Immediate Care and Transport of the High-Risk Mother in West Virgina

The Transport Guidelines Committee of the West Virginia Perinatal Partnership developed these guidelines in response to a need for them expressed by nurse managers from around the state.  Please direct comments to Ann Dacey.  These guidelines were last updated: 03/16/2010.

CONTENTS
General Considerations
    Transport to Cabell Huntington Hospital
    Transport to Charleston Area Medical Center Women and Children's Hospital
    Transport to WVU Children's Hospital
Maternal Transport Log for Community Hospitals
Preparation For Maternal-Fetal Transport
Maternal Transport Checklist
Ambulance Transport - Basic Stabilization Requirements For All Patients
Maternal Transport Equipment
Reverse Transport
Discharge Home
Specific Stabilization Requirements
    PIH/Pre-eclampsia/HELLP
    Preterm Labor
    Suspected PPROM (Preterm Premature Rupture of Membranes)
    Bleeding
References
Nurses' Maternal Transport Notes Form 


General Considerations

The transportation decision should be made by the receiving physician in collaboration with the referring physician based on clinical judgment, with careful consideration given to following questions:

  • How soon does the patient need to reach the referral center?
  • What are the weather/ground conditions that might inhibit air transport?
  • What are the transport times for ground versus air transport from the referring institution?
  • Are nursing and paramedic staff available for transport?  

Back to Top Menu Transport to Cabell Huntington Hospital

Maternal Transport Phone Number:  877-531-2244

Maternal Transport Services Available:  Cabell Huntington Hospital has a maternal transport team staffed by credentialed transport RNs who are employed by the hospital and work in Labor and Delivery. They travel to referring hospital by helicopter, fixed wing, or ground ambulance.

How to Initiate a Maternal Transfer:

  1.  Call 877-531-2244 hotline to be patched through to maternal transport RN
  2.  Transport RN takes information from referring physician
  3.  Information discussed with on-call obstetrician
  4.  Referring physician is notified of acceptance or deferral and if deferred, help is provided in placing patient at another institution.

Back to Top Menu TRANSPORT TO Charleston Area Medical Center Women and Children's Hospital

Maternal Transport Phone Number:  877-Cam-Care (877-226-2273)

Maternal Transport Services:  Women and Children’s Hospital does not have a maternal transport team but uses the services of Kanawha County Emergency Ambulance Authority (KCEAA) and Healthnet.

Back to Top Menu Transport to WVU Children’s Hospital, WVU Hospitals, Inc. (WVUH) Morgantown

Maternal Transport Phone Number: 800-WVA-MARS (800-982-6277).

Maternal Transport Services Available: WVU Children’s Hospital does not have a maternal transport team. Patients are transferred from the care of the referring physician or certified nurse midwife to the receiving physician at WVUH. The referring physician arranges local transportation of high-risk obstetrical patients. In cases of extreme emergency, the WVU HealthNet team may be sent. For HealthNet to be sent, the WVU perinatologist consults with the MEDICAL COMMAND physician on call. The type of transport and escort required are determined in agreement by both referring and accepting providers. Arrangements are then made for appropriate personnel with obstetrical experience (Physician, Certified Nurse Midwife, Registered Nurse, Medic, or Paramedic) to accompany the woman.

How to Initiate a Maternal Transfer/Transfer Process:

Call the toll free Medical Access and Referral number: 1-800-WVA-MARS (1-800-982-6277). phone calls from referring physicians are transferred to the attending faculty ob/gyn physician.  There is always a faculty attending ob/gyn in house. The attending faculty member on-call may accept a transport or can reach the attending perinatologist at all times. The decision regarding maternal fetal transport is the joint responsibility of the patient’s referring physician and the accepting perinatologist (or faculty attending) at WVU Hospitals, Inc.

Back to Top Menu  Preparation For Maternal-Fetal Transport

Relative Contraindications for Transfer:

Maternal instability should be corrected as much as possible prior to transport. In addition, delivery in a transport vehicle is undesirable and it is safer for delivery to occur in a facility with greater manpower, room and resources. Therefore, contraindications for transfer include:

  •  Mother’s condition not stabilized
  •  Fetus is in acute distress (delay in delivery would result in death or damage to the fetus)
  •  Delivery is imminent
  •  No experienced attendants are available to accompany mother
  •  Weather conditions are hazardous for travel

The following types of laboring patients may possibly not be accepted for transport because it may be considered more acceptable to deliver the patient in the referring facility and to transport postpartum as required.

  • 20-26 weeks gestation in active labor, with cervical dilatation and/or brisk vaginal bleeding
  • 27-36 weeks gestation in active labor, with cervical dilatation of greater than 3 cm and/or brisk vaginal bleeding
  • 36-40 weeks gestation - multipara with cervical dilatation of greater than 3 cm
  • 36-40 weeks gestation - primipara with cervical dilatation of greater than 6 cm

Back to Top Menu  Ambulance Transport - Basic Stabilization Requirements For All Patients

Digital exams should not be performed on patients with vaginal bleeding or have suspected PPROM and who are not in labor.  Patients with suspected PPROM should have a sterile speculum exam for nitrazine and ferning to confirm ruptured membranes. Cervical dilatation can be assessed visually at the time of sterile speculum exam.

  • Patient should have an IV with an 18 gauge (or larger) catheter. (Since IVs are difficult to start while in motion, two sites are recommended.)
  • Keep patient NPO.
  • Maintain the patient in left lateral or semi-Fowler (with left lateral uterine tilt) position as appropriate.
  • Experienced personnel as indicated and agreed upon by referring physician and accepting perinatologist should accompany the patient. (For instance, a registered nurse should always accompany a patient on magnesium sulfate.)
  • Vital signs including FHR should be obtained every 15 minutes.  If the ambulance is lacking a portable fetal monitor, the FHR should be auscultated for a full 60 seconds. If the patient is in labor, the FHR should be auscultated before, during and after uterine contractions at the appropriate time intervals. Due to noise levels, it is recommended that a battery operated ultrasonic Doppler fetal heart detector and digital readout sphygmomanometer be used if available. It might be necessary to stop the ambulance for a check of blood pressure and fetal heart rate.
  • Oxygen by mask should be used any time fetal or maternal status requires.
  • In the event of unanticipated, non-remedial fetal distress, imminent delivery, or unstable maternal status, receive instructions from Medical Command or Maternal Transport Consultant. The patient should be taken to the nearest hospital. The ambulance crew should notify the hospital of the patient’s intended arrival and it’s instructions from Medical Command

Back to Top Menu  Maternal Transport Equipment

  • Equipment for fetal maternal monitoring:
    • BP Equipment
    • fetoscope or Doppler (portable fetal monitor preferred)
    • reflex hammer
    • stethoscope
  • Equipment for maternal IV administration:
    • adhesive tape and alcohol sponges
    • infusion pump
    • IV catheters (16 and 18 gauge)
    • IV solutions: Ringer’s lactate, dextrose
    • needles and syringes of different sizes
  • Equipment for respiratory support:
    • Endotracheal tubes and stylets
    • Laryngoscope handle with blades
    • Oral airways
    • Oxygen mask
    • Suction Catheters (# 14, #16, #18) and suction equipment
  • Medications
    • Calcium gluconate
    • Diazepam
    • Lidocaine hydrochloride (Xylocaine)
    • Magnesium sulfate
    • Methlyergonovine maleate (Methergine)
    • Oxytocin
    • Plasma expanders; plasma protein fraction (Plasmanate) and albumin
  • Emergency Delivery Equipment
    • Basin
    • Bulb syringe
    • Cord Clamp
    • Suction and suction catheters
    • Hemostats
    • Curved Kelly Clamps
    • Sterile Gloves
    • Sterile sponges
    • Straight scissors
    • Towels and blankets
  • Infant Resuscitation equipment
    • Oxygen mask (premature and neonate sizes)
    • 100% oxygen and infant size positive pressure bag
    • Infant stethoscope
    • Neonatal , laryngoscope sizes 0 and 1,  ET tubes and tape
    • Infant suction catheters (Sizes 5, 8, 10, 12)
  • Medications
    • Naloxone NRP Recommended concentration = 1.0 mg/ml
    • epinephrine NRP Recommended concentration = 1:10,000
    • sodium bicarbonate
    • volume expanders

Back to Top Menu  Reverse Transport

  • In the event that the patient’s condition improves and it is determined that the patient may now be adequately cared for at the referring hospital, a reverse transport may be arranged.
  • The primary physician should be notified.
  • The patient may or may not be transported by ambulance.
  • A copy of the dictated summary, including recommendations for further care, should accompany the patient.

Back to Top Menu  Discharge Home

  • In the event that the patient’s condition improves and it is determined that she may now be adequately cared for as an outpatient, she may be discharged.
  • Referring providers should always be notified of the imminent discharge of any undelivered patients.
  • Decision for follow-up should be a joint decision between the referring provider and tertiary perinatologist. The attending perinatologist should determine the follow-up care plan in consultation with the primary care provider.
  • A copy of the discharge summary including recommendations for further care should be sent to referring provider

Back to Top Menu  Specific Stabilization Requirements

Back to Top Menu  PIH/Pre-eclampsia/HELLP

  • Loading dose of MgSO4 4-6 grams followed by a continuous infusion of 2-3 gm/hour depending on status and always given via infusion pump. Loading dose should be given prior to transport.
  • MgSO4 level if patient has been receiving MgSO4 for longer than 12 hours.
  • Foley Catheter (for accurate I&O measurement)
  • Baseline labs + liver enzymes, platelets, DIC profile, and 24 hour urine (if in process)
  • Document reflexes, edema, visual acuity
  • Seizure precautions (ear plugs, eye covers, low stimulation)
  • Sedation if indicated
  • Antihypertensive medications if indicated
  • Assess and note signs and symptoms of disease progression:
    • Headache
    • Blurred Vision, Aura, or Scotomata
    • Nausea And Vomiting
    • Change in Level of Consciousness
    • Epigastric Pain
  • Emergency management of seizure activity
    • Turn patient on side, do not restrict movements
    • Protect patient
    • Insert airway if possible, do not force jaw open
    • Call for assistance and orders from MEDICAL COMMAND
    • Administer MgSO4 as ordered to control seizure activity
    • Once seizure activity stops, administer O2  at 10 liters/minute by tight face mask and suction mouth as necessary
    • Assess Blood, pressure, pulse, respirations, and fetal heart rate every 5 minutes until stable
    • Note characteristics of seizure:
      • Presence or absence of aura
      • Site of initial body movements and progression of movements
      • Duration of seizure
      • Tonic, clonic phases
      • Duration of post-dictal phase
      • Length of unconsciousness
      • Maternal and fetal responses
      • Assess for placental abruption and/or imminent delivery

Back to Top Menu  Preterm Labor

  • Vaginal exam (only if no PPROM) and assessment of presentation
  • Prior loading dose MgSO4 of 4-6 grams or other labor suppressant depending on patient status in consultation with accepting perinatologist.
  • Foley catheter (optional depending on status and patient output)
  • Obtain cervical culture
  • Urinalysis (sterile catheterized specimen preferred)

Back to Top Menu  Suspected PPROM, (Preterm Premature Rupture of Membranes)

  • Assess confirmation of PPROM by sterile speculum exam for pooling and microscopic exam for ferning. Nitrazine testing is not always accurate
  • No vaginal exam unless contractions/active labor are present
  • Temperature every one - two hours.
  • Assess for signs of chorioamnionitis (odor, temperature, uterine tenderness)

Back to Top Menu  Bleeding

  • No vaginal exams unless placenta previa has been ruled out and active labor is present.
  • Vital signs
  • All previous ultrasound reports
  • Careful assessment of fetal status
  • Assessment for source of bleeding. Pain?
  • Estimation of blood loss and potential for hemorrhage.
  • Hematocrit &Hemoglobin, Type and Cross Blood,
  • Note blood products received
  • More than one IV site - one with 16 gauge if possible
  • Foley catheter to monitor output if significant blood loss

References

American College of Obstetricians and Gynecologists. 2008 Compendium of Selected Publications. ACOG, 2008

American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, Fifth Edition. AAP, ACOG, 2006

Ronstant, , DM, Cady, RF, AWHONN Liability Issues in Perinatal Nursing. Philadelphia, J.B. Lippincott Co, 1996.

Simpson, K.R., Creehan, P.A. AWHONN Perinatal Nursing. Philadelphia, J.B. Lippincott Co, 1996.

Troiano, N.H., Mandeville, L.K.: AWHONN High-Risk and Critical Care Intrapartum Nursing. Philadelphia, J.B. Lippincott Co, 2001.