Transport of the Critically Ill Obstetric Patient




INTRODUCTION



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The broad framework of regionalization is based on the notion that sophisticated perinatal care should be available to every patient within a designated region, even if it is not specifically available at each hospital within the region. The level of care provided within individual hospitals is determined by the availability of technology, skilled nursing and medical personnel, and other related support services. Thus, when transport becomes necessary, its purpose is to match a patient to the level of technology and support she and her baby need.




INDICATION FOR MATERNAL TRANSPORT



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Maternal transport to a tertiary facility should be considered when the facility at which a patient is located does not have the capacity to manage actual or anticipated complications of either mother or child. Low analyzed 463 maternal transports in the United States over a 6-month period, noting prematurity as the primary reason for transport in 330 (71%) cases, hemorrhage in 79 (17%), pregnancy induced hypertension in 41 (9%), and eclampsia in 8 (2%). In a study done by the author, acute maternal medical complications were the indication for transport in 360 of 1541 (23.4%) maternal patients transported in Arizona over an 18-month period. Fifty-two percent had hypertensive crises, 36% had hemorrhage, 6% were trauma victims, and 3% had respiratory compromise.




OBSTETRIC INTENSIVE CARE DURING TRANSPORT



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In general, critical care obstetric patients should be stabilized at the referring hospital prior to transport. Hypertensive emergencies such as severe preeclampsia should be treated with magnesium sulphate to stabilize the neuromuscular irritability that can progress to eclamptic seizures. In addition, diastolic hypertension should be lowered to 100 to 105 mm Hg by cautious administration of intravenous hydralazine or labetalol. Third trimester bleeding due to placenta previa or abruptio placentae can cause hypovolemic shock and disseminated intravascular coagulopathy (DIC). The estimated blood loss should be replaced with crystalloid solutions such as normal saline or lactated Ringer solution in a 3:1 ratio (3 mL of crystalloid for each milliliter of blood loss). Because maternal intravascular volume increases by about 50% during pregnancy, signs and symptoms of shock may not be apparent until blood loss approaches 2000 to 2500 mL. Magnesium sulfate may also be used as a tocolytic. DIC is treated with blood component therapy (see Chapter 2). During transport, left-side recumbent positioning should be utilized to optimize uteroplacental function, as described later. Table 19-1 illustrates an example of typical maternal transport standing orders.




TABLE 19-1Maternal Transport Standing Orders






































Premature labor and/or rupture of membranes (PROM), multiple pregnancy, abnormal presentations

Prior to transport




  1. Assess blood pressure (BP), temperature, pulse, respiratory rate, and fetal heart tones.



  2. Assess contractions (frequency, duration, quality), status of membranes; time of PROM (if applicable), color, and how PROM was confirmed. If membranes intact, may perform vaginal examination as needed. If PROM, do not do digital examination.



  3. Administer medications as ordered by obstetric transport director.



  4. Start IV (if absent) with 18 or 16 g catheter; 1000 mL LR at 50-150 mL/h. Fluid restrict, when necessary.



  5. Left/right lateral uterine displacement.



  6. Record above data, obtain consent for transport, and obtain copies of the patient’s chart.



  7. Assess maternal/fetal condition and call maternal-fetal physician, if necessary, for consultation and further orders.



  8. Help facility prepare for birth, if imminent; notify dispatch if neonatal transport team is needed.



During transport




  1. Vital signs with fetal heart tones q15min.



  2. Administer tocolytics and other medicines, prn.



  3. Record above information.



  4. Explain procedures to patient and family; reassure patient.



Emergency medications




  • Terbutaline: 0.25 mg SQ when contraction frequency is more than q10min, providing there are no contraindications such as maternal heart disease, maternal diabetes mellitus, shortness of breath, tachycardia, or heavy maternal bleeding. May repeat every 1/2 to 1 h if pulse <120.



  • Meperidine: 25-50 mg IVP for labor pain. May repeat every hour. Observe pulse and BP closely. For other causes of pain, speak with medical director before administering.



  • Magnesium sulfate: IVPB 40 g/1000 mL LR. Bolus 6 g over 10-15 min. Follow with 3 g/h via infusion pump to suppress contractions—adjust as needed. Note: 6 g bolus diluted to not greater than 10% solution. May use 100 mL bag of LR or NS for MgSO4 bolus.



  • Antidote for magnesium toxicity: Calcium gluconate l g, slow IV push, over 3 min. Observe BP closely.



  • Continually assess urine output, deep tendon reflexes, and respiratory rate/effort.


Preeclampsia/eclampsia

Prior to transport




  1. Assess vital signs, fetal heart tones, and deep tendon reflexes.



  2. Assess contractions (frequency, duration, quality), status of membranes (see PROM/premature labor orders).



  3. Right/left lateral uterine displacement.



  4. Start IV. Mainline 1000 mL LR, infuse at 0-100 mL/h as indicated by cardiopulmonary status, etc (hold total fluids at 75 mL/h, if possible).



  5. Mix MgSO4 40 g/1000 mL LR (6 g bolus diluted to not greater than 10% IV solution). May use 100 mL bag of NS or LR for MgSO4 bolus.



  6. Administer medicines as indicated by condition:


    MgSO4 4-6 g IV bolus over 10-15 min, considering patient’s weight, urine output, and deep tendon reflexes. MgSO4—continuous infusion of 2-3 g/h via infusion pump.



  7. Foley catheter if patient cannot void, or is oliguric.



  8. Record above information, obtain copy of chart, obtain consent to transport.



  9. Assess maternal/fetal condition for transport and call maternal-fetal physician for consultation or further orders.



During transport




  1. Take vital signs with fetal heart tones q15min.



  2. Administer medicines, prn.



  3. Explain procedures to the patient and the family.



  4. Foley catheter, prn.



Emergency medications




  • Hydralazine: First choice for hypertension. May require hydration before medicating. Give when diastolic ≥110 mm Hg. Give 2-10 mg IV push every 15-20 min until BP begins to decrease. Stop when diastolic blood pressure is 100-105 mm Hg or a total of 30 mg given. Consult medical director.



  • Labetalol: Give when diastolic ≥110 mm Hg. 20 mg (8 mL) over 2 min IV push. If desired effect not reached after 10 min, give 40 mg (16 mL) IV push. Call medical director.



  • Oxygen: 12 L by non-rebreathing mask, prn.



  • Morphine: 2-5 mg, slow IV push for acute pulmonary edema.



  • Furosemide: 20-40 mg, slow IV push over 2-3 min for acute pulmonary edema.


Eclampsia



  • Establish airway: Provide supplemental oxygen. Assist with bag/mask or endotracheal intubation, as needed.



  • If seizure persists: Rebolus with 2 g MgSO4 (total bolus should not exceed 8 g).



  • If seizure persists after second MgSO4 bolus: Sodium amobarbital IV push 250 mg over 3-5 min (discuss with medical director).

Hemorrhage (General)

Prior to transport




  1. Assess vital signs and fetal heart tones.



  2. Assess contractions, status of membranes, extent of bleeding, number of bleeding episodes, and amount of blood loss (weigh pads, when possible).



  3. O2 12 L/non-rebreathing mask.



  4. Start IV with 16 g needle. Infuse 1000 mL LR using blood transfusion tubing at 125 mL/h or as necessary to maintain adequate blood pressure and urine output greater than 30 mL/h.



  5. With active bleeding or suspected abruption, place a second IV line. Use 16 g catheter.



  6. Check hemoglobin/hematocrit, type and cross (or screen).



  7. May travel with blood infusing. Use NS to clear tubing.



  8. Administer medications as ordered (IV ritodrine and terbutaline are contraindicated). See Premature Labor, PROM Section for tocolytics.



  9. Foley catheter.



  10. Assess maternal-fetal condition for transport and call maternal-fetal physician, prn.



  11. Record above information, obtain copy of chart, and permit for transport.



  12. No vaginal examination unless placenta previa has been ruled out; then, if necessary, perform gentle vaginal examination or sterile speculum examination to document cervical status prior to departure.



During transport




  1. Check vital signs and fetal heart tones q15min, or as deemed necessary.



  2. Check blood loss, keep pad count.



  3. Record above information.



  4. Reassess the patient and call maternal-fetal physician for consultation or further orders.



Acute hemorrhage with hypoperfusion




  1. O2 12 L/non-rebreathing mask.



  2. Start additional IV lines and increase IV fluids, as needed.



  3. Military anti-shock trousers (MAST) application, as indicated (see Chapter 18).



  4. Left/right lateral uterine displacement.



  5. Elevate feet.



  6. If hypotensive, consider ephedrine 5-25 mg slow IV push. Observe BP closely. Call obstetric transport director.



Acute postpartum hemorrhage




  1. Oxytocin 20-30 u/L NS, 125-150 mL/h.



  2. Methylergonovine 0.2 mg, IM. Contraindicated in the presence of maternal hypertension or sepsis.



  3. 15- Methyl F2α 0.25 mg, IM. Contraindicated in the presence of maternal asthma or pulmonary hypertension. Call medical director.



Excessive nausea and vomiting




  • Promethazine 25 mg, IV.



Emergency delivery




  1. Perform emergency delivery whenever imminent during transport.



  2. May perform small midline episiotomy, as necessary, to prevent laceration.



  3. Cut and clamp the umbilical cord 1/2 in from stump.



  4. Administer oxytocin 10-20 units, IM or added to full IV bag after placenta is delivered.



  5. Obtain cord blood when time permits.



  6. Resuscitate newborn (see Chapter 24), provide warmth, O2 by bag and mask, with intubation, prn. If estimated time of arrival is greater than 20 min and situation permits, obtain chem strip for glucose.



  7. For neonatal glucose less than 40 mg/dL, give dextrose 10% IV or gavage, if necessary. Give 2-4 mL/kg over 3-5 min.


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Jan 12, 2019 | Posted by in OBSTETRICS | Comments Off on Transport of the Critically Ill Obstetric Patient

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