RE: OB transport

[Mauseth Patrice <Patrice.Mauseth@HCAHealthcare.com>]

Your right.  I did interpret the definition of ultrasound to mean abdominal
ultrasound.  We call the fetal heart rate monitor a fetal doppler.  You
definitely are aiding yourself in determining fetal lie by combining it with
leopolds.  Though I have heard many babies high on the abdomen that could
have been either vertex or breech, so obviously it's not absolute.  We
monitor our patients according to AWHONN standards during transport.  We do
all interfacility flights, so we can assume our patients fit into the high
risk category.  We monitor every 15 minutes for one minute, and/or through
every contraction including one minute after.  The purpose is to listen for
decelerations in the fetal heart rate.  If you do experience decels, you
could reposition the patient, start O2, maybe give some terbutaline to
decrease the U/C's further.  The decels could be caused by either cord
compression, uterine insufficiency or head compression.  Of course there are
other causes, but these are the most common.  Basically, the fetal heart
rate pattern is the only way to reassure the caregiver that the baby is well
oxygenated.  For laboring patients we now have fetal oximetry, but for
transport fetal doptone is sufficient.  I'm not sure if I addressed all your
questions.

Patti Mauseth, RN
Perinatal Transport/Outreach Coordinator
Good Samaritan Hospital
408 559-2153


> -----Original Message-----
> From:	Ken Lawson-Williams [SMTP:Macgyver@FlightMedicMail.com]
> Sent:	Monday, September 16, 2002 1:17 PM
> To:	flightmed@flightweb.com
> Subject:	RE: OB transport
> 
> David, Patrice, Jery et al:
> 
> Thanks for the advice. I guess the difference is in the definition of
> ultrasound. I was refering to using a doppler to determine fetal
> heart-rate and then combining that with palpation to determine lie. Not an
> abdominal ultrasound in the hospital diagnostic imaging suite sense of
> the word. 
> 
> However I am not sure exactly which the Jery intended to determine.... Not
> to many teams fly with abdominal ultrasound machines, although I am sure
> that more will soon now they are small and available.
> 
> As to community standards etc, what was the purpose of the ultrasound? If
> it is to determine if the fetus is alive, twins or a breech presentation
> prior to deciding to deliver in the community or fly to a specialist
> centre, then I agree poor reading and poor outcome could be a concern.
> Brow presentations, nuccal cord and disporportion etc cannot be determined
> by a handheld doppler (at least not as far as I know) used for FHR
> measurement. 
> 
> On scene calls, where the team is from 1 to 4 hours from a community
> hospital (with abd U/S), and 4 to 8 to a tertiary centre (with a nursery
> and specialists etc) and no access to a MD, Midwife or NNP etc. the choice
> is to fly or deliver. We would love to have the equipment and skill to do
> full abd U/S but it is not likely to happen this decade for us. 
> 
> So far in 10 years operation, we have never had an adverse outcome -we
> also have never had an in-flight delivery. (Although we have had the odd
> stillborn, dystocia, nuccal cord, twins, breech etc usually because the
> mother was too far along in labour for it to be stopped - so a field
> delivery was the safest option.) 
> 
> With an overall average of only 18 (+/- 6) field deliveries annually from
> 140 or so fetal position assessments performed, we obviously don't have
> the depth of experience that a specialty team would have. And I am not
> aware of studies that show the optimum number of FHR/position assessments
> annually that would be required to "maintain proficency". However, there
> also is in almost all cases, no other option in our area. Sometimes we
> scoop and run, sometimes we stay and deliver. Flight duration, mothers
> condition/history, stage of labour, dilation and fetal position are all
> variables that constantly have to be assessed. 
> 
> I can't see how NOT attempting to determine fetal position prior to making
> these decisions can be better in a medico-legal sense - or from the
> mothers/baby's perspective!! I don't want to revisit the "get them to
> aurgery" debate again, as with the available resources in the Arctic,
> acceptable community medical standards are not the same as in the highly
> populated areas south of the 49th (or even 55th) parallel. In fact, the
> closest dedicated perinatal specialty team probably would have to come out
> of Seattle or Denver (possibly Anchorage?) as there are none in Edmonton,
> Calgary, Vancouver, Saskatoon or Winnipeg.   
> 
> Fly Safe. 
> Ken L-W CCEMT-P/WMT
> 
> Duct tape is like the force, it has a light side and a dark side, and it
> holds the universe together.
> 
> 
> 
> >The above are 'Words of Wisdom'.   It is difficult enough to keep
> physicians
> credentialed and comfortable in FAST ultrasounds in the Trauma Resus area
> given the complexity (false negatives) of Ultrasound.
>  
> Granted, Fetal Presentation Ultrasound exam may be less complex than a
> F.A.S.T.
> Ultrasound, but what is your "community Standard of Care"; given a poor
> outcome
> when decisions for patient care were determined by this exam?
>  
> Just an opinion.
>  
> David Summers RN, etc
> Jupiter FL
> 
> --- Mauseth Patrice <Patrice.Mauseth@HCAHealthcare.com> wrote:
> >Just food for thought.  I'm responding from a specialty team that you
> didn't
> >want to hear from...  Our hospital does over 4000 deliveries per year.
> We
> >have a hand full of RN's who are certified through AWHONN for ultrasound.
> >They barely do enough ultrasounds to keep their skills up.  I always
> caution
> >people doing more and more specialty work when they may not do enough
> >consistently to maintain their skills.
> >
> >Patti Mauseth, RN
> >Perinatal Transport/Outreach Coordinator
> >Good Samaritan Hospital
> >408 559-2153
> >
> >
> >
> >
> >> -----Original Message-----
> >> From:	Ken Lawson-Williams [SMTP:Macgyver@FlightMedicMail.com]
> >> Sent:	Monday, September 16, 2002 10:58 AM
> >> To:	flightmed@flightweb.com
> >> Subject:	Re: OB transport
> >> 
> >> Medics as well as RN's are (and do) at Medflight (Yellowknife).
> Assuming
> >> that you mean determining the fetal lie by the use of traditional
> handheld
> >> doppler in conjunction with 'Leopoulds' style hands-on assessment. 
> >> 
> >> We do about 1000 flights a year (6.5 hr average length, fixed wing) and
> >> about 55% are primary transports (scene calls). Roughly 35% of all of
> our
> >> flights in total are high risk perinatal/neonatal/pede patients - with
> >> perinatal about 2/3rds of those. Only about 2/5 of our perinatal trips
> are
> >> interfacility. Average out over 4 crews and you do about 35 perinatal
> >> scene responses a year each. 
> >> 
> >> Fly Safe. 
> >> Ken L-W CCEMT-P/WMT
> >> 
> >> Duct tape is like the force, it has a light side and a dark side, and
> it
> >> holds the universe together.
> >> 
> >> 
> >> --- message from "jery" <jery@internetcds.com> attached: << Message: OB
> >> transport >> 
> >
> 
> I would like to know if there are "garden variety" flight RN's that are
> trained in identifying fetal positioning by ultrasound.  I would like
> responses from flight programs that do the OB transports instead of using
> specialty OB teams.  Thanks.
>  
> 
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