Disaster settings: Care of pregnant patients

INTRODUCTION — The health issues affecting pregnant women during disasters are compounded by unique reproductive needs. Care is often delivered by providers untrained in pregnancy management. This topic will discuss obstetric care during the emergency phase of a disaster.

Issues specific to gynecologic care in disaster settings and environmental health are discussed separately:

●(See "Disaster settings: Care of gynecologic problems".)

●(See "Overview of occupational and environmental risks to reproduction in females".)

●(See "Overview of occupational and environmental health".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

DEFINITION — A disaster is defined by the World Health Organization as a situation or event that overwhelms local capacity and seriously disrupts the functioning of a community or society, necessitating a request to national or international level for external assistance [1].

Disasters are typically classified into two groups, natural and man-made [2]:

●Natural disasters – Natural disasters encompass physical phenomena caused by events which can be geophysical (eg, earthquakes, landslides, tsunamis, volcanic activity); hydrological (eg, avalanches, floods); climatological (eg, extreme temperature, drought, wildfires); meteorological (eg, cyclones, storms); or biological (eg, disease epidemics, insect/animal plagues).

●Man-made disasters – Man-made disasters (also called human-made disasters) describe events that are caused by humans and occur close to or in human settlements. Such disasters may be accidental (ie, technological) or intentional (ie, terrorism). These include complex emergencies and/or conflicts, famine, displaced populations, industrial accidents, and transport accidents. Disasters may also arise out of a combination of political conflict and instability.

EPIDEMIOLOGY — Natural disasters kill on average 45,000 people per year globally, which represents approximately 0.1 percent of global deaths [3]. Population displacements have increased significantly over time, with ongoing wars and internal conflicts particularly negatively impacting the health of women and children [4].

●Impact of disaster on pregnancy outcomes – One in five women of childbearing age is pregnant in a disaster setting, and the obstetric needs of women are constant within the backdrop of the various phases of response and recovery. Studies suggest an association between disaster and poor pregnancy outcomes. Observed outcomes following disasters include early pregnancy loss, birth defects (possibly related to toxic exposure or lack of preventive measures such as folic acid supplementation), low birth weight, preterm birth, and placental abruption [5-8].

Examples include:

•Maternal and child mortality – Maternal and child mortality is reported to be 10 to 30 percent higher in humanitarian contexts compared with nondisaster settings [9]. It is estimated that 50 percent of global maternal deaths occur in conflict or disaster zones [10,11]. Pregnant women are at increased risk of maternal death because of limited or no access to prenatal care, assisted delivery, emergency obstetric care, and family planning services [12,13]. Increased rates of peripartum infection have also been reported [14]. The increased mortality rates result from a complex interplay of factors (figure 1). In a systematic review of health outcomes after floods, mortality rates in general increased up to 50 percent in the first year after the event [15]. In this study, one of the mechanisms of death was an increase in infectious diseases such as hepatitis E, gastrointestinal diseases, and leptospirosis. These diseases may also play a role in adverse pregnancy outcomes.

•Unintended pregnancy and induced abortion – Increased unintended pregnancies and unsafe abortions have been reported [12,13].

•Spontaneous abortion – Increased spontaneous abortions and birth defects have been documented following disasters, which contribute to decreased fecundity, presumably secondary to traumatic or toxic exposures [16,17].

•Preterm birth – Preterm birth rates appear to increase following disaster exposure during the index pregnancy and for years later. While the mechanism for poorer pregnancy outcomes is unclear, the intensity of the disaster experience appears to be a risk factor.

-Pregnancy during disaster event – In a prospective study of 301 pregnant women who experienced Hurricane Katrina, preterm birth increased threefold in women with high exposure compared with low exposure (preterm birth rates of 14 versus 5 percent) [18]. There was no significant difference in preterm birth for women with or without posttraumatic stress disorder or depression.

-Pregnancy years after disaster event – In a study of over 73,000 Chinese pregnant persons, exposure to the 2008 Wenchuan earthquake years before conception was associated with increased risks of adverse outcomes compared with unexposed individuals, including still birth (2.00 versus 1.33 percent), preterm birth (14.14 versus 7.32 percent), low birth weight (10.82 versus 5.76 percent), and small for gestational age (11.32 versus 9.52 percent) [19].

•Underlying medical morbidity and poor birth outcomes – A study that compared maternal and neonatal outcomes before and after the 1997 Red River flood in North Dakota reported an increase in underlying maternal medical morbidities (eg, anemia, lung disease, uterine bleeding), low birth weight, and preterm delivery following the event [17,20].

●Policy to reduce impact disaster risk – Due to rising mortality from disasters, international stakeholders, led by the United Nations Office for Disaster Risk Reduction, adopted the Sendai Framework, which is a 15-year agreement that recognizes the responsibility of states, local government, private sectors, and other stakeholders to aim for the substantial reduction of disaster risk and losses in lives, livelihoods, and health as well as in the economic, physical, social, cultural, and environmental assets of persons, businesses, communities, and countries [21].

ESTABLISHING AN OBSTETRICS FIELD HOSPITAL — During a disaster response, both basic and comprehensive emergency obstetric and newborn care must be established as soon as possible. The planning for a minimum initial service package (MISP) for managing reproductive health during crises is provided elsewhere. A systematic review of 141 articles on health emergency systems in natural disasters and human conflict identified the importance of telecommunication, coordination with other disaster responders, planning for supplies, and staff training in disaster protocols [22]. Overall planning is crucial and pertinent to the care of pregnant individuals in disasters as they make up about 20 percent of victims treated at field hospitals [23].

The MISP calculator helps workers anticipate the reproductive health needs of a population. Site-specific data on crude birthrates, contraceptive prevalence rate, sexually transmitted infection prevalence rate, and maternal mortality ratio are entered into the calculator to estimate:

●Number of currently pregnant women

●Number of births

●Complications

●Cesarean deliveries

When time allows, this information can be used to estimate need when preparing for obstetric care and for acquiring supplies during a disaster. Use of the MISP calculator helps determine estimated number of pregnant women, the anticipated number of women who will deliver or miscarry, and the resultant number of Inter-Agency Working Group (IAWG) reproductive health kits to order. That kits can only be ordered by United Nations agencies, funding systems, or nongovernmental organizations (NGOs) that have a memorandum of understanding further emphasizes the importance of providing disaster relief efforts within an established organization. Information for ordering IAWG reproductive health kits is available online. Kits are ordered per 10,000, 30,000, or 150,000 anticipated people. Regardless of the estimated need, during the disaster, a robust supply chain must be in place to ensure proper replacement of equipment, medications, and supplies.

In disasters, the facility may be fixed or erected by the medical team. The Obstetrics and Gynecology specialist should take a leadership role in assessing the availability and set-up of all necessary reproductive health care resources. In our experience, the minimum medications for an obstetric pharmacy cache include oxytocin, misoprostol, tranexamic acid, and magnesium sulfate. As clean water may not be available, an alcohol-based cleanser or similar should be included. Portable ultrasound is invaluable. When no other options are available, tarps can be hung or erected to provide some patient privacy. If the environment is unsafe (structure or environment), the pregnant patient is ideally transported to a safer zone whenever possible.

An example of human and material resources that were used to provide reproductive care to the 1.4 million women and adolescent girls during the Nepal earthquake of 2015 is presented in the table (table 1) [24].

Impact of disaster setting on pregnancy and trauma care — Disasters cause acute resource scarcity and providers must consider availability of resources to safely facilitate procedural and postprocedural care. For instance, the indications for cesarean delivery in a field hospital, with increased risk of infection and blood loss and limited ability to address complications, may be narrower and differ from traditional practices. Thus, clinicians must prioritize procedures for those who need immediate maternal life-saving interventions, followed by fetal interventions. In a disaster setting, the health and wellbeing of the mother is the primary consideration. For instance, the decision to perform a cesarean delivery for a breech presentation may be deferred in favor of cesarean deliveries only for women with abdominal trauma in which the procedure will aid maternal resuscitation. Potential contingencies and decisions such as these must be discussed before the team is deployed.

Examples of applying differing criteria to the same procedure in response to the austerity of the environment can be found in the trauma literature. In a qualitative interview of 11 women who were pregnant during Hurricane Katrina in New Orleans, Katrina disrupted pregnancy plans and led to tremendous anxiety and uncertainty [25]. However, none of these women were physically injured. Three of them safely underwent cesarean delivery, as indicated by usual obstetric criteria. For comparison, in the first two weeks after the Haitian earthquake, the United States disaster team evaluated 60 pregnant women [26]. The environment was austere; all women who delivered were homeless and living under tarps in a violent and insecure setting. There were several cases of adult and neonatal tetanus. The team delivered 12 women vaginally; the gestational ages ranged from 34 to 40 weeks. No cesarean deliveries were performed, in part because the benefit-to-risk ratio for vaginal delivery far outweighed that of cesarean delivery. In addition, successful vaginal delivery was facilitated by having an experienced obstetrician on the team and the ability to perform active labor management with oxytocin. This report also highlights the need for including a skilled obstetric provider on disaster relief teams.

Triage and response considerations — Disaster triage is the most important and, psychologically, the most difficult mission of disaster medical response in mass casualty incidents. The objective of disaster triage is to do the greatest good for the greatest number of patients. Determinants of triage in disasters are based on three parameters: severity of injury/disease, likelihood of survival, and available resources. Disaster medical triage may be conducted at three different levels depending on the level of casualties to capabilities (resources):

●Field triage – Acute (nonambulatory) versus nonacute (ambulatory). This is often the first level used in disasters.

●Medical triage – Medical triage involves a rapid (less than one minute) assessment of impacted individuals to identify life-threatening injuries, determine those with the best chance of survival, and allocate care in settings of insufficient resources. While several systems exist for this purpose (table 2 and algorithm 1A), outcomes-based data are limited [27-29]. One commonly used system is called START (Simple Triage and Rapid Assessment Treatment) and was developed by Hoag Hospital and the Newport Beach Fire Department in Newport Beach, CA (algorithm 1B).

●Evacuation triage – Often used in austere environments.

The ethical principles of nonmaleficence, beneficence, justice, and respect for autonomy form the basis for establishing health services during disaster relief [30]. During the acute phase of a disaster, timeliness is the most important response factor for saving lives and doing no harm. When triaging the distribution of limited medical supplies and resources, the principles of beneficence and justice are used to guide allocation of goods and services [31]. According to the World Medical Association (WMA) Statement on Medical Ethics in the Event of Disasters, "In selecting the patients who may be saved, the physician should consider only their medical status, and should exclude any other consideration based on nonmedical criteria" [30]. Patients whose conditions cannot be treated by the available resources may be classified as "beyond emergency care." According to WMA, "It is ethical for a physician not to persist, in treating individuals 'beyond emergency care.'" Although clinicians are expected to make every effort to begin and sustain available treatments, resource allocation requires that triage be performed initially by providers trained in triage management.

Information on different triage techniques can be found at:

●WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured – This compilation of all World Health Organization documents relative to emergency and trauma care also provides clinical guidelines for emergency care in low resource settings.

EVALUATING THE PREGNANT PATIENT — The type of disaster, phase of the disaster response, the available physical resources, availability of interpreters, and the coexisting medical and surgical conditions of the pregnant patient all impact the health care provider's ability to obtain a history, perform a physical examination, and make an assessment. To the degree possible, a safe and physically protected location is used to conduct the interview and perform the examination. Either a separate tent or a partitioned-off space will protect the woman's modesty and potentially improve trust [32]. Clinicians should be aware that in many cultures male health care providers are not allowed to examine women [33,34]. In situations where only male clinicians are present, we have found that partnering with a female health worker from the community helps increase acceptability of male providers by female patients.

History — While a complete history does not differ for pregnant and nonpregnant women, we find asking about the information below particularly helpful when assessing a pregnant, or possibly pregnant, woman in the field.

●Current complaint – Details of the main issue and review of relevant symptoms.

●Last menstrual period – All postmenarchal females are asked about the first day of their last known menstrual period (LMP) and about the regularity of menses, regardless of presenting symptom(s). Discussing menstrual frequency in relation to significant local cultural events can be helpful. If a woman is unable to determine her LMP and/or describes menstrual irregularity (menses occurring more than every six weeks), then she should be offered a pregnancy test. If no pregnancy test is available, a physical examination can be performed to estimate uterine size or the clinician can assume possible pregnancy and adjust care accordingly. (See 'Physical examination' below.)

●Pregnancy-related symptoms – We ask all women with confirmed or possible pregnancies about pregnancy-related symptoms such as amenorrhea, breast enlargement and tenderness, nausea and vomiting, increased urination, and fatigue.

●General medical history – Baseline medical conditions, particularly those that could be life threatening if untreated, such as hypertension, diabetes, and kidney disease, are identified. We also ask about anemia, malaria infection, HIV infection, hepatitis, epilepsy, and psychiatric illness, as these are often exacerbated both in pregnancy and following natural disasters [35].

●Surgical history – Obtaining information on prior uterine, tubal, and pelvic surgeries is particularly important for pregnant women.

●Medications and allergies

●Vaccination history (particularly for tetanus)

●Obstetric history – Relevant questions include the patient's total number of pregnancies, number of children (both living and dead), and route of delivery for each (vaginal versus cesarean). It is also important to ask about premature deliveries, miscarriages, ectopic pregnancies, and prior labor complications (eg, uterine rupture, placental abruption, and hemorrhage).

For women who are, or may be, pregnant, it is particularly important to ask about exposure to, or known infection with, syphilis, HIV, and genital herpes. Active HIV or genital herpes infections typically warrant a change management at the time of labor and delivery.

•(See "Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings".)

•(See "Prevention of vertical HIV transmission in resource-limited settings".)

•(See "Genital herpes simplex virus infection and pregnancy".)

●Social history – We include questions about the woman's living conditions; employment; access to clean water, food, and transportation; intimate partner violence/domestic violence; and issues for safety in her surroundings.

Physical examination — In addition to a complete physical examination of the woman, the evaluation of a pregnant woman includes a determination of uterus size to roughly estimate gestational age and assessment of fetal heart tones.

●Complete physical examination – Physical examination assesses for obvious injury, adds valuable information that contributes to overall care of the patient, and helps guide triage. Inspection and palpation of the abdomen can identify contusions, abrasions, and burns. Identification of tachycardia and hypotension should lead to left lateral uterine displacement as well as urgent placement of intravenous lines and hydration as well as evaluation for internal bleeding.

●Estimation of uterine size – The uterine size should be measured, with a measuring tape, from the pubic bone to the fundus (ie, top of the uterus) (figure 2). The size of the uterus in centimeters roughly correlates with weeks of gestational age in a normally grown pregnancy. If the uterine size exceeds the date of pregnancy, there should be concern for an expanding hemorrhage once multiple gestation has been excluded. (See "Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of gestation".)

If a measuring tape is not available to formally measure the fundal height, we use the following general rubric to estimate the weeks of gestation:

•8 to 10 weeks – The uterus is approximately the size of an orange on palpation.

•12 weeks – The uterus is palpable just above the pubis symphysis.

•16 weeks – The uterus is palpable midway between the pubis symphysis and umbilicus.

•20 weeks – The uterine fundus lies at the level of the umbilicus.

•28 weeks – The uterus is palpable midway between umbilicus and lowest rib.

•36 to 40 weeks – The uterus sits at or just below the ribs [36].

●Assessment of fetal heart tones – Fetal heart tones are audible at 10 to 12 weeks of gestation by Doppler ultrasound and at approximately 20 weeks of gestation by Pinard stethoscope. If equipment and electricity are available, continuous fetal monitoring via cardiotocography is performed on pregnant trauma patients with a live fetus and viable gestation [37]. The purpose is to assess for evidence of fetal well-being, or distress, and uterine contractions over time. (See "Overview of antepartum fetal assessment".)

Laboratory testing — Access to laboratory testing may be limited in these settings and depends, in part, on the preexisting health infrastructure of the region. In our experience, laboratory data are often limited to point of care testing (complete blood count, glucose, rapid HIV); an iSTAT device is commonly used by emergency response teams. If possible, a urine pregnancy test is performed; however, the clinician most often relies on clinical information obtained from the history and physical examination to diagnose pregnancy. Other helpful tests include a complete blood count, blood type and RhD antigen status, and screening for malaria and syphilis. If a woman is beyond 20 weeks of gestation and has a blood pressure higher than 140/90 mmHg, a urine protein dipstick is recommended to evaluate for preeclampsia. (See "Preeclampsia: Clinical features and diagnosis".)

Imaging — Imaging in austere environments is often limited to portable ultrasonography. Some response teams may be equipped with radiograph ability as well.

●Ultrasound – If available, obstetric ultrasound is performed to determine the fetal heart rate, estimate the gestational age, confirm the fetal presentation, evaluate the placenta, and exclude evidence of placental abruption, fetal injury, and intraabdominal or pelvic fluid [38]. Handheld portable ultrasounds are easy to transport and are an invaluable tool in a field hospital [39,40]. Additionally, ultrasound confirmation of a viable fetus can comfort survivors of a catastrophe. Reduced fetal movement after a disaster is common and leads to increased fear and distress among pregnant women survivors [41]. (See "Overview of ultrasound examination in obstetrics and gynecology", section on 'Obstetric sonography'.)

●Ionizing radiation – In general, imaging using ionizing radiation should be limited in pregnancy; however, preference is given to preventing diagnostic delay, especially in life-threatening situations. A missed or delayed diagnosis due to inappropriate or delayed imaging may pose a greater risk to the patient and her fetus than any hazard associated with ionizing radiation. When possible, the gravid uterus is shielded with a lead apron to minimize the radiation exposure to the fetus. If shielding is not possible, techniques for reducing the radiation dose are used, such as limiting the number of images or field of exposure. (See "Diagnostic imaging in pregnant and lactating patients".)

Documentation — History should be documented either by a paper record form or in-field electronic medical record [42]. A disaster may create unanticipated practical and logistic challenges to documentation. Organizations who have a role in managing disasters will often have a plan for managing health information documentation. Where possible, hospital facilities and existing health information systems (HIS) should be utilized [7]. Clinical information for each patient's encounter is best captured electronically, to avoid challenges with patient recall regarding medical history, privacy, and potential medical errors [43]. Electronic data capture can avoid having to piece together a patient's medical history both prior to the disaster and throughout disaster management.

●In one author's experience working with in a disaster setting with an organization without a formal HIS, the team created secure electronic patient registries that captured patient identification, diagnosis, medications, allergies, and immunizations on site. This information was readily available for all clinicians, maintained on a secure computer, and backed up nightly.

●For those using paper, we advise taking steps to prevent water and heat damage. In one author's experience, paper journals were stored in large Ziploc bags to minimize water damage.

PREGNANT WOMAN NOT IN LABOR — It is important to plan for appropriate medications and supplies to care for pregnant, laboring, and postpartum patients. The World Health Organization publishes a Model List of Essential Medicines [44]. The appendix has medications and necessary surgical equipment for cesarean sections.

Pregnant woman with trauma — The initial evaluation of pregnant trauma patients follows established trauma principles. (See "Initial evaluation and management of major trauma in pregnancy", section on 'General principles'.)

Regardless of setting (routine or disaster), factors to consider include control of active bleeding, stabilization of fractures, rapid antibiotic treatment of secondary infections, management of the airway, and management of secondary medical events such as renal failure after crush injuries. In general, pregnant women face the same type of traumatic injuries as nonpregnant women and men in disaster settings, but the anatomic changes of pregnancy increase the likelihood of abdominal trauma and somewhat alters the pattern of injury compared with nonpregnant women (eg, head trauma is less likely) [45-47]. (See "Initial evaluation and management of major trauma in pregnancy", section on 'Initial evaluation and management of major trauma'.)

In caring for the pregnant trauma patient, the primary objective is caring for the mother; the needs of the fetus are addressed once the mother is stabilized [38]. Simple interventions for fetal wellbeing that can often be initiated while the mother is being treated include left-lateral uterine displacement, volume replacement, and supplemental oxygen, if available. (See "Initial evaluation and management of major trauma in pregnancy", section on 'Pregnancy evaluation and management after initial maternal stabilization'.)

Common obstetric issues

Bleeding in pregnancy — For women who present with bleeding during pregnancy, we use the diagnostic approaches outlined in the algorithms and modify them as needed based on available laboratory and imaging resources (algorithm 2 and algorithm 3). Common causes of bleeding during pregnancy include abortion (complete, incomplete, and septic), ectopic pregnancy, molar pregnancy, placental abruption, abnormal placentation, and uterine rupture. Abortion, molar pregnancy, and ectopic pregnancy tend to occur in the first and early second trimesters (ie, up to 20 weeks), while placental abruption, bleeding from abnormal placentation (eg, placenta previa and accreta), and uterine rupture tend to occur after 20 weeks of gestation, although these are general time frames. In regions where induced abortion is restricted or illegal, patients may also present with vaginal bleeding resulting from complications related to unsterile or improperly performed abortion. If appropriate diagnostic laboratory and imaging resources are not available, the diagnosis, and thus treatment, is based on the available clinical information. For pregnant individuals with vaginal bleeding, determination of RhD antigen status and provision of anti-D immune globulin to nonsensitized RhD-negative individuals should be performed if available.

Patients may present with complications of a known early pregnancy or present with symptoms of bleeding and/or infection and then have early pregnancy diagnosed. For women who present with bleeding during pregnancy, we use the diagnostic approaches outlined in the algorithms and modify them as needed based on available laboratory and imaging resources (algorithm 2 and algorithm 3).

●Pregnancy loss – Pregnancy loss, also known as miscarriage, is a nonviable intrauterine pregnancy. When pregnancy loss occurs at 20 weeks of gestation or more, it is referred to as stillbirth. Pregnancy loss can be uncomplicated, complicated, or asymptomatic. In the setting of a disaster, clinicians should consider additional factors that may have contributed to pregnancy loss, such as trauma and toxin exposure [5,48]. A careful history and physical examination should ensue. (See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology", section on 'Terminology of pregnancy loss'.)

Pregnancy loss typically presents with heavy vaginal bleeding and uterine cramping; however, many patients may be asymptomatic. It may be further characterized as complete or incomplete and complicated or uncomplicated. If the patient presents with heavy bleeding or signs of hypovolemia, uterine evacuation is often warranted. (See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation".)

•Complete pregnancy loss – These patients may initially present with heavy bleeding and spontaneously pass pregnancy tissue. After eight weeks of gestation, the pregnancy tissue comprises the fetus, amniotic sac, placenta, and blood. Complete passage is typically associated with resolution of the bleeding. If available, ultrasound can be helpful to evaluate the uterine cavity for residual pregnancy tissue. Supportive care is generally adequate.

Gross inspection of pregnancy tissue and confirmatory visualization of both villi and gestational sac are adequate to confirm the diagnosis. This can be performed by rinsing the pregnancy tissue with warm water, then placing it in a dish of warm water. Decidual tissue will not float; conception products should float and appear white [49]. If unable to confirm completion of pregnancy loss, ultrasound should be performed to assess the uterine lining for retained products and the adnexa for ectopic pregnancy. If feasible, women can be counseled regarding a home pregnancy test two weeks after loss to ensure pregnancy resolution and minimize risk for late bleeding or infectious complications [50].

•Incomplete pregnancy loss – These patients typically present with heavy vaginal bleeding, an open cervix, and products of conception at the cervical os. If tissue is present in the cervical os, it can be gently removed using forceps, and confirmatory gross inspection of tissue should be performed (as presented in the bullet above). If there is ongoing bleeding or maternal hypovolemia (on the basis of tachycardia, orthostatic vital signs), timely uterine evacuation should be performed either with manual or vacuum aspiration to mitigate progression to hemorrhagic shock. Safe uterine evacuation consists of appropriate anesthesia using sterile equipment. If these resources are unavailable, the patient should be urgently transfer to a Comprehensive Emergency Obstetric and Newborn Care (CEmONC) facility.

Maternal volume resuscitation is a critical component of care and constitutes either intravenous, oral, or rectal hydration to compensate for blood loss. Early recognition of hemorrhagic shock is imperative, with resuscitation [51] including intravenous crystalloid delivered through two large bore intravenous lines, maternal blood products, tranexamic acid, and uterotonic medications [52].

●Ectopic pregnancy – Ectopic pregnancy is the implantation of a fertilized egg outside of the uterine cavity. While implantation in the fallopian tube is most common, it can also occur in the ovary, abdominal cavity, and cervix. Patients generally present with intermittent or persistent abdominal pain, amenorrhea followed by vaginal spotting or bleeding, nausea, vomiting, and/or dizziness. Examination may reveal abdominal tenderness, an adnexal mass, and cervical or posterior fornix tenderness. Treatment options depend on patient symptoms, hemodynamic status, and treatment modalities. A rigid or distended abdomen, scapular pain, or hypovolemic shock may be signs of rupture, which can cause life-threatening bleeding and require emergency surgery. Diagnosis and management of ectopic pregnancy are presented in detail separately; approach to management is adapted to the disaster setting and available resources.

•(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

•(See "Ectopic pregnancy: Choosing a treatment".)

●Abortion – In countries where access to abortion is legally restricted or no longer available in the disaster setting, pregnancy interruption may be performed under unsafe conditions (eg, untrained personnel, nonsterile or unsanitary equipment, use of harmful or toxic substances). Patients may present with complications, including bleeding and infection. In general, management is directed at stabilizing the patient, addressing the immediate presenting complication(s), and then completing the uterine evacuation. Patients with evidence of sepsis require immediate fluid resuscitation and intravenous antibiotic therapy.

•(See "Disaster settings: Care of gynecologic problems", section on 'Infections with or without sepsis'.)

•(See "Pregnancy loss (miscarriage): Clinical presentations, diagnosis, and initial evaluation", section on 'Septic abortion'.)

Both surgery and medication can be used for pregnancy termination. Selection is based on gestational age, patient preferences, and availability of resources. Treatment options, candidates, contraindications, and protocols are presented elsewhere.

•(See "Overview of pregnancy termination".)

•(See "First-trimester pregnancy termination: Uterine aspiration".)

•(See "First-trimester pregnancy termination: Medication abortion".)

•(See "Overview of second-trimester pregnancy termination".)

Related content on the etiology, evaluation, and management of bleeding in pregnancy are discussed in detail separately:

●(See "Evaluation and differential diagnosis of vaginal bleeding before 20 weeks of gestation".)

●(See "Pregnancy loss (miscarriage): Terminology, risk factors, and etiology".)

●(See "Ectopic pregnancy: Clinical manifestations and diagnosis".)

●(See "Hydatidiform mole: Epidemiology, clinical features, and diagnosis".)

●(See "Acute placental abruption: Pathophysiology, clinical features, diagnosis, and consequences".)

●(See "Placenta previa: Epidemiology, clinical features, diagnosis, morbidity and mortality".)

●(See "Placenta accreta spectrum: Clinical features, diagnosis, and potential consequences".)

●(See "Uterine rupture: After previous cesarean birth".)

Pregnancy-induced hypertension, preeclampsia, and eclampsia — It can be difficult to distinguish hypertension resulting from the stress of the event from gestational hypertension, which is new onset of hypertension (defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) at ≥20 weeks of gestation in the absence of proteinuria or new signs of end-organ dysfunction [53]. Repeat blood pressure checks in a relatively calm setting may facilitate making the correct diagnosis. The definitions and diagnoses of hypertensive disorders of pregnancy are discussed in detail separately. (See "Gestational hypertension", section on 'Clinical findings and diagnosis'.)

The diagnosis of preeclampsia is the same for routine and disaster settings. The diagnosis of preeclampsia should be made in a previously normotensive woman with the new onset of hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at least four hours apart) and proteinuria after 20 weeks of gestation (table 3) [53-56]. A subset of women will develop preeclampsia with severe features. Women with severe-range blood pressure can warrant treatment with antihypertensive medication. During delivery, women with preeclampsia (with or without severe features) receive magnesium sulfate, 5 g ampoule (500 mg/mL, 10 mL) given either intravenously (IV) over 20 minutes to avoid respiratory distress or by intramuscular (IM) injection, to reduce the risk of eclampsia (seizures). For IM injection, a 5 g ampoule should be given into each buttock for a total dose of 10 g.

●(See "Preeclampsia: Clinical features and diagnosis".)

●(See "Preeclampsia: Antepartum management and timing of delivery".)

●(See "Treatment of hypertension in pregnant and postpartum patients".)

Delivery is indicated for women with severe preeclampsia. Vaginal delivery is preferred if medically feasible. In selecting the delivery route, the clinician must balance the maternal and fetal conditions, gestational age, and operative as well as postoperative risks to the mother. (See "Preeclampsia: Antepartum management and timing of delivery".)

Eclampsia is diagnosed as convulsions during the third trimester of pregnancy, or within 48 hours after delivery (see "Eclampsia", section on 'Clinical findings'). Other causes of convulsions in disaster settings may be cerebral malaria, HIV-related encephalopathy, and meningitis. Regardless of seizure cause, immediate patient management includes:

●Protect the patient against injury – Place her in a recovery position and protect her airway.

●Administer magnesium sulfate, as described above.

●Provide supplemental oxygen.

●Administer antihypertensive medication for systolic blood pressure ≥160 mmHg or for diastolic blood pressure ≥110 mmHg.

●Arrange for delivery, either vaginally or by cesarean delivery.

These interventions are reviewed in detail separately. (See "Eclampsia", section on 'Management'.)

Prelabor rupture of membranes — Prelabor rupture of membranes refers to rupture of amniotic membranes prior to the onset of regular uterine contractions. This event can occur in previable, preterm, and term gestations. The differential diagnosis of fluid per vagina includes urinary incontinence, expulsion of mucous plug, and leucorrhea. For confirmation, we perform a sterile speculum examination and look for pooling fluid in the vaginal or leaking from the cervical os with Valsalva. Evaluation also involves excluding intraamniotic infection and evaluating for potential cord prolapse. (See "Preterm prelabor rupture of membranes: Clinical manifestations and diagnosis", section on 'Diagnostic evaluation and diagnosis' and "Umbilical cord prolapse".)

Inpatient admission and labor induction is recommended for women greater or equal than 34 weeks of gestation. Prior to 34 weeks, expectant management is recommended, unless there is evidence of intraamniotic infection or poor maternal/fetal status. In the presence of intraamniotic infection, IV antibiotics are administered and labor induction is advised regardless of gestational age. Induction of labor is not an emergency procedure and should be done in a CEmONC facility to allow rapid intervention in the event of complications. Detailed discussion of management approaches are presented in the following:

●(See "Prelabor rupture of membranes at term: Management".)

●(See "Preterm prelabor rupture of membranes: Clinical manifestations and diagnosis".)

●(See "Prelabor rupture of membranes before and at the limit of viability".)

Preterm labor — Preterm labor is the onset of uterine contractions contributing to cervical change prior to 37 weeks of gestation. In the setting of unstoppable preterm labor, delivery is typically rapid. Prior to delivery, we advise collecting the necessary supplies, preparing for infant warming (ie, skin-to-skin contact) and newborn resuscitation. Discussions of managing labor and delivery are presented separately. (See "Precipitous birth not occurring on a labor and delivery unit" and "Labor and delivery: Management of the normal first stage".)

In disaster settings, preterm labor can be caused by acute infectious outbreaks, abdominal trauma, and occult placental abruption. Other causative factors include pregnancy-induced hypertensive disorders, multiple pregnancy, and malnutrition. Management involves evaluating for underlying infection (eg, rapid diagnostic testing for malaria, evaluation of diarrheal disorders, and exclusion of urinary tract infections) and immediately treating identified causes. Expectant management is advised in the settings of gestational age ≥34 weeks, life-threatening maternal conditions, or intrauterine fetal death. Otherwise, administration of antenatal corticosteroids with dexamethasone IM 6 mg every 12 hours for 48 hours is advised. If chorioamnionitis is not likely and severe maternal trauma is not present, tocolytic therapy can be started, if available, for gestations less than 34 weeks of age. However, in the authors' experience, most cases of preterm labor are associated with maternal infection and/or trauma, and thus tocolytic therapy is not usually initiated.

●(See "Spontaneous preterm birth: Overview of risk factors and prognosis".)

●(See "Preterm labor: Clinical findings, diagnostic evaluation, and initial treatment".)

●(See "Inhibition of acute preterm labor".)

Limit of fetal viability — In a crisis situation, the resources available for neonatal resuscitation and support must be assessed, and the estimated age of viability may need to be considered against the risks and benefits of available interventions. As an example, the route of delivery may change from cesarean delivery to vaginal delivery if there is low expectation of neonatal survival.

The limit of viability, or periviability, is the gestational age at which there is a reasonable chance of survival after birth. With active intervention in optimal care settings, most infants born at 26 weeks of gestation and above have a high likelihood of survival in a high-income region such as North America, while virtually none below 22 weeks will survive. An as example, a cohort study of over 115,000 women and their infants born in 25 United States hospitals reported neonatal death rates ranging from 44 percent (23 weeks of gestation) to 0 percent (36 weeks of gestation) [57]. In contrast, in low- and middle-income countries (LMICs), even in nondisaster settings, neonatal survival prior to 26 weeks is less predictable. Additionally, there is limited infrastructure to support premature infants below 35 weeks in LMICs; mortality rates up to 33 percent have been reported [58,59]. (See "Periviable birth (limit of viability)".)

Intrauterine fetal death — Most patients who present with an intrauterine fetal demise will undergo induction of labor. Vaginal delivery is advised unless fetal anomalies prevent the vaginal route of birth. Induction of labor is started as soon as medically feasible and safe to limit the risk of coagulopathy that can result from prolonged exposure to a demised infant. If possible, transfer to a CEmONC facility is advised.

Medical and mental health issues — While the evaluation of medical issues in pregnancy does not differ by type of setting, the resources available during a crisis are often limited. In addition to routine issues that affect pregnancy, medical issues commonly seen in disaster settings include acute diarrhea, respiratory illness, renal failure, dehydration, hypovolemia, electrolyte abnormalities, congestive heart failure secondary to the sequelae of untreated rheumatic heart disease, tuberculosis, HIV disease, tetanus, and sequelae of gender violence. Additionally, women may present later in the disease course because of limited access to transportation and reduced availability of medical services.

●(See "Critical illness during pregnancy and the peripartum period".)

●(See "Approach to the pregnant patient with a respiratory infection".)

●(See "Approach to the adult with acute diarrhea in resource-limited settings".)

In addition to causing loss and adverse health, disaster events have significant mental health and behavioral consequences [60-64]. Psychological impacts of disasters tend to be more expansive in scope, more extended in time, and potentially more debilitating in severity than the injurious physical effects [60].

Pregnant women appear to be at risk for poor obstetric outcomes in part because of the mental health challenges that occur in disaster settings. In one study of 40 women who experienced an earthquake during pregnancy or immediately postpartum, women who were in their first trimester at the time of the event had significantly shorter gestations compared with women in later trimesters [65]. A prospective evaluation of pregnant women near ground zero during the 9/11 World Trade Center attacks had alterations in gestational length and fetal head circumference [66]. A prospective study of 171 pregnant women who were near the epicenter of a major Taiwanese earthquake reported an association between low birth weight and the loss of a spouse [67]. There is an increase in intimate partner and gender-based violence after disasters, and pregnant women are especially vulnerable to increased physical and sexual abuse [68].

Routine prenatal care — Whenever possible, we attempt to perform routine elements of maternal and fetal assessment despite the surrounding crisis setting. Normal prenatal care includes counseling about healthy diet, exercise, substance use, infections and infection prevention, and common discomforts of pregnancy, including nausea, back pain, and constipation. We also discuss fetal movements (kick counts) and potential concerning symptoms of premature labor, preeclampsia, bleeding, and fever.

Basic elements of prenatal care are outlined by the World Health Organization's Antenatal care for a positive pregnancy experience. Médecins Sans Frontières (Doctors Without Borders) has published a detailed Essential obstetric and newborn care guide for clinicians in adverse environments.

A complete discussion of prenatal care is presented separately:

●(See "Prenatal care: Initial assessment".)

●(See "Prenatal care: Second and third trimesters".)

●(See "Overview of antepartum fetal assessment".)

●(See "Decreased fetal movement: Diagnosis, evaluation, and management".)

WOMAN IN LABOR

Referral to health care facility — If possible, laboring women should be referred to an appropriate health care facility for delivery. Prior to transfer, the clinician should assess, as best as possible, the gestational age of the patient, available levels of neonatal care, and the limits of fetal viability in a specific disaster setting. (See 'Limit of fetal viability' above.)

These facilities are typically divided into Basic Emergency Obstetric and Newborn Care (BEmONC) and Comprehensive Emergency Obstetric and Newborn Care (CEmONC) units [69]:

●BEmONC – These facilities provide 24-hour access to skilled birth attendants and possible access to intramuscular (IM) and/or intravenous (IV) antibiotics, uterotonics, and anticonvulsants. Skilled services provided can include manual extraction of the placenta, uterine evacuation in case of retained placenta following delivery or miscarriage, assisted vacuum delivery, and basic neonatal resuscitation. Women who are candidates for BEmONC delivery include those who are primiparous; have a history of intrauterine fetal death, hemorrhage, or assisted vaginal delivery (forceps or vacuum); height less than 1.40 m; pelvic disproportion (such as from polio sequelae); or grand multiparity.

●CEmONC – These facilities typically serve as referral hospitals and include all the above supports and should also have providers and facilities to perform cesarean delivery and hysterectomy; perform safe blood transfusion; and provide care to sick, premature, or low birth weight newborns. Patients who benefit from delivering at a CEmONC facility include those who require cesarean delivery (eg, prior vertical uterine incision or uterine rupture) or those in whom cesarean delivery is likely (eg, obstructed labor, history of vesicovaginal fistula, prior lower uterine segment scar, or breech presentation).

Cultural considerations — If possible, the team should enlist the help of a local cultural guide to understand local customs concerning labor and delivery [70].

Labor (first stage) — The first stage of labor, including the latent and active phases, begins with the onset of regular uterine contractions that result in cervical change and ends with full dilation of the cervix [69]. In a disaster setting, the usual resources for managing the first stage of labor are often not available, which impacts the approach to care. Common modifications of labor management are discussed below, although adaptations to specific environments or cultures may be needed. Information on routine labor care is presented in detail separately. (See "Labor and delivery: Management of the normal first stage", section on 'Management of the first stage of labor'.)

In austere environments, minimal steps to ensure the safety of the mother include [69]:

●Provide protection and privacy when possible. Keep the woman comfortably warm if the environment is cold. Allow family members to be present at the bedside.

●Encourage oral hydration and monitor urine output (eg, ask the patient to perform a measured void every two hours, if possible).

●Allow the patient to move freely during labor as this can assist with fetal descent and pain management.

●Monitor pulse, blood pressure, and temperature at least every two hours. Heart rate higher than 140 beats per minute, blood pressure higher than 140/90 mmHg, and temperature higher than 38°C (100.4°F) warrant further evaluation for bleeding, hypertensive disorders of pregnancy, and infection, respectively.

●Monitor the fetal heart rate with either a Pinard stethoscope or fetal Doppler. The frequency is determined by the stage of labor. Once the woman has reached 6 cm dilation, the fetal heart rate is typically checked every 30 to 60 minutes [69,71-73]. The frequency is increased to every five minutes during the second stage of labor, at which time the clinician should listen for at least 60 seconds and include the time periods before, during, and after pushing. The normal fetal heart rate ranges from 120 to 160 beats per/minute. If the fetal heart rate is abnormal (less than 110 beats per minute or higher than 170 beats per minute), the clinician should continue to listen through the next three contractions to confirm the abnormality and then take appropriate steps to ameliorate the abnormality, if persistent, and expedite delivery. (See "Intrapartum fetal heart rate monitoring: Overview" and "Intrapartum category I, II, and III fetal heart rate tracings: Management".)

●Assess progress in labor with transvaginal examinations of cervical dilation. While the optimal frequency of such examinations is not known [74], we advise minimizing the number of examinations for both patient comfort and to reduce risk of infection from vaginal flora. Determining the onset of labor, measuring its progress, and evaluating the components that affect its course (eg, uterine contractile force, size and position of the fetus, shape of the pelvis) is imprecise. We generally assess cervical change at the following times:

•On admission

•At two- to four-hour intervals in the first stage

•Prior to administering analgesia/anesthesia

•When the patient feels the urge to push (to determine whether the cervix is fully dilated)

•At one- to two-hour intervals in the second stage

•If fetal heart rate abnormalities occur (to evaluate for complications such as cord prolapse or uterine rupture or fetal descent)

Labor abnormalities can be described as protraction disorders (ie, slower than normal progress) or arrest disorders (ie, complete cessation of progress). The assessment of normal, and abnormal labor, as well as interventions are presented in detail elsewhere. (See "Labor: Overview of normal and abnormal progression" and "Labor and delivery: Management of the normal first stage", section on 'Monitoring the progress of labor'.)

●IV access can be helpful in women with the following:

•At increased risk of uterine atony and postpartum hemorrhage, such as women with multiple gestations, prior postpartum hemorrhage, and grand multiparity.

•Known severe anemia, as these women are at increased risk of requiring blood transfusion.

•Hypertension (blood pressure >140/90). These women may require antihypertensive medication or magnesium sulfate therapy (for women with preeclampsia).

•Fever >38°C (>100.4°F) and likely need for IV antibiotics.

•Prior cesarean delivery, which increases the risk of uterine rupture.

In situations where IV access may not be possible, intraosseus infusion may be an option.

Delivery (second stage) — The second stage of labor begins with full dilation and ends with delivery of the neonate. Importantly, episiotomy should not be routinely performed as it is a risk factor for anal sphincter laceration and infection. (See "Labor and delivery: Management of the normal second stage".)

The newborn is stimulated to cry by actively drying the child, which can help with early resuscitative efforts [75,76]. Skin-to-skin contact (ie, placing the newborn directly on bare skin, usually the mother) immediately after birth should be promoted. The infant should be placed prone on the mother's chest for one hour, if possible, and covered with a warm blanket and cap. The intervention appears to help with initiation of and maintenance of breastfeeding [77]. It also assists in cardio-respiratory stability and decreases infant crying and has no apparent short- or long-term negative effects. (See "Precipitous birth not occurring on a labor and delivery unit", section on 'Newborn care and assessment'.)

Whenever possible, cord clamping is delayed to reduce the risk of neonatal anemia [78]. However, the cord can be clamped and cut immediately if neonatal resuscitation requires an untethered infant. (See "Labor and delivery: Management of the normal second stage".)

Other aspects of delivery that are altered in resource limited environments include:

●Operative vaginal delivery – Operative vaginal delivery involves use of forceps, vacuum, or other devices to extract the fetus from the vagina. Benefits include expedited delivery and avoidance of cesarean delivery. Potential procedure-related risks that can be exacerbated by the lack of resources in the field setting include neonatal complications (eg, subgaleal hemorrhage, cephalohematoma, and nerve injury) and shoulder dystocia. In addition, neonatal care providers are often of limited availability. In deciding whether to perform an operative vaginal delivery, these risks must be weighed against the risks of cesarean delivery (if available) and postoperative maternal recovery. There are no good data to guide this complex decision making. To minimize risk of harm, this technique should be performed only by experienced operators. (See "Assisted (operative) vaginal birth".)

●Symphysiotomy – Symphysiotomy, surgical incision of the pubis symphysis, can be performed to facilitate delivery in the settings of obstructed labor, shoulder dystocia, or breech entrapment when all other alternative options have been exhausted and cesarean delivery is not available. This potentially life-saving technique involves surgically incising the pubis symphysis to allow separation of the joint expansion of the pelvic diameter. The incision is performed after injection of local anesthetic and requires minimal surgical skills (figure 3). Contraindications include a demised fetus, brow presentation, incompletely dilated cervix, and severe cephalopelvic disproportion or unengaged fetal head [69]. Following delivery, the mother should rest on her side and avoid abduction for 7 to 10 days. (See "Shoulder dystocia: Intrapartum diagnosis, management, and outcome", section on 'Symphysiotomy'.)

●Cesarean delivery – Per the Medecins Sans Frontiers (Doctors Without Borders) Essential obstetric and newborn care guide, absolute indications for cesarean delivery include severe, uncontrolled antepartum hemorrhage, malpresentation that cannot be resolved with rotation, absolute feto-pelvic disproportion, uterine rupture, and three or more prior cesarean deliveries [69]. These situations, which impact 1 to 2 percent of all deliveries, are viewed as absolute because they are life-threatening for the mother. In our experience, there is tremendous pressure to expedite deliveries in the field and the team needs to be prepared resist the temptation to perform cesarean sections for nonobstetric reasons [26].

The indications and decision making for cesarean delivery may vary across disaster settings due to differences in cultural norms (ie, routine breech extractions), surgical safety, and resource availability. Prior to departure, we advise team members to discuss the approach to ethical decision making in the face of resource scarcity and the threshold for resource allocation. This conversation will help anticipate the challenges that will be encountered at the point of care [79]. Specific to cesarean delivery, the clinician must consider the risks/benefits for the mother and the infant in the given context of available resources for each. The risks to the mother should be evaluated in the short term (death, infection, thromboembolism, etc) and the medium/long term (risk of future uterine rupture, placenta previa or accreta during another pregnancy, etc). In low-resource contexts with difficult access to services and a high fertility rate, both the immediate and the longer-term risks to the mother from cesarean delivery often outweigh the potential benefits to the infant. (See "Cesarean birth: Preoperative planning and patient preparation" and "Cesarean birth: Surgical technique" and "Cesarean birth: Postoperative care, complications, and long-term sequelae".)

Resuscitative hysterotomy/perimortem cesarean delivery (PMCD) — Resuscitative hysterotomy or perimortem cesarean delivery is a rare but potentially life-saving intervention performed for pregnant individuals in extremis from massive trauma, cardiac arrest (table 4), and/or active uterine hemorrhage and is a critical component of maternal resuscitation [80]. The rationale for PMCD in maternal cardiac arrest is that 25 to 40 percent of cardiac output generated by chest compression cannot overcome the reduction of functional residual pulmonary capacity due to diaphragmatic displacement by the gravid uterus plus occlusion of the inferior vena cava. Cesarean delivery restores blood flow and respiratory capacity. For this reason, PMCD to improve outcomes in maternal cardiac arrest is only indicated for uterine sizes greater than 24 weeks. As gestational age can be difficult to assess by fundal height, the procedure should not be performed if the known or estimated gestational age is less than 20 weeks.

●Timing – PMCD should be performed within four minutes of cardiac arrest (algorithm 4) [81].

●Simultaneous CPR – CPR is continued while PMCD is being done. CPR is best performed with the patient in the supine position while another individual uses their hands to displace the uterus to the left. The compression force is 80 percent stronger supine versus left lateral while the manual displacement of the uterus increases cardiac output by 25 percent. (See "Sudden cardiac arrest and death in pregnancy", section on 'Delivery as part of the resuscitation process'.)

●Procedure and equipment – This high-stress intervention should be performed by disaster responders with prior training [82]. Emergency cesarean delivery can be performed in austere environments with limited sterility if blood products and basic surgical equipment are available. The steps of an emergency cesarean section have been well described [83]. Important additional concepts for PMCD include performing immediate cesarean without moving the patient, treatments to address a lack of sterility, and informed consent [84].

●Outcomes data – In a review 65 studies that reported on 320 cases of PMCD, maternal survival ranged from 34 to 54 percent and fetal survival ranged from 0 to 89 percent [84].

Delivery of placenta (third stage) — Third stage of labor involves delivery of the placenta and repair of perineal lacerations as needed. Gentle traction can be placed on the umbilical cord to aid delivery of the placenta, which is then followed by uterine massage to aid uterine contraction. Administration of oxytocin immediately following birth is advised to reduce the risk of postpartum hemorrhage [69]. Typical dose is oxytocin 5 to 10 international units IM or by slow IV injection. (See "Repair of perineal lacerations associated with childbirth" and "Labor and delivery: Management of the normal third stage after vaginal birth".)

POSTPARTUM WOMAN

Routine — Postpartum care, as established by the World Health Organization 2013 Recommendations on postnatal care of the mother and newborn, is provided within the first 24 hours of delivery, on the third day after delivery, and then followed by a two-week and six-week postpartum visits. A 2015 summary of the care guidelines is also available. (See "Overview of the postpartum period: Normal physiology and routine maternal care".)

When disaster strikes, mothers and infants are at high risk for injury and illness, especially if there are limited supplies. Knowledge of normal postpartum physiology, the basics of postpartum care, and potential risks during this time can help determine when there is need for intervention. Both mothers and their newborns are vulnerable during the postnatal period [85]. An estimated 65 percent of all maternal deaths occur after delivery, and almost 50 percent of these postpartum deaths occur within the first 24 hours after delivery [86]. Maternal bleeding, sepsis, and hypertensive disorders can occur after birth and up until six weeks postpartum. The first 24 hours in a baby's life are also critical. Two-thirds of infant deaths occur within the first week after birth. More than 50 percent of all infant deaths happen in the first 24 hours after birth [87].

Newborn evaluation and care is discussed separately:

●(See "Assessment of the newborn infant".)

●(See "Neonatal resuscitation in the delivery room".)

●(See "Overview of the routine management of the healthy newborn infant".)

Postpartum complications — Common maternal complications are similar for disaster and routine settings, but the limited available resources can exacerbate the risks to mother and baby during a crisis. In a disaster situation, care of women with postpartum complications can be rendered at either a basic emergency obstetric care center or, for women requiring more extensive care, at a comprehensive emergency obstetric care facility, which typically requires maternal transfer. (See 'Referral to health care facility' above.)

●Postpartum hemorrhage

•Immediate postpartum hemorrhage – Immediate postpartum hemorrhage can be caused by an incompletely contracted uterus (atony), vaginal or cervical lacerations, retained placental fragments, or, less commonly, uterine rupture, or a combination of these. The initial evaluation includes a complete rectovaginal examination to identify the source of the bleeding and then initiation of targeted treatment. A noncontracted uterus is treated with fundal massage. Cervical and vaginal lacerations are repaired. The placenta is examined to confirm it was removed intact. In cases of atony, uterotonic medications and aggressive bimanual massage are initiated, followed by medication to encourage uterine contraction and limit bleeding. (See "Overview of postpartum hemorrhage".)

The following are appropriate medications in cases of hemorrhage. Drug selection is typically initiated in the order listed, but is also guided by availability. At minimum, oxytocin is included in the United Nations Population Fund/Inter-Agency Working Group delivery kits [88].

-Oxytocin 10 mg intramuscularly (IM) or slowly intravenously (IV) 5 to 10 international units as a single dose. The drug can also be infused IV, 10 to 40 units per 500 to 1000 mL solution, at a rate to sustain uterine contraction.

-Tranexamic acid 1 g (10 mL of a 100mg/mL solution) is infused over 10 to 20 minutes, as infusion >1 mL/minute can cause hypotension. Tranexamic acid is given in addition to other medications or procedures to control bleeding.

-Methylergonovine (commercial name Methergine) 0.2 mg IM or directly into the myometrium (never IV). May repeat at two- to four-hour intervals, as needed. Repeat doses, either oral or IM, can be given at two to four hours after the prior dose, as needed. Methergine is only for women who are not hypertensive.

-Carboprost tromethamine (commercial name Hemabate) 250 mcg IM every 15 to 90 minutes, as needed, to a total cumulative dose of 2 mg (eight doses). Carboprost should be avoided in women with asthma as it can cause transient bronchoconstriction.

-Misoprostol (PGE1) is most useful for reducing blood loss in settings where injectable uterotonics are unavailable or contraindicated (eg, hypertension, asthma). Available guidelines suggest administering 600 to 1000 mcg of misoprostol by oral, sublingual, or rectal routes [89]. We use 400 mcg administered sublingually.

A detailed discussion of the management of uterine atony is presented separately. (See "Postpartum hemorrhage: Medical and minimally invasive management".)

•Delayed postpartum bleeding – Delayed postpartum bleeding, which can occur days to weeks after delivery, is more commonly caused by infection, retained products of conception, or delayed involution of the placental implantation site. Depending on the etiology, treatment options includes uterotonic medication or uterine evacuation with dilation and curettage. (See "Secondary (late) postpartum hemorrhage".)

●Fever – Common sources of fever in the postpartum period include endomyometritis, perineal infection, mastitis, urinary tract infection, pyelonephritis, and pneumonia (more common after floods or in severe weather conditions). Women who present with postpartum fever should be evaluated for each of these potential causes.

•Uterine infection – Uterine infection (endometritis or endomyometritis) typically occurs within a few days of delivery but can occur weeks later. Risk factors include cesarean delivery, retained placental fragments, manual removal of the placenta, vaginal infections, long labor and prolonged rupture of membranes, and immunocompromised status. Symptoms and signs include lower abdominal/uterine pain; enlarged uterus, which is soft and painful to touch; dilated cervix; malodorous or purulent vaginal discharge. Left untreated, this can lead to pelvic abscess and peritonitis. Clinical presentation, diagnosis, and management are presented in detail elsewhere. (See "Postpartum endometritis".)

•Perineal laceration breakdown and/or infection – Obstetric lacerations can become infected, and repaired lacerations can break down, both with and without infection. Typical presenting symptoms include pain, discharge, and, in the case of infection, fever. Other causes of perineal pain include hematoma, uterovaginal prolapse, and hemorrhoids. Physical examination is performed to elucidate the source of the symptoms. (See "Postpartum perineal care and management of complications" and "Obstetric anal sphincter injury (OASIS)".)

•Breast engorgement and/or mastitis – Breast engorgement may be normal two to four days after delivery and can last a few days. Comfort measures include wearing a tight bra, paracetamol, and applications of cold packs or ice if available. However, mastitis, which is characterized by fever, redness, pain, and, in some women, a breast lump, body aches, and malaise, should be treated to prevent abscess formation. Choice of treatment varies with infection severity and presence of risk factors for methicillin-resistant Staphylococcus aureus (MRSA) (table 5). These and other issues related to breastfeeding are discussed in detail in the related topics:

-(See "Common problems of breastfeeding and weaning".)

-(See "Lactational mastitis".)

●Hypertensive disorders – Clinical hypertension can be an acute response to stress, pain, and anxiety, but may also represent evolving preeclampsia. Signs and symptoms include elevated blood pressure, headache, visual changes, right upper abdominal pain/epigastric pain. This can lead to eclampsia or convulsions in the postpartum period. (See "Treatment of hypertension in pregnant and postpartum patients" and "Treatment of hypertension in pregnant and postpartum patients", section on 'Postpartum hypertension'.)

●Anemia – Anemia can present as weakness, fatigue, lethargy. At risk women include those with antenatal anemia, malnutrition, and hemorrhage. Treatment can consist of iron or prenatal vitamin supplements, if available, improved diet high in iron, and IV iron infusion. (See "Anemia in pregnancy".)

●Dehydration and malnutrition – (See "Etiology, clinical manifestations, and diagnosis of volume depletion in adults".)

●Psychological stress – Childbirth can be a stressful time in the best of circumstances, and in disaster settings, the stress can be extreme, influenced by injury or fear of death for herself and her newborn and loved ones; panic and separation from family (especially children); property loss; and relocation [90]. Psychological counseling to help in self-care and care of her newborn is often needed. (See "Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical features, assessment, and diagnosis".)

Breastfeeding in disaster settings — Breastfeeding should be promoted and supported in disaster settings [91,92]. Breastmilk is often the only reliable source of food for the infant during a disaster. Formula-fed infants are more susceptible to infection and diarrhea due in part to lack of protective antibodies in breastmilk [92]. In addition, clean water may not be available to make formula, bottles may not be available or clean, and formula can be contaminated. As a result, dehydration and malnutrition can develop in formula-fed infants. A child who is not exclusively breastfed for the first six months of life is more than 14 times more likely to die compared with a baby who gets breast milk only [93]. Breastfeeding is essential not only for nourishment, but also aids mother-infant bonding and reduces maternal anxiety and stress [92]. Women under stress can produce milk and many women who have weaned can reestablish breastfeeding if they desire and are appropriately supported.

Disaster relief efforts should provide new mothers with attention, coaching, and emotional support in addition to nourishment, hydration, and safe places for breastfeeding [94]. Examples of support materials for breastfeeding in disaster settings include the American Academy of Pediatricians document "Infant feeding in disasters and emergencies" and the Centers for Disease Control and Prevention (CDC) emergency preparedness checklist for breastfeeding mothers.

Detailed information on the initiation and support of breasting is presented in the following discussions:

●(See "Initiation of breastfeeding".)

●(See "Breastfeeding the preterm infant".)

●(See "Breastfeeding: Parental education and support".)

●(See "Prevention of HIV transmission during breastfeeding in resource-limited settings".)

MAINTAINING CLINICIAN READINESS

Disaster training — Physicians interested in providing care during disasters should first obtain proper training on caring for themselves and others in austere environments. Physicians should not make last minute heroic attempts to try to provide care outside of an organized incident response. Experience has shown that unorganized efforts by inexperienced providers in disasters results in ineffective medical care and can complicate organized responses when basic resources such as food and water must be diverted to "freelance" volunteers and when evacuation of these inexperienced personnel becomes necessary after they become injured or ill in the disaster zone.

Fortunately, appropriately trained disaster volunteers make up 90 percent of the disaster workforce based upon estimates by the American Red Cross (ARC) and allow the ARC to respond to nearly 70,000 disasters per year [95]. These disaster volunteers provide an invaluable service to local, national, and international communities in terms of skills, preparedness, and assistance with disaster recovery.

Successful disaster volunteers share the following traits [96]:

●Able to work in hardship positions

●Are multifunctional

●Integrate well in a camp and military-like environment

●Able to make complex and hard decisions

●Able to work cooperatively within the hierarchical structure of an organizational response

Prior to volunteering and undertaking training, the physician should carefully consider the requirements of disaster relief work. Individuals responding to disasters must understand the essential concepts of the Incident Command System [97]. Functional requirements, not titles, determine the Incident Command System hierarchy.

Additional training information is available online through the Inter-Agency Working Group (IWAG) on Reproductive Health in Crises, the American Red Cross's website, and the London School of Hygiene and Tropical Medicine. Organizations such as Doctors Without Borders, International Medical Corps, Project Hope, Habitat for Humanity, and governmental agencies in many countries also offer disaster training for individuals who enlist as future disaster responders. The United Nations Department of Safety and Security publishes BSAFE, which contains vital security information for personnel, family members, and others. Several disaster management guidelines have emerged in response to the need for best practice and safety protocols [43,98,99].

Individual preparedness — Once clinicians enlist as disaster volunteers, they may be placed on standby for disaster response as indicated by their skill sets. Deployment notification, duration of deployment, and team rotations during a disaster are specific to each disaster relief organization and specific type of disaster. Because disasters are unpredictable, deployments may occur with very short notice.

Prior to traveling to the disaster zone, the physician should ensure the sponsoring agency can provide adequate security, food, water, shelter, and communication (eg, satellite phone and, where possible, internet access) for medical workers. The agency should also have significant experience with supporting health care efforts during a disaster, be integrated into the specific disaster response, and be able to provide timely situational awareness of the disaster setting for its workers. United Nations-affiliated organizations typically provide the highest level of protection and support during disaster relief.

All disasters pose significant risks to any volunteer. These risks can be mitigated through proper preparation as follows:

●Disaster relief workers should be in good physical condition and capable of moderate-to-strenuous activity on an ongoing basis during deployment and as determined by the requirements of their position.

●Prior to departure the clinician should be up to date on all recommended travel immunizations and health screenings. Prior to departure, we advise obtaining tuberculosis screening and appropriate vaccinations such as hepatitis A and B and typhoid. Other prophylactic vaccinations or treatment depend upon the location of the disaster. Information on recommended vaccines by country and need for malaria prophylaxis are available through the United States Centers for Disease Control and Prevention's Traveler's Health webpage. Because of the higher risk for exposure, prophylaxis against HIV should be available for team members providing obstetric care.

●Individuals should pack appropriately for the environment in which they will be working. Packing lists depend upon anticipated weather and other environmental hazards. More information on disaster medical teams and preparedness can be found online. Providers should also have adequate amounts of cash (approximately USD $500 to $1,000) and a credit card for emergency expenses.

●When responding outside of their own country, the clinician must have a passport and necessary visas. They should also familiarize themselves with cultural systems and beliefs of the region to enhance their effectiveness and to avoid unnecessary conflict with local inhabitants.

Team readiness — Obstetrician/gynecology specialists are often deployed as part of a general medical team and play an essential role during the disaster response as experts in maternal and perinatal care. They are a resource for obstetric training for team members and for overseeing the implementation of emergency obstetric care during the disaster response.

Medical teams should have clear lines of authority and communication during a disaster response. Whenever possible, the organizational structure and team leadership roles within the team should be established prior to deployment. A team discussion regarding the approach to ethical decision making in the face of scarcity and the threshold for resource allocation helps anticipate the challenges that will be encountered at the point of care [79]. If possible, predeployment training in ethics and ethical decision making is invaluable [100]. Specific obstetric issues that may also benefit from predeployment discussion include the gestational age limit of viable birth and acceptable use of cesarean delivery. (See 'Limit of fetal viability' above and 'Delivery (second stage)' above.)

RESOURCES FOR PATIENTS AND CLINICIANS — The following organizations provide online resources to the public at no cost:

●United Nations – United Nations Office for Disaster Risk Reduction

●World Health Organization – WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured

●World Health Organization – Best Practice Guidelines on Emergency Surgical Care in Disaster Situations

●Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis – Resources

●Federal Emergency Management Agency (FEMA) – National Training and Education Division

●Centers for Disease Control and Prevention (CDC) – Crisis and Emergency Risk Communication (CERC) Manual

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Disaster management: Links to UpToDate resources and society guidelines".)

SUMMARY AND RECOMMENDATIONS

●Definition – A disaster is defined by the World Health Organization as a situation or event that overwhelms local capacity and seriously disrupts the functioning of a community or society, necessitating a request to the national or international level for external assistance. There are four general phases of disaster response and recovery. The obstetric needs of women are constant within the backdrop of these various phases of response and recovery. (See 'Definition' above.)

●Impact on maternal and neonatal health – Such crises are associated with increased maternal and neonatal deaths, owing to limited or no access to reproductive health services as well as to increased adverse obstetric outcomes, such as early pregnancy loss, birth defects, low birth weight, and preterm births. (See 'Epidemiology' above.)

●Clinician training for disaster response – Clinicians interested in providing care during disasters should first obtain proper training on caring for themselves and others in austere environments. Training information is available online through the American Red Cross's website and the London School of Hygiene and Tropical Medicine. (See 'Disaster training' above.)

●Evaluation of pregnant trauma patient – The evaluation of pregnant trauma patients follows established trauma principles (algorithm 1A-B). The primary objective is caring for the mother; the needs of the fetus are addressed once the mother is stabilized. Clinicians must prioritize procedures for those who need immediate maternal life-saving interventions, followed by fetal interventions. (See 'Impact of disaster setting on pregnancy and trauma care' above.)

●Common obstetric issues – Common obstetric issues that will continue to present in disaster settings include vaginal bleeding (algorithm 2 and algorithm 3), hypertensive disorders of pregnancy, prelabor rupture of membranes (which may also occur at premature gestations), and intrauterine fetal death. In a crisis situation, the resources available for neonatal resuscitation and support must be weighed in light of resource scarcity and balanced against the maternal and neonatal risks and benefits. (See 'Common obstetric issues' above.)

•Transfer of laboring patients – If possible, laboring women should be referred to an appropriate health care facility for delivery. These are typically divided into Basic Emergency Obstetric and Newborn Care and Complete Emergency Obstetric and Newborn Care units. (See 'Referral to health care facility' above.)

•Role of perimortem cesarean delivery – This rare but potentially life-saving intervention is performed for pregnant individuals in extremis from massive trauma, cardiac arrest, and/or active uterine hemorrhage or in situations where the mother has died but there is a viable fetus. PMCD should be performed within four minutes of cardiac arrest (algorithm 4); maternal CPR is continued during the surgery [81].

•Risk of maternal mortality – In crisis settings, both mothers and their newborns are extremely vulnerable during the postnatal period. An estimated 65 percent of all maternal deaths occur after delivery, and almost 50 percent of these postpartum deaths occur within the first 24 hours after delivery. (See 'Postpartum woman' above.)