The Safety Ledger: Why Labor & Delivery Needs Its Own Emergency Room
Pregnant women still get sent from one ER to another, sometimes with fatal delays. It’s time to treat L&D as what it already is: a 24/7 emergency department for two patients at once.
It was 2 a.m. during a blizzard, and I was the ObGyn resident covering the general ER. The snow outside was two feet deep; the waiting room was worse. A 12-week-pregnant woman walked in, shivering, clutching her coat.
“I want a Pap smear,” she said.
I explained, gently, that this was an emergency room, not a clinic. She sighed. “I know. But the clinic’s overcrowded, and they told me I’d have to wait three weeks. I couldn’t.”
She wasn’t bleeding, she wasn’t in pain—she was simply locked out of preventive care until desperation drove her to the ER.
Years later, another patient would arrive—24 weeks pregnant, doubled over, barely able to speak. The main ER sent her to Labor & Delivery because she was pregnant. L&D sent her back because she wasn’t in labor. Somewhere between those two doors, she went into septic shock from a ruptured appendix.
Both women had the same problem: the system couldn’t decide who they belonged to.
They were in the dead zone between two systems that both thought she belonged to the other.
The Two-Door Problem
Hospitals love boundaries.
Cardiology handles hearts. Orthopedics does bones. And labor & delivery (L&D) handles pregnancies—unless, of course, something doesn’t look like “labor.”
But medicine doesn’t always fit into neat folders. When a pregnant patient walks into an emergency room, she’s often bounced between two teams: the general ER and the L&D ER (if it exists). Some hospitals don’t even have a dedicated obstetric triage unit. Others have one but restrict who can be seen there: only patients over 20 weeks, only those with contractions, only those already registered with the hospital’s obstetric service.
So what happens to everyone else? They wait. They get shuffled. And sometimes, they get sicker.
How often do pregnant patients use the ED or L&D triage?
ED use in pregnancy is common and rising; studies report that a large share of pregnant patients have at least one ED visit during pregnancy, with some analyses noting up to ~58% using the ED at some point.
Utilization varies by insurance and access to prenatal care; Medicaid/uninsured patients have higher rates of ED use.
National samples highlight that pregnant ED users are more likely to be publicly insured and people of color, underscoring equity concerns.
Common OB-specific reasons (often evaluated in L&D/OB triage)
Labor evaluation / contractions, especially at term; “rule-out labor” is among the most frequent low-acuity presentations.
Vaginal bleeding across gestation, from implantation bleeding to placenta previa/abruption.
Leakage of fluid / suspected rupture of membranes (ROM).
Decreased fetal movement requiring assessment and fetal monitoring.
Hypertensive disorders / preeclampsia symptoms: severe headache, visual changes, RUQ/epigastric pain, edema, elevated BPs.
Hyperemesis gravidarum and persistent nausea/vomiting with dehydration.
Postpartum complications returning to ED/L&D: hemorrhage, infection/endometritis, mastitis, wound issues, headache/neurologic symptoms, hypertensive crises.
Early pregnancy–focused presentations (often start in ED, sometimes co-managed with OB)
First-trimester bleeding / pain: rule-out ectopic or early pregnancy loss; hemodynamic instability escalates to resuscitation pathways.
Hyperemesis with electrolyte disturbance, weight loss, ketonuria.
Urinary tract infection/pyelonephritis presenting with dysuria, flank pain, fever.
Non-obstetric medical emergencies during pregnancy (commonly start in the main ED, require OB collaboration)
Chest pain / dyspnea: pulmonary embolism, pneumonia, asthma, peripartum cardiomyopathy.
Neurologic symptoms: severe headache, seizure (eclampsia vs other), focal deficits.
Fever/sepsis from obstetric or non-obstetric sources.
Diabetes-related issues: hyperglycemia or DKA, especially in type 1 diabetes.
Thromboembolism suspicion (leg swelling, pain, SOB).
Non-obstetric surgical emergencies in pregnancy
Appendicitis: most common non-obstetric surgical emergency in pregnancy; incidence roughly 0.5–2 per 1,000 pregnancies (about 1 in 500–1 in 635 in some series).
Biliary disease/cholecystitis, nephrolithiasis/renal colic, bowel obstruction, and other acute abdomens.
Trauma and environmental/other presentations
Trauma: motor vehicle collisions, falls, intimate partner violence; requires maternal stabilization and fetal assessment.
Syncope, palpitations, dizziness, often overlapping with anemia or arrhythmia workups.
Psychiatric crises / substance use concerns requiring safety assessment and coordinated care.
What triage tools and guidance say
ACOG: endorses hospital-based obstetric triage to prioritize acuity and ensure timely, appropriate location of care.
AWHONN’s Maternal-Fetal Triage Index (MFTI): standardized acuity tool listing urgent scenarios such as decreased fetal movement, hypertensive symptoms, chest pain/SOB, suspected ROM, bleeding, thromboembolism, infection, and postpartum hemorrhage; also accounts for scheduled procedures and non-urgent complaints.
When Does L&D “Take Over”?
There’s no universal rule, and that’s the problem.
In many hospitals, the cutoff is 20 weeks of gestation—the point when the uterus rises above the pelvis and fetal monitoring becomes possible. But “possible” is not the same as “appropriate,” or “the safest”.
A pregnant woman with appendicitis at 24 weeks should be seen in a space where both her needs and her baby’s needs are managed simultaneously. Yet few ERs are equipped to handle obstetric monitoring, and few L&D units are trained or staffed for acute medical emergencies outside of labor.
So we rely on the crude metric of gestational age, a bureaucratic shorthand that substitutes for clinical reasoning. It’s as if someone decided that at 19 weeks and 6 days, the body is “medicine,” but at 20 weeks exactly, it becomes “obstetrics.” Something has to change.
The Case for an Obstetric Emergency Department
In many U.S. hospitals, L&D units already function as mini emergency departments—except without the title, resources, or staffing. Pregnant patients come in with chest pain, shortness of breath, bleeding, falls, trauma, fevers, headaches, or hypertension. Each could represent a life-threatening condition like pulmonary embolism, sepsis, or preeclampsia.
These are not “routine pregnancy complaints.” They are medical emergencies complicated by pregnancy. Yet most hospitals don’t treat them that way.
A true L&D Emergency Department—or “OBED”—should not be a luxury. It should be a requirement for any hospital that delivers babies.
It should have:
A dedicated obstetrician physically present 24/7.
Rapid access to anesthesiology, blood bank, and imaging.
Seamless collaboration with the main ER, surgery, and ICU teams.
Clear criteria for when a patient is managed primarily by L&D versus jointly with other services.
When that system works, lives are saved quietly every day. When it doesn’t, tragedies unfold in the space between “Who’s responsible?” and “She’s just pregnant.”
Why the Fragmentation Persists
Part of the issue is billing.
Pregnant women sent to L&D are often not “admitted” through the emergency department, so hospitals don’t get reimbursed for ER-level care. That disincentive quietly shapes triage policies more than any clinical guideline.
Another issue is training.
ER physicians receive minimal exposure to obstetric emergencies. Labor nurses may not be trained in non-obstetric triage, like chest pain or appendicitis. Each side fears making a mistake in unfamiliar territory, so both err on the side of “not it.”
Finally, there’s culture.
Obstetrics is its own world—its own language, hierarchy, and liability structure. The main ER runs differently. Collaboration requires humility and trust across professional borders, and those are not always abundant in modern healthcare.
A Better System Exists—Just Not Everywhere
Some hospitals have already fixed this.
At NewYork-Presbyterian, Texas Children’s, and several large academic centers, OB Emergency Departments operate like trauma bays for pregnant patients. Any woman with a positive pregnancy test beyond the first trimester is triaged directly to L&D, where she is evaluated by an obstetrician with backup from other specialties.
The results are striking:
Shorter wait times.
Fewer missed diagnoses.
Lower maternal morbidity.
Fewer “ping-pong” transfers between ER and L&D.
It’s not just safer—it’s smarter medicine.
Lessons for Hospitals Without an OBED
Even hospitals that can’t afford a full obstetric ED can create hybrid protocols:
Joint Triage: Every pregnant patient is first seen by an ER nurse and an L&D nurse together to decide the safest location of care.
Shared Access: ERs should have immediate access to fetal monitoring, and L&D should have protocols for stabilizing medical emergencies until internal medicine or surgery arrives.
Unified Documentation: No more double-charting or “separate” medical records. A single electronic system prevents confusion and lost data.
Standing Orders: If a patient is pregnant and shows signs of sepsis, hypertension, or bleeding, both the obstetric and medical teams are automatically activated.
These are low-cost, high-yield changes. They require coordination, not construction.
The Ethical Dimension
Every time a pregnant woman is sent to the wrong department, we are not just making a logistical mistake. We are violating a professional duty.
The Professional Responsibility Model of Obstetric Ethics emphasizes preventive ethics: anticipating foreseeable problems rather than reacting to them. It is entirely foreseeable that pregnant patients will show up sick, confused, and scared—sometimes with conditions unrelated to pregnancy but profoundly affected by it.
To send them wandering between floors in search of ownership is not just inefficient. It is unethical.
Reflection / Closing
The woman with appendicitis survived, but barely.
Her story is not rare. It’s repeated in hospitals across America, in the gaps between billing codes and service lines.
Pregnancy doesn’t pause other diseases.
And yet our hospital systems still act as if it does.
So here’s the question every hospital should ask:
If we’re proud to have a trauma center for car accidents, why don’t we have one for pregnancy?
REFERENCES
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Kearns A, Sineshaw H, Wang AY, et al. Pregnancy and Emergency Department Utilization in North Carolina, 2016-2021. PMC Open Access / Scientific Reports / Public Health. 2024; Articles. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10546499/ PubMed Central