A fetal heart rate suddenly deteriorates.
A patient hemorrhages.
A woman with hypertension has a seizure.
Everyone runs.
The obstetrician arrives. An emergency cesarean is performed. Blood is ordered. Anesthesia responds. The neonatal team begins resuscitation.
Later, when the case is reviewed, everyone asks the obvious question:
What happened during those final minutes?
Sometimes that is the wrong question.
The more important question may be:
What happened during the hours, days, or even weeks before the emergency?
That is where some of the most important failures in obstetric care occur.
