# Situation: The nurse works in the obstetric admitting and labor unit of a provincial hospital that receives referrals from birthing facilities of rural health units (RHUs). A midwife at a birthing facility that provides basic emergency obstetric and newborn care (BEmONC) calls about four clients. All have stable vital signs. Based on the functions expected of a BEmONC facility, which client MOST needs transfer to a hospital that provides comprehensive emergency obstetric and newborn care (CEmONC)?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the obstetric admitting and labor unit of a provincial hospital that receives referrals from birthing facilities of rural health units (RHUs).

A midwife at a birthing facility that provides basic emergency obstetric and newborn care (BEmONC) calls about four clients. All have stable vital signs. Based on the functions expected of a BEmONC facility, which client MOST needs transfer to a hospital that provides comprehensive emergency obstetric and newborn care (CEmONC)?

## 보기

1. A client 4 days after birth with a temperature of 38.4 °C, foul lochia, and uterine tenderness who is alert and drinking well
2. A primigravida fully dilated for 2 hours, head at +2 station, occiput anterior, with good contractions
3. A multipara whose placenta has not separated 40 minutes after birth, with light bleeding
4. A multipara in active labor with intact membranes whose fetus is in a transverse lie **✔ 정답**

**정답: 4**

## 해설

A BEmONC facility is expected to give parenteral antibiotics, uterotonics, and anticonvulsants, remove a retained placenta manually, remove retained products, perform assisted vaginal birth, and resuscitate the newborn. A CEmONC hospital adds cesarean birth and blood transfusion. A transverse lie in active labor cannot deliver vaginally and needs cesarean birth, so this client must be referred.

## 심화 해설

Step 1 — Understand the clinical question

The question asks which client MOST needs transfer from a BEmONC facility to a CEmONC hospital. The key is to identify the intervention each client requires and then determine whether that intervention is within the BEmONC signal functions or requires the additional capabilities of CEmONC.

The defining difference between BEmONC and CEmONC is that CEmONC adds the capacity to perform cesarean birth and blood transfusion. If a client needs either of those two interventions, transfer is required.

Step 2 — Compare each option against BEmONC signal functions

| Client | Clinical picture | Required intervention | Available at BEmONC? | Needs CEmONC transfer? |
| --- | --- | --- | --- | --- |
| 1 | 4 days postpartum, fever 38.4 °C, foul lochia, uterine tenderness, alert and drinking | Parenteral antibiotics for postpartum endometritis | Yes — parenteral antibiotics are a BEmONC signal function | No |
| 2 | Primigravida, fully dilated for 2 hours, head at +2 station, occiput anterior, good contractions | Assisted vaginal birth (vacuum or forceps) if second stage is prolonged | Yes — assisted vaginal birth is a BEmONC signal function | No |
| 3 | Multipara, placenta not separated 40 minutes after birth, light bleeding | Manual removal of retained placenta | Yes — manual removal of placenta is a BEmONC signal function | No |
| 4 | Multipara in active labor, intact membranes, fetus in transverse lie | Cesarean birth — transverse lie cannot deliver vaginally | No — cesarean birth is only available at CEmONC | Yes |

Step 3 — Why the transverse lie is the priority for transfer

A transverse lie means the fetal long axis is perpendicular to the maternal long axis. In active labor with intact membranes, the fetus cannot engage in the pelvis and cannot rotate into a longitudinal lie. Vaginal delivery is impossible with a transverse lie in active labor; the only safe route of birth is cesarean section.

If labor is allowed to continue, the membranes may rupture spontaneously, leading to cord prolapse, shoulder presentation, or uterine rupture — all of which are life-threatening for both the mother and fetus. Because a BEmONC facility cannot perform cesarean birth, this client must be referred to a CEmONC hospital before rupture of membranes or advanced labor occurs.

Watch out! The other three clients are stable and their needs — antibiotics, assisted vaginal birth, and manual placental removal — are all within the BEmONC scope. Do not transfer them unnecessarily.

Key point! Any condition requiring cesarean birth or blood transfusion automatically exceeds BEmONC capacity and mandates referral to CEmONC. Transverse lie in active labor is a classic example of such a condition.

Step 4 — Why the other options stay at BEmONC

Client 1 has findings consistent with postpartum endometritis. She is hemodynamically stable, alert, and tolerating oral intake. The first-line treatment is parenteral broad-spectrum antibiotics, which is one of the seven BEmONC signal functions. Transfer is not indicated unless she deteriorates or fails to respond.

Client 2 is a primigravida who has been fully dilated for 2 hours. In a primigravida, the second stage may normally last up to 3 hours with regional anesthesia or 2 hours without. The fetal head is at +2 station with occiput anterior position and good contractions, meaning descent is progressing. If intervention becomes necessary, assisted vaginal birth (vacuum or forceps) can be performed at a BEmONC facility.

Client 3 has a retained placenta at 40 minutes postpartum with only light bleeding. The standard management is manual removal of the placenta, which is a BEmONC signal function. The light bleeding suggests the uterus is contracting adequately and the client is not in hemorrhagic shock. Blood transfusion is not currently indicated.

Step 5 — Link to EmONC service delivery evidence

The EmONC framework is built around signal functions — a set of life-saving interventions that define the level of care a facility can provide. BEmONC facilities are expected to perform seven signal functions: administer parenteral antibiotics, administer parenteral uterotonics, administer parenteral anticonvulsants, manually remove the placenta, remove retained products of conception, perform assisted vaginal birth, and perform neonatal resuscitation [1]. CEmONC facilities perform all BEmONC signal functions plus cesarean birth and blood transfusion [2].

In resource-limited and referral-challenged settings, the gap between BEmONC and CEmONC capacity is a major driver of maternal and neonatal mortality. Studies from Indonesia and Ethiopia emphasize that facility readiness and the actual availability of signal functions — not just their presence on paper — determine whether a BEmONC facility can safely manage an obstetric emergency [1][3]. In conflict-affected and rural settings, referral delays and transport barriers further increase the risk when a client who needs cesarean birth remains at a BEmONC facility [2][4].

This is precisely why the transverse lie client is the priority for transfer. Delaying referral until membranes rupture or labor becomes obstructed converts a controlled situation into an obstetric emergency with far worse outcomes. Early recognition that cesarean birth is required — and immediate referral before complications develop — is the core clinical decision in this scenario.References (research sources)

- [1]Assessing basic Emergency Obstetric and Neonatal Care (BEmONC) service provision in community health centers: a mixed-methods study from Jember, Indonesia.Research articleWijaya MC, Yuen CM, Gilbert HN, Prasetyo B, Nanwani S, Nurfaizi A, Good BJ. (2026) · DOI: 10.1186/s12913-026-14794-7

- [2]Provision of emergency obstetric care at secondary level in a conflict setting in a rural area of Afghanistan - is the hospital fulfilling its role?Research articleLagrou D, Zachariah R, Bissell K, Van Overloop C, Nasim M, Wagma HN (2018) · DOI: 10.1186/s13031-018-0137-1

- [3]Quality of comprehensive emergency obstetric and newborn care services and associated factors among mothers with obstetric emergencies in public hospitals of west shoa zone, central Ethiopia: A cross-sectional study design.Research articleDamme TG, Abeya SG, Demissie DB. (2026) · DOI: 10.1177/20503121261449066

- [4]Emergency obstetric and newborn care in conflict-affected Somalia: rural access inequities, referral barriers, and health-system priorities - a policy and practice review.Research articleHassan AM, Hussein AM, Siyad AO. (2026) · DOI: 10.3389/fgwh.2026.1914864

## 임상 시나리오

BEmONC vs CEmONC Referral DecisionWhich client must be transferred for cesarean birth
The defining difference between BEmONC and CEmONC is that CEmONC adds cesarean birth and blood transfusion. Any client needing these interventions must be referred.

A fetus in transverse lie during active labor cannot deliver vaginally and requires cesarean birth, which is available only at a CEmONC facility.

Postpartum endometritis is managed with parenteral antibiotics, prolonged second stage with assisted vaginal birth, and retained placenta with manual removal—all are BEmONC signal functions and do not require transfer.

CautionDo not delay transfer for a transverse lie in active labor; intact membranes do not make vaginal delivery possible, and rupture may lead to cord prolapse or obstructed labor.

## 핵심 개념

- **BEmONC** — Basic Emergency Obstetric and Newborn Care; includes parenteral antibiotics, uterotonics, anticonvulsants, manual removal of placenta, removal of retained products, assisted vaginal birth, and newborn resuscitation.
- **CEmONC** — Comprehensive Emergency Obstetric and Newborn Care; includes all BEmONC functions plus cesarean birth and blood transfusion.
- **Transverse lie** — Fetal long axis is perpendicular to the maternal long axis; vaginal delivery is not possible and cesarean birth is required.
- **Assisted vaginal birth** — Use of vacuum or forceps to facilitate vaginal delivery; a BEmONC signal function.
- **Retained placenta** — Placenta not delivered within 30 minutes after birth; managed by manual removal, a BEmONC function.

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