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ObjectivesCharacterise the demographics, management and outcomes of obstetric patients transported by emergency medical services (EMS).DesignProspective observational study.SettingFive Indian states using a centralised EMS agency that transported 3.1 million pregnant women in 2014.ParticipantsThis study enrolled a convenience sample of 1684 women in third trimester of pregnancy calling with a ‘pregnancy-related’ problem for free-of-charge ambulance transport. Calls were deemed ‘pregnancy related’ if categorised by EMS dispatchers as ‘pregnancy’, ‘childbirth’, ‘miscarriage’ or ‘labour pains’. Interfacility transfers, patients absent on ambulance arrival and patients refusing care were excluded.Main outcome measuresEmergency medical technician (EMT) interventions, method of delivery and death.ResultsThe median age enrolled was 23 years (IQR 21–25). Women were primarily from rural or tribal areas (1550/1684 (92.0%)) and lower economic strata (1177/1684 (69.9%)). Time from initial call to hospital arrival was longer for rural/tribal compared with urban patients (66 min (IQR 51–84) vs 56 min (IQR 42–73), respectively, p<0.0001). EMTs assisted delivery in 44 women, delivering the placenta in 33/44 (75%), performing transabdominal uterine massage in 29/33 (87.9%) and administering oxytocin in none (0%). There were 1411 recorded deliveries. Most women delivered at a hospital (1212/1411 (85.9%)), however 126/1411 (8.9%) delivered at home following hospital discharge. Follow-up rates at 48 hours, 7 days and 42 days were 95.0%, 94.4% and 94.1%, respectively. Four women died, all within 48 hours. The caesarean section rate was 8.2% (116/1411). On multivariate regression analysis, women transported to private hospitals versus government primary health centres were less likely to deliver by caesarean section (OR 0.14 (0.05–0.43))ConclusionsPregnant women from vulnerable Indian populations use free-of-charge EMS for impending delivery, making it integral to the healthcare system. Future research and health system planning should focus on strengthening and expanding EMS as a component of emergency obstetric and newborn care (EmONC).

Background The rate of re-excision in breast conserving surgery (BCS) remains high, leading to delay in initiation of adjuvant therapy, increased cost, increased complications and a negative psychological impact to the patient (1-3). We initiated a phase I clinical trial to determine the feasibility of using the intraoperative MRI to assess margins in the Advanced Multimodality Image Guided Operating (AMIGO) suite. Methods All patients received contrast-enhanced 3D MRI under general anesthesia in the supine position, followed by standard breast conserving therapy with or without wire guidance and sentinel node biopsy. Additional margin re-excision was performed of suspicious margins and correlated to final pathology (Figure 1). Feasibility was assessed in two components: (1) demonstration of safety & sterility and acceptable duration of the operation and imaging, (2) adequacy of intraoperative MRI imaging for interpretation and its comparison to final pathology. Results Eight patients (mean age: 48.5), 4 with stage I breast cancer and 4 with stage II breast cancers were recruited. All patients underwent successful breast conserving therapy in the AMIGO suite with no AMIGO-specific complications or break in sterility during surgery. The mean operative time was 113 minutes [93-146]. Conclusion Our experience AMIGO suggests that it is feasible to use intraoperative MRI imaging to evaluate margin assessment in real time. Further research is required to identify modalities that will lead to reduction in re-excision in breast cancer therapy.