Maternal Transport

Maternal Transport

Susan Drummond

Determining the Need for Maternal Transport

An essential component of any perinatal care system is the capability of providing interhospital transport of pregnant women and neonates.1 Maternal transport refers to the process of transferring the pregnant woman under the supervision of skilled medical personnel from a level I or level II institution (referring hospitals) to a level III institution (receiving hospital). Each situation is considered individually. The transfer can be accomplished by private vehicle, ambulance, rotary-wing aircraft (RWA) (helicopter), or fixed-wing aircraft (FWA). The decision regarding the type of vehicle depends on the condition of the pregnant woman and fetus as well as distance and travel time. It is a decision that should be shared jointly by the referring care provider and flight personnel or receiving physician.

Over the last few decades, the transport of the premature or sick newborns to intensive care units of regional centers after birth has become widely accepted. These babies are often referred to as outborn neonates, in distinction to those born within the referral hospital (i.e., inborn neonates). The survival rates and quality of life for the high-risk neonate have improved significantly. However, neonates born to women transported prior to birth have better survival rates and decreased risks of long-term complications than those transferred following birth.1 A recent meta-analysis shows that very low–birth-weight (VLBW) infants born at non level III hospitals have higher odds of death during the neonatal period or prior to hospital discharge compared to infants born at level III hospitals.2 Morbidity and/or mortality are decreased by delivering an infant in a facility that has the equipment, staffing, and resources appropriate for optimal care.3,4,5

Transport of the neonate involves not only the availability of a local neonatal intensive care unit (NICU), but also the complication risk during transport, the need for highly skilled personnel and specialized equipment, and the expense of the transport. In utero transport of selected risk pregnancies is strongly recommended. Therefore, when possible, the primary emphasis should always be on prenatal diagnosis and subsequent maternal transfer. Even with advanced training and technologies, women usually make the best transport incubator.6 Transport within regionalized perinatal care networks allows for benefits of high-technology maternity and fetal/neonatal care and services, while presumably reducing costs and decreasing duplication of services within a region. Perinatal outreach education has been shown to be an effective strategy to promote transfer of pregnant mothers so that VLBW infants are born at level III centers.7

Interfacility transport also benefits the woman. An increase in the prevalence of high-risk conditions such as hypertension, diabetes, obesity, and abnormal placentation has contributed to a recent rise in maternal morbidity and mortality.8 Over the past 20 years, the U. S. pregnancy-associated mortality ratio has doubled to 14.3 per 100,000.9 In one study, transport of women with pregnancy complications to an appropriate facility has resulted in a reduction of maternal mortality.10

Advantages include several considerations:

  • If the baby is transferred in utero, the need for sophisticated equipment and the risk of neonatal problems during transport are reduced. Advanced testing and treatment at the center enable a more accurate assessment of when and how to deliver the baby.

  • Advanced therapeutic techniques can be provided for the high-risk woman.

  • If an ill or severely preterm baby is delivered, immediate steps can be taken to stabilize and treat the newborn without losing precious time during transport.

  • The hospital stay of the woman and her newborn tends to be shorter, resulting in a reduction of hospital costs.

  • Finally, maternal transport ensures that the woman and newborn are together during the first few days after birth. This provides the opportunity for the woman and newborn to become acquainted and attached to each other in the unique process of bonding.

Probably the greatest concern in transferring the undelivered woman to a regional center is the physical separation from family and friends. If possible, a family member should accompany the woman
or follow in a car at the time of transport. The woman and/or her newborn, after receiving specialized care at a referral center, may be back transported (returned) to the original referring hospital for continuing care after the complications that required the transfer have been resolved. This may result in a decreased amount of time that the woman and newborn are separated from family and community.

NOTE: The referring nursing staff and transport personnel must help to reduce the disruption and stress for the pregnant woman and her family during transfer. Create a quiet private place to explain to the expectant woman and her family why the transfer is necessary and exactly how it is going to take place. Stress any positive aspect of the clinical situation (e.g., the baby is doing well presently).

The rate of admissions to NICUs increases with a maternal transport system. A great percentage of these newborns have extremely low birth weights. In the past, these babies did not survive. They require special care, which is met in tertiary care centers that have established maternal–fetal medicine programs. Resource management to maximize efficiency, effectiveness, and safety is essential.1

Timing of Maternal Transport

Transport of the undelivered woman to a regional center should be considered in the following situations:

  • It is anticipated that the newborn might require intensive care not available at the referring hospital.

  • The obstetric, medical, or surgical needs of the woman require diagnosis, treatment, and care using highly specialized equipment, skills, and staff not available at the referring hospital.

When possible, referral should be made while the woman and fetus are in a stable condition and birth is not expected to occur within a reasonable time frame that transport could occur. This presents a low risk for transferring the woman and fetus. It is optimum, of course, to refer early enough to allow beginning assessment and treatment at the receiving hospital, thus preventing a crisis situation for either woman or fetus when they reach the receiving hospital. Transport team members should be selected from appropriately trained, licensed healthcare providers.1

High-reliability perinatal units promote clinical practices based on nationally recognized guidelines and espouse a team philosophy of “safety first.” One feature of such perinatal units is that “patients are transferred in a timely and reliable way” to facilities that can care for all potential problems rather than operating on the hope “that the disaster will not occur.”11 (Behavioral scientists define high-reliability organizations as those with “the ability to operate technologically complex systems essentially without error over long periods.”11) “Hope” is never a “plan.”

Transfer of patients in early labor is recommended in the following circumstances:

  • Time for transport will take less than 2 hours.

  • The woman’s condition is stable.

  • Birth is not anticipated for 4 to 6 hours.

  • A professional attendant, such as a nurse, physician, or trained emergency medical technician, can accompany the woman.

High-risk transport situations include the following:

  • The woman’s condition is unstable.

  • Time of birth is unpredictable.

In high-risk transport situations, the decision as to whether the woman is stable enough for transport and who should accompany the woman should be made by the perinatal specialist and transport team experienced in such decision-making.

NOTE: Maternal transport might be contraindicated in women who are too unstable at the time of the transport request. For example, a woman in premature labor who is dilated beyond 5 cm should be evaluated carefully. Decisions depend on the makeup of the transport team, distance, and time. Safety of the woman and the fetus is the primary consideration. It may be advisable to have the newborn transport team dispatched prior to an anticipated high-risk birth so that this highly skilled team can provide immediate resuscitation and stabilization to the newborn.

Other contraindications may include women with the following:

  • Actively bleeding placenta previa

  • Abruptio placentae

  • Unstable fetal condition

Remember: Critical factors in successful maternal transport are appropriate treatment of the mother before transport and attendance by skilled personnel.

Conditions Requiring Transport to a Regional Center

The majority of maternal transports will be carried out because of concern for a potentially compromised fetus. Prematurity remains the predominant cause of neonatal morbidity and mortality. In 2010, preterm births represented 12% of all births in the United States. Although the rate of preterm births increased approximately 30% from 1981 to 2006, in 2007 this trend began to reverse. The U. S. preterm birth rate decreased for the fourth consecutive year in 2010.12 The downward trend is continuing. In 2013, preterm births represented 11.4% of births, although the range among the states was 8.1% to 16.6%.13 Preterm infants also constitute approximately 75% of neonatal mortalities. Statistics from selected regional centers indicate uniformly better outcomes for in utero fetal transport (i.e., the mortality risk for fetuses transported in utero is approximately half that of newborns transported after birth).

Other conditions that may require the woman to be transported to a regional center for high-risk care are outlined as follows.14,15,16

Obstetric Complications

  • Preterm premature rupture of membranes occurring before 34 weeks’ gestation or with a fetus estimated to weigh less than 2,000 g. (For additional information on management and complications of preterm premature rupture of membranes, refer to Module 10.)

    NOTE: Management varies with gestational age. At 34 weeks’ gestation or greater, birth is recommended for all women with ruptured membranes.16 A vaginal/rectal culture for group B streptococcus (GBS) should be obtained using a sterile cotton-tipped applicator on women when presenting with preterm premature rupture of membranes. Infection with GBS is responsible for serious neonatal morbidity and mortality.17 See Module 12 for GBS discussion.

  • Any condition in which the probability exists for the birth of an infant less than 34 weeks’ gestation or weighing less than 2,000 g, such as the following:

    • Preeclampsia with severe features or other hypertensive complications

    • Certain anticipated multiple births (e.g., discordancy, higher-order multiples)

    • Poorly controlled or severe diabetes mellitus

    • Intrauterine growth restriction

    • Some women with third trimester bleeding

    • Rh isoimmunization

    • Severe oligohydramnios

    • A woman at high risk for hemorrhage (e.g., placenta accreta or >3 previous C/S) as many community hospitals do not have a blood bank supply to respond to such an emergency

Maternal Medical Complications

  • Infection or sepsis

  • Severe organic heart disease

  • Acute or chronic renal failure

  • Drug overdose

  • Some women with carcinoma

  • Morbid obesity

  • Uncontrolled diabetes mellitus or diabetic ketoacidosis

Maternal Surgical Complications

  • Trauma requiring intensive care or surgery beyond the capabilities of local facilities or where the procedure can result in the onset of premature labor

  • Acute abdominal emergencies at less than 34 weeks’ gestation or with a fetus estimated to weigh less than 2,000 g

  • Thoracic emergencies requiring intensive care or surgical correction

Fetal Complications

  • Fetal congenital anomalies diagnosed by ultrasound can dictate the need for maternal transport so that the newborn can be cared for immediately following birth by the appropriate neonatal services specific for the condition (e.g., gastroschisis, cardiac defects).

NOTE: Transfer from a level II institution should be considered for the following:

  • Any fetus anticipated to require long-term ventilation support after birth.

  • Any fetus anticipated to require neonatal care at less than 28 to 34 weeks’ gestation. (This will depend on the skilled personnel and advanced technology of the institution.18)

  • Suspected genetic or congenital disorder requiring further evaluation.18

The need to transfer to a higher level of care may not be anticipated before birth.

After birth, many babies are cyanotic, often peripherally. Typically, cyanotic babies have the following characteristics19:

  • Premature, have experienced a difficult birth or ingested meconium, or had premature rupture of membranes

  • Marked respiratory distress

  • Radiographic evidence of lung disease

  • Elevated PCO2 levels

  • PO2 increases with 100% oxygen

On the other hand, a newborn with an unknown cardiac abnormality usually has the following characteristics19:

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Jul 10, 2020 | Posted by in NURSING | Comments Off on Maternal Transport

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