Re: High Risk OB Dilemna

[Dave Sharpe <dsharpe@calstar.org>]

I appreciate everyone's responses to this interesting question.  For 
those who want to know "the rest of the story", i'll summarize it here.
	Upon arrival at the sending hospital, the crew found a 26 week 
pregnant patient, G1P0 who was reported to have come in the day prior 
with premature contractions.  The flight crew consisted of 1 staff 
Flight Nurse and 1 Labor and Delivery Transport Nurse from the 
receiving hospital. (Our service has an agreement with the receiving 
hospital to use their staff on certain high-risk OB transports.  Their 
transport nurses receive initial and recurrent annual training on 
transport issues, including flight safety and helicopter operations, 
etc.  Our own Flight Nurses are required to have NRP and PALS 
certifications, as well as to do recurrent annual rotations in the NICU 
and L&D)  In this case, the patient had not had a sterile vaginal exam 
since the initial presentation, but had been placed on a Mag gtt at 
3gm/hr which successfully stopped her contractions.  Her initial SVE 
showed that she was dilated to 10 cm with bulging but intact membranes. 
 Just prior to the transport team's arrival she underwent an ultrasound 
exam, which showed her cervix to be at "8 or 9 cm with funneling".  The 
Flight Nurse felt that this patient was not suitable for transport 
because of the risk of precipitous delivery en-route (in a BO 105 with 
no access to the patient below the abdomen).  The L&D transport nurse 
consulted with the sending and receiving perinatologists and concluded 
that the pt was probably stable enough to transport on a 20" flight.  
She was unwilling to conduct her own SVE if there was a chance that we 
would not transport the patient, as she felt this would unnecessarily 
stimulate the uterus.  After discussion with the Chief Flight Nurse, 
the flight was declined, given the fact that one member of the team had 
valid concerns about the appropriateness of the transport. (we have a 
"three to say go, 1 to say no" policy for all flights)
	The following day, the receiving hospital called again, asking to 
arrange the transport.  The receiving perinatologist felt strongly that 
the patient was stable for transport, and would benefit from being at 
the receiving maternal unit.  The decision was made to send the 
aircraft with the perinatologist and a L&D nurse to provide all medical 
care, and the pilot with a single Flight Nurse to provide safety and 
logistical support, but no medical care.  The crew had been able to 
switch back into our Bell 222 during the night, so would have access to 
the entire patient.  Upon arrival at the pt's bedside, a repeat 
ultrasound revealed the patient to be dilated to 4-5 cm.  The flight 
was completed without incident.

I appreciate all of the input on this difficult case - difficult from 
both a clinical perspective, as well as a political and medical-legal 
perspective.  I'd welcome any comments you have to share about this 
situation.


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