Mind Over Mater-nal Transfer

In this section on obstetric transfers, Dr Karin Anneliese Fox, associate professor in obstetrics and gynaecology at Baylor College of Medicine (Houston, Texas, USA) and Medical Director of maternal transport at Texas Children’s Hospital discusses the important considerations for transferring critically-ill obstetric patients…

Decision To Transfer

• Safe and timely inter-hospital transfer of the peripartum patient can reduce maternal and fetal morbidity and facilitate better outcomes.
• Patients at high risk have a higher propensity for severe maternal morbidity when managed at low-acuity hospitals compared with high-acuity centres. It is therefore key to be prepared to transfer peripartum patients expediently, in order to achieve the best possible outcome.

Common Indications For Transfer

1. Maternal medical or surgical conditions – both obstetric and non-obstetric indications requiring a higher level of care than can be supported at the presenting hospital.
2. Emergency presentation or trauma at a hospital without obstetric facilities.
3. Obstetric or labour emergency.
4. Lack of availability of neonatal care services at the presenting hospital.

A recent study published from Ohio, USA, found that among 136 pregnancy-related deaths, 15 deaths identified as potentially preventable by transfer to a higher level of care, and only 5 were transported between hospitals.

Data from Maternal Transport Unit, Texas Children’s Hospital, Houston, Texas, USA. The graph demonstrates the most common causes for transportation by diagnosis. PTL – PreTerm Labour; HTN – Hypertensive disease; ICU/Med Surg – requirement for specialist bed/treatment; PPROM – preterm premature rupture of membranes

Contra-indications to maternal transfer may include the following…

• The patient’s condition is insufficiently stable for transfer and resources are available locally to deliver and stabilise prior to transfer.
• The fetus’s condition is unstable and threatening to deteriorate rapidly prior to arrival at the receiving centre.
• The birth is imminent.
• No experienced attendants are available to accompany the woman.
• Transfer is not possible due to hazardous weather or road conditions.

What is good for the baby is sometimes not good for the mother and vice versa…

• Any situation where maternal well-being or wishes contradicts fetal benefit constitutes a maternal–fetal conflict, which is a litigious term that accurately describes the medical dilemma faced when caring for pregnant patients. Advice or an ethics consult should be sought.

Preparation For Transfer

Risk Management

• A maternal transfer can be considered high risk whenever:
  • the mother’s condition is unstable
  • the time of birth is unpredictable

Pregnancy and labour status may change over time and is not always predictable

• The patient should be thoroughly assessed for the likelihood of inter-transfer delivery.
• Consider the use of tocolysis to delay delivery if it is felt appropriate by the obstetric team.
• Fetal assessment may include:
  • Doppler assessment of fetal heart rate (HR)
  • Cardiotocography (CTG) and fetal HR variability > 28 weeks. Do not use CTG monitoring for pre-viable pregnancy or during active seizure.
  • Ultrasound scan (for fetal HR, movement and breathing)
  • Fetal pH
  • Fetal fibronectin testing if appropriate
• Personnel depends on the skill mix required and may include:
  • Paramedic
  • Neonatal nurse
  • Labour nurse or midwife
  • Experienced transfer practitioner, such as an anaesthetist
  • Obstetric doctor

Remember to designate roles, including for emergency scenarios such as emergency delivery and cardiac arrest

• You may need specialist drugs, such as:
  • Drugs to manage pre-eclampsia and eclampsia (e.g. antihypertensives, magnesium sulfate, benzodiazepines)
  • Uterotonics
  • Tocolytics
  • Blood products
  • Antenatal corticosteroids and magnesium sulphate
  • Analgesia e.g. via epidural
  • Anti-emetics, pro-kinetics and antacids
• Additional equipment may be necessary:
  • Doppler
  • Equipment for emergency delivery and perimortem caesarean section
  • Forced air warming and blood warming equipment
  • Neonatal resuscitation equipment

Continuity of care is key…

• When preparing the transfer ask for all medical records including the maternal medical records, chronological notes of her admission so far, and any ultrasound images and CTG traces must be included for the receiving facility.
• Where possible and appropriate, ante-natal investigations and blood results should also be sought.

Ensure the patient has consented to transfer (if able) and the partner has been informed

Intra-Transfer Considerations

Positioning

• Aorto-caval compression during any stage of the transfer is a key concern. The enlarging uterus may compress the aorta to produce increased afterload and compress the inferior vena cava leading to decreased venous return and hypotension.
• Left lateral tilt should be used

Monitoring

• As as minimum, observations included in a maternal early warning scores should be recorded.
• Fluid balance.
• Fetal heart rate monitoring may be necessary.

Emergencies

Cardiac Arrest

• Will it be possible to divert to a nearby facility?
• Do you have a plan for perimortem caesarean section?

Onset of Active Labour

• Are uterine resuscitation, uterotonics or tocolysis required?
• Do you have equipment to assist delivery?

Uterine Resuscitation

• Judicious IV fluids
• Relief of aortocaval compression
• Supplemental oxygen

References