Re: High Risk OB dilemma

[Obstat@aol.com]

Dave,

Excellent question indeed!

Your scenario is a difficult one for sure! Here are some things that are against you in this situation:

1. You are flying in a BO 105 where you do not have access to both ends of your obstetrical patient.  Should any OB patient that you transport become "unstable" enroute, you cannot get to the patients perineum to deliver the infant AND take care of mom's airway should she need assistance (she was on MgSO4 so is at risk for pulmonary edema, resp. depression, vomiting and aspirating, etc)

2.  Your patient is only 26 weeks pregnant.  The neonate would end up weighing somewhere in the neighborhood of a little over one pound!  Could your team provide adequate stabilization of that small of an infant in your helicopter?  Even the most skilled professionals who do this daily would most likely have difficulty intubating and stabilizing this size neonate in your helicopter. Is your precipitous delivery pack and neonatal resuscitation equipment readily available at your fingertips?  How would you keep this infant warm? Can you insert an UVC line and push meds if needed?... Etc, Etc. Would you be depending on the L&D nurse to perform these tasks?  (most of the time they would not be authorized to do these things, which comes back to the ball being in your court!)

3.  Worst of all, she was 10 cm dilated.  That is completely dilated....and at that gestational age, it doesn't require much effort for that baby to come right out (coughing, sneezing, vomiting...no joke).  The fact that she was not having contractions makes it more precarious.  Unless she had an "incompetent cervix", she needed contractions to get to complete dilation. Perhaps they were not showing up on the contraction monitor because of improper placement on the mothers abdomen.  This is where palpation of the uterus by the health care provider is vitally important. How were you expected to monitor the fetal heart rate and contraction patterns in the helicopter? Do you carry a fetal monitor?

4.  As we all know, referral facilities are often in a rush to get patients transferred to a more appropriate facility.  There are EMTALA regulations in place that state a pregnant patient should be stabilized prior to transferring her. A patient who is completely dilated at 26 weeks gestation would most likely not be considered "stable".  This could get all involved in trouble with EMTALA violations.

5. The patient in this scenario may have benefited from being transferred the day she arrived once she responded to appropriate tocolytic therapy, rather than waiting 24 hours till the day you were called.

5.  You have the right (and the duty) to refuse this transport on the grounds that the patient is not considered stable when she is completely dilated at 26 weeks gestation....regardless of which number baby this is for her.  This is an unsafe situation for all involved!

Please hear me correctly.....I am one of the biggest advocates of maternal transports.  However, they must be done at the most appropriate time, with the most skilled providers, in the best environment for the patient and unborn fetus.  Not only should you question this particular transport, you should ensure that you and your teammates are knowledgeable and comfortable with any complications that could arise out of maternal transports.  If anyone on the team is not comfortable, encourage your staff to seek both didactic education specific for OB transports, as well as clinical time in a high risk OB setting with specific skills lists required to be completed.

Best of luck on your future maternal transports.  Thanks for a challenging scenario!

Pam

Pamela J. Adams, RN, EMT-P
President
O.B. STAT, Inc.
23 Turnberry Dr.
Arden, NC 28704
(828) 684-1708
www.obstat.org

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