The main objective of obstetric transports is to provide safe and rapid transport of the high-risk obstetrics (HROB) patient to a facility most appropriate to meet the needs of the mother and the fetus (1). This is accomplished by careful assessment, stabilization, and transport by skilled personnel who are comfortable dealing with obstetric and neonatal crisis and emergencies. There is definitive evidence that perinatal and neonatal outcomes are significantly improved when delivery occurs in a tertiary referral center that includes a Level 3 NICU. In utero transport results in reduced morbidity for infants of high-risk pregnancies. There is a 90% survival rate for infants transported in utero versus an 81% survival rate of out-born infants transported after delivery, proving that in most cases the mother is truly the best transport incubator (2).
There are many factors that must be considered when caring for a pregnant patient in the transport environment. Foremost is an understanding that two patients are being transported. The fetus cannot be visually assessed; therefore, the crew must be trained in assessment of the fetus in utero. This includes training in reviewing and interpreting fetal monitoring tracings as well as having knowledge of antepartum testing. The teams must understand that all treatments and interventions provided to the mother have the potential to adversely or positively affect the status of the unborn fetus.
Interfacility transfers are classified as either one-way transports or two-way transports. A one-way transport involves moving the patient using a local transport vehicle (ground ambulance or helicopter) that can respond promptly and move the patient from one facility to another. During a one-way transport, the referring physician calls for a transport vehicle and then usually remains responsible for the patient’s care until she reaches the receiving facility. This type of transfer can be tricky as many referral facilities turn the patient over to a transport crew that they assume will provide the same level of care that was given at the referring facility. The reality is that many times the level of care is actually decreased in transport, without the knowledge of the referral physician who is still ultimately responsible for that patient throughout the transfer. If the patient’s condition worsens en route, appropriate evaluation and intervention are dependent on the skill level and expertise of the transport personnel. In an effort to address this potential problem, referring facilities may desire to send one of their nurses or physicians with the patient. This can lead to added problems, as those persons are often unfamiliar with the uniqueness of transport medicine. They are not accustomed to working in the unstable environment of a moving transport vehicle where vibration, motion, noise, and a cramped, poorly lit workspace make it challenging to continually assess and alter patient care. In addition, should the patient originate from a small community facility, the facility may not be able to function well with one less caregiver or ambulance for several hours while they are on a transport (3).
A two-way transport usually involves using the transport system that is associated with or contracted by the receiving facility. With a two-way transport, the receiving facility accepts responsibility of the patient when their transport team arrives and assumes her care. This type of transport is usually preferable for the receiving facility, as the caregivers on this transport team often originate from and are viewed as an extension of the receiving facility. They work under standing protocols designed to meet the needs of this type of obstetric patient. Should a situation arise where they have questions or concerns regarding care, they will contact their medical director, thereby releasing the referral physician from any further liability. A disadvantage of this type of transport is the length of time it can take for the team to arrive to assume care of the patient. That is often the reason that referring hospitals use local transport providers.
Prior to using either type of transport team, it is wise for the referral facilities to have full knowledge of exactly what training and experience each team has received for HROB patients and what equipment they use and what treatments they can provide. It is also important that written letters of agreement are made between both the referral and receiving facilities clearly stating each institution’s responsibility to assure compliance with local, state, and federal laws.
TEAM CONFIGURATION
All EMS and transport crew members will eventually be called upon to transport a pregnant medical, trauma, or laboring patient. When this request occurs in the pre-hospital environment, the crews will follow the standing orders of their field medical director.
Transport teams that accept the responsibility of caring for HROB patients must be capable of meeting the needs of the most critical OB and neonatal patients. For transporting HROB patients from one facility to another (interfacility transport), the teams’ training should encompass triage, assessment, stabilization, and decision making regarding how and when to safely move these patients. Suggested minimal and optimal qualifications for each team member should be considered while keeping in compliance with his or her scope of practice as well as local and state guidelines (Table 13.1). The level of care that team members can provide is then categorized according to their individual performances defining them as either primary or secondary team members (Table 13.2). The team members must have completed or must be in the process of completing the skills competency checklist and should possess complete knowledge and understanding of the standing orders mandated by their institutions’ medical director (Table 13.3) (4).
TABLE 13.1 I Team Qualifications
The configuration of the team may vary based on local and state guidelines as well as facility medical direction. There must be a core crew consisting of two team members meeting the minimal qualifications, with the primary team leader meeting both minimal and optimal team qualifications.
Minimal Maternal Transport Team Qualifications
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Registered nurse and/or paramedic licensed in the state of the base of operation.
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Respiratory therapist and/or EMT must be licensed in the state of the base of operation to function as a secondary team member.
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BLS (Basic life support) certified.
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NRP certified.
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Successful completion of a flight safety and orientation course as specified by organizational protocols and meeting state and federal guidelines.
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Completion of a ground transport orientation in compliance with state guidelines.
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Other non-team members such as obstetrician, OB fellow, certified nurse, midwife, OB nurse practitioner, or critical care transport nurse may be added to the core transport team on a case specific basis.
Optimal Maternal Transport Team Qualifications (primary leader must complete)
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Completion of a high-risk obstetrical transport course.
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Completion of maternal transport competency skills checklist with proficiency.
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ACLS certified.
Team configuration should be based on consideration of the following:
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Established local and state guidelines.
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Legal scope of practice of team members.
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Program policies and protocols.
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Medical director approval.
Beginning with the initial report received, the patient can be placed into a Priority 1, 2, or 3 status based on her acuity (Table 13.4) (4). This priority level is different than that of current trauma criteria where the Priority 1 patient has no vital signs, yet the HROB Priority 1 patient is still the sickest and most acute of the pregnant patients requiring transportation. In some circumstances, the teams may want to reconfigure their team members based on the priority status of the patient and the training level of the team currently in place. This allows for more qualified personnel to be added to, or changed out, based on: patient acuity, possibility of delivery prior to returning to the receiving facility, etc.
TABLE 13.2 Performance Objectives
The primary team leader must be proficient in all aspects of high-risk maternal transport. Proficiency shall be based on individual performance of the following:
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Technical and clinical competencies.
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Critical thinking and leadership skills.
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Competent in community relations and interpersonal communication.
The secondary team member must be capable of assisting the primary team leader with assessment and stabilization, as well as comfortable with assuming care of the mother or neonate in the event of an emergency delivery.
Primary team leader
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Completed transport skills competency list (must meet with medical director approval and fall within the scope of practice of the individuals’ licensing bureau).
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Consistently proficient with all levels of care including triage, stabilization, patient packaging, transport, and follow-up. Proficiency in maternal assessment and stabilization should include the following:
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Performance of a complete maternal physical examination
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Advanced airway management including intubation
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IV access and medication stabilization
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Advanced cardiac life support certification
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Accurate vaginal examinations including sterile speculum (when applicable)
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Testing of amniotic fluid for nitrazine and ferning
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Ultrasound identification for fetal positioning
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Fetal heart rate monitoring and interpretation
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Administration of tocolytic medication
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Emergency delivery if necessary
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Proficiency in neonatal resuscitation
Secondary team member
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Completed or working to complete transport skills competency list.
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Completion of helicopter/ground vehicle orientation. Aware of transport safety issues.
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Proficiency in assistance of maternal assessment and stabilization to include
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IV access.
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Fetal monitor interpretation.
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Basic life support certified.
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NRP certified.
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Competent to assist with emergency delivery and initial resuscitation.
TABLE 13.3 Team Education Competency
The items included in the transport competency checklist of each individual program will be based on the program’s protocols and medical direction. Primary team members must demonstrate competency in all of the areas listed on the transport checklist. Secondary team members must be working toward completion of competencies for their position on the team.
A. Triage
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Accept verbal report from sending facility.
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Categorize transport according to severity and mode of transport.
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Estimate ETA for referral facility.
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Activate appropriate transport personnel and vehicle.
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Notify medical director, NICU, perinatal center of new admission.
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Prepare appropriate equipment for departure.
B. Vaginal examinations
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Perform vaginal examinations on laboring women in controlled setting with a preceptor. Differentiate between normal and abnormal rate of cervical dilation, effacement, and descent of presenting part.
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Must show competency by consistently demonstrating 90% accuracy when determining dilation, effacement, and station as well as fetal presentation and position.
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Examination competency includes showing proficiency in determining all dilation stages from a closed/thick cervix to complete dilation.
C. Speculum examinations for PROM
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Demonstrate proficiency in proper insertion of speculum.
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Assess color, amount, and odor of the amniotic fluid.
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Visualize cervix to assess dilation when applicable.
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Confirm rupture of membranes with nitrazine or fern test.
D. Ultrasound identification of fetal position
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Proficiency in utilizing ultrasound examination to determine fetal position (in accordance with institutional policy and nurse practice act).
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Confirmation of correct fetal position vital prior to transport.
E. Fetal heart rate monitoring and interpretation
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Completion of basic fetal monitoring course or equivalent.
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Passing of fetal monitoring test with 90% or higher.
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Recognize normal and abnormal fetal heart rate patterns and identify nonreassuring tracings.
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Promptly initiate appropriate nursing interventions for non-reassuring FHR tracings and notify appropriate physician.
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Recognize normal and abnormal contraction patterns.
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Initiate appropriate nursing interventions for abnormal contraction status and notify appropriate physician.
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Apply direct fetal monitoring devices in accordance with nurse practice act, institution policy, and medical direction when necessary
F. Obstetrical pharmacology administration
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Competency validation of medication knowledge including medication desired effect, route, dosage, adverse effect, interactions, and considerations.
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Monitor the mother and the fetus for desired and deleterious effects of administered medications. Prepare for medication discontinuance and reversal if necessary.
G. Medical directing standing orders
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Competency validation of knowledge of standing orders.
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Requesting of further orders from medical direction when completion of standing orders achieved if needed.
H. Equipment
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Competency validation of safe usage of equipment in multiple transport settings.
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Yearly or more frequent equipment updates or in-service.
I. Neonatal resuscitation procedures
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Current neonatal resuscitation procedure—(NRP) certification.
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Advanced procedures—Intubation, UVC insertion, medication administration in accordance with medical direction, institution policy, and nurse practice act.
J. Transportvehicle safety competency
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