The broad framework of regionalization is based on the notion that sophisticated perinatal care should be available to every patient within a designated region, even if it is not specifically available at each hospital within the region. The level of care provided within individual hospitals is determined by the availability of technology, skilled nursing and medical personnel, and other related support services. Thus, when transport becomes necessary, its purpose is to match a patient to the level of technology and support she and her baby need.
INDICATION FOR MATERNAL TRANSPORT
Maternal transport to a tertiary facility should be considered when the facility at which a patient is located does not have the capacity to manage actual or anticipated complications of either mother or child. Low analyzed 463 maternal transports in the United States over a 6-month period, noting prematurity as the primary reason for transport in 330 (71%) cases, hemorrhage in 79 (17%), pregnancy induced hypertension in 41 (9%), and eclampsia in 8 (2%). In a study done by the author, acute maternal medical complications were the indication for transport in 360 of 1541 (23.4%) maternal patients transported in Arizona over an 18-month period. Fifty-two percent had hypertensive crises, 36% had hemorrhage, 6% were trauma victims, and 3% had respiratory compromise.
OBSTETRIC INTENSIVE CARE DURING TRANSPORT
In general, critical care obstetric patients should be stabilized at the referring hospital prior to transport. Hypertensive emergencies such as severe preeclampsia should be treated with magnesium sulphate to stabilize the neuromuscular irritability that can progress to eclamptic seizures. In addition, diastolic hypertension should be lowered to 100 to 105 mm Hg by cautious administration of intravenous hydralazine or labetalol. Third trimester bleeding due to placenta previa or abruptio placentae can cause hypovolemic shock and disseminated intravascular coagulopathy (DIC). The estimated blood loss should be replaced with crystalloid solutions such as normal saline or lactated Ringer solution in a 3:1 ratio (3 mL of crystalloid for each milliliter of blood loss). Because maternal intravascular volume increases by about 50% during pregnancy, signs and symptoms of shock may not be apparent until blood loss approaches 2000 to 2500 mL. Magnesium sulfate may also be used as a tocolytic. DIC is treated with blood component therapy (see Chap 2). During transport, left-side recumbent positioning should be utilized to optimize uteroplacental function, as described below. Table 19-1 illustrates an example of typical maternal transport standing orders.
TABLE 19-1.Maternal Transport Standing Orders |Favorite Table|Download (.pdf) TABLE 19-1. Maternal Transport Standing Orders
|Premature labor and/or rupture of membranes (PROM), multiple pregnancy, abnormal presentations |
|Prior to transport |
Assess blood pressure (BP), temperature, pulse, respiratory rate, and fetal heart tones.
Assess contractions (frequency, duration, quality), status of membranes; time of PROM (if applicable), color, and how PROM was confirmed. If membranes intact, may perform vaginal exam ...