 0.05) was also observed in both groups. Conclusions Completion of the Australian ALSO course in Australia has a positive effect on the confidence and perceived knowledge of doctors and midwives to manage obstetric emergencies. However, there needs to be some means of reinforcing the effects of the course for longer term maintenance of knowledge and confidence.

We evaluated the effect of so-called monitoring and treatment charts on the management of eclampsia in a referral hospital in Malawi. Baseline characteristics, clinical management, as well as overall maternal and perinatal outcome were compared by reviewing the medical files of two groups, before and after introduction of the charts in 2006. The use of the charts has resulted in improved monitoring of women with eclampsia and may have contributed to the reduction in the planned prelabour caesarean section rate from 87% to 33%, as more women underwent induction of labour after stabilisation (P = 0.020). Overall maternal and perinatal outcomes were similar.

Background: The Fetal Welfare Obstetric emergency Neonatal resuscitation Training (FONT) project was initiated on a background of rising notifications of adverse events in NSW maternity units, the significant proportion of which were related to fetal welfare assessment. Aims: The aim of the study is to describe the development and introduction of the NSW state-wide interprofessional FONT project. Methods: Following development and risk assessment, FONT was launched in February 2008. The project consists of an online component and two face-to-face training days to be completed each 3 years; the first day for fetal welfare assessment and the second for obstetric and newborn emergencies. Eight, 2-day training sessions were conducted throughout NSW for FONT trainers. Each trainer underwent pre- and post-testing for changes in knowledge of fetal welfare assessment. The 2005–2008 NSW adverse event report numbers were assessed. Results: From 20 February to 17 April 2008, 240 trainers had been trained in fetal welfare assessment, and by the end of 2008 these trainers had trained 954 clinicians. There were significant improvements in the interpretation and management planning of electronic fetal heart rate patterns following training. Analysis of Severity Assessment Codes 1 and 2 showed no significant trend in the number of notifications for adverse events related to fetal welfare assessment. Conclusions: In the first 11 months, 25% of the state’s maternity practitioners had received training in the first stage of the FONT project. The FONT project has shown short-term improvements in learning and communication skills and in the participants of the project.

• Acute uterine inversion is a rare and unpredictable obstetric emergency. • Mortality and morbidity are reduced by early recognition and management. • Shock and uterine replacement must be addressed simultaneously. • The importance of teamwork cannot be overemphasised. • There is a need for skills and drills training because of the rarity of acute inversion. Learning objectives: • To understand the pathophysiology. • To understand and to be able to evaluate critically the general management principles. Ethical issues: • Management of uterine inversion is guided by a relatively small evidence base, resulting in treatment modalities being used without proper evaluation. Please cite this article as: Bhalla R, Wuntakal R, Odejinmi F, Khan RU. Acute inversion of the uterus. The Obstetrician & Gynaecologist 2009;11:13–18.

Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.

Objectives: To summarize the quantitative and qualitative immediate assessments of the Managing Obstetric Emergencies and Trauma (MOET) course and to examine the individual changes in score obtained for each of the scenarios. Methods: Students’ knowledge before and after the course was evaluated with a standardized comprehensive questionnaire. Results: All candidates showed an improvement in postcourse, compared to precourse, scores. In the individual score analysis only one scenario showed a non-significant change. The majority of other scenarios showed highly significant improvement between the two scores. Conclusion: This paper summarises the development of the first MOET course to be run outside the UK. It demonstrates the reliability of the model-based scenario foundation with a highly significant improvement in knowledge about obstetric emergency management. Further evaluation of longer term practice changes is now required.

Dystocia of the shoulder is an unpredictable obstetric emergency that may result in injury to the mother or fetus. In an effort to reduce such risks, attempts have been made to identify patients having a fetus who may subsequently develop shoulder dystocia. The literature, however, clearly reflects that even the combination of prenatal historic facts, estimated fetal weight and sequence of intrapartum events is ineffective in prospectively identifying infants whose births are complicated by shoulder dystocia. During a ten year period at the University of Mississippi Medical Center, the incidence of macrosomia, shoulder dystocia and subsequent brachial plexus injury was reviewed. The majority of instances (89 percent) of shoulder dystocia occurred in patients weighing less than 8 pounds 13 ounces at birth. In the current retrospective review, only 11 percent of the women had risk factors for macrosomia or shoulder dystocia and among these, none were identified prospectively. Additionally, 91 percent of patients with brachial plexus injury recovered with no sequelae. One instance of brachial plexus injury occurred at the time of cesarean section. These data reveal that macrosomia and subsequent shoulder dystocia cannot be predicted. Therefore, it is not feasible to prevent brachial plexus injury prospectively by prophylactic cesarean section. Great clinical acumen and technical expertise by the obstetrician using a variety of methods may be useful in avoiding, as much as possible, injury to the mother and fetus when shoulder dystocia does occur.

Over a 17-year period, 15 patients with acute puerperal inversion of the uterus were managed at the University Hospital, Kuala Lumpur, an incidence of 1 in 4,836 deliveries. Injudicious traction on the umbilical cord before the uterus was well contracted, was probably the most important causative factor. Haemorrhage was more severe when removal of the placenta was done prior to correction of the inversion. Either the hydrostatic method or manual replacement were used but more often a combination of both techniques was found necessary. With careful management of the third stage of labour, this complication can be avoided.

Summary: This paper analyses emergency obstetric calls in the Wimmera Plains over the 10-year period, 1967–1976. There were 120 calls and 39 of these were managed at the local hospitals. In a district of this type there is a place for a visiting obstetric emergency service.

Summary: A case of uniovular twin pregnancy is described in which the cord of twin 2 around the neck of twin 1 was clamped and cut soon after delivery of the head of twin 1, thereby creating an unusual obstetric emergency.

Acute inversion of the uterus is a very uncommon but potentially fatal obstetric complication. A case of acute spontaneous puerperal inversion is presented, together with a survey of data concerning this obstetric emergency.