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PIPER Perinatal: Emergency Maternal Referrals

  • Overview/procedure description

    The interhospital transfer of high risk pregnant women must be supported by robust processes that consider and evaluate the risks associated with a decision to transfer. PIPER supports a collaborative referral and triage process that involves experienced referring clinicians, PIPER Consultant Obstetricians and senior Ambulance personnel. This process must be responsive to the dynamic circumstances of this patient group to ensure these transfers proceed safely.

    Related Policy


    Definition of Terms

    PIPER  Paediatric Infant Perinatal Emergency Retrieval  
    ARV  Adult Retrieval Victoria 
    AV  Ambulance Victoria  
    AAV  Air Ambulance Victoria  
    ICU  Intensive Care Unit  

    Procedure details


    PIPER Perinatal coordinates more than 1200 referrals per year resulting in approximately 800 transfers.  Most transfers are for maternal conditions that increase the risk of preterm birth before 32 weeks. Threatened preterm labour with or without ruptured membranes, antepartum haemorrhage and moderate to severe preeclampsia are the common precipitating morbidities.

    Extremely preterm babies born outside (“outborns”) a maternity service with a neonatal ICU have up to 4 times the risk of dying compared to their “inborn” peers. This makes balancing the risk of harm versus benefit from transfer critical.

    The possibility of a birth of an extremely premature baby occurring in an ambulance or aircraft inevitably generates anxiety in the clinical staff involved, especially paramedics whose core clinical work rarely involves such situations.

    In Victoria birth in transit following referral to and triage by PIPER Perinatal Consultant Obstetricians is extremely rare. There are however still significant numbers of extremely preterm babies born in non-tertiary maternity hospitals in Victoria each year.

    Most emergency interhospital maternal transfers referred to PIPER Perinatal are undertaken by AV ALS paramedics. The vast majority of these transfers do not involve a physiologically unstable woman requiring transfer to an adult ICU collocated with a level 6 maternity service. Those that do are referred to Adult Retrieval Victoria (ARV) for consideration of the need for a medical escort.

    Referral, triage and decision making

    The PIPER Perinatal referral and triage process is as follows:

    The referring clinician and PIPER Obstetric Consultant assess the clinical and logistic circumstances and determine the need for transfer. PIPER encourages the most senior clinician available to make these referrals.

    They determine if there is a window to safely effect transfer.

    If a safe window exists, stabilising treatment is discussed e.g. antenatal steroid, antibiotics, tocolysis, analgesia and magnesium sulphate.

    Activating Ambulance Victoria to undertake the transfer

    In Victoria, Health services do not have a single process to activate AV for PIPER Perinatal transfers.

    Following PIPER referral where a decision to transfer is agreed some Health services prefer to contact AV directly using established internal processes to arrange ambulance transfer, just as they would for any patient from their health service requiring an ambulance.

    Other Health services expect/prefer PIPER to activate AV for the transfer.

    It is not PIPER’s role to direct the use of one process or the other.

    To ensure there is a clear delineation of roles and tasks it is proposed that where a transfer is agreed following referral to PIPER Perinatal, the PIPER coordinator specifically asks the referrer if they wish to take responsibility for contacting AV to arrange ambulance transfer or if they prefer PIPER to do this.

    The referral to AV should include a level of clinical handover commensurate with the risk and complexity of the patient.

    If AV is activated by the referring Health service the AV Clinicians are encouraged to contact PIPER for additional information if desired. In such cases the PIPER coordinator will immediately place the AV Clinician in a conference call with the PIPER Perinatal Obstetrician responsible for the case.

    Ongoing Management of the Referral and Transfer Process

    PIPER locate a receiving unit and inform the referring hospital and or AV once this is confirmed.

    If the woman is deemed not safe to transfer at the time of the referral then stabilising treatments are initiated/continued and review of the decision made within 30-60 mins.

    It is not uncommon that interventions to suppress preterm labour are successful and change an uncertain situation to one where transfer can be confidently predicted to be safe.

    If birth appears imminent at the time of the referral the PIPER Neonatologist is involved and the need to mobilise a neonatal retrieval determined.

    Even in these circumstances the situation can change such that maternal transfer becomes a possibility. Therefore all involved need to be aware of the importance of any change in clinical circumstances that may warrant reconsideration of the current plan of action.

    Care in Transit and accompanying Clinical staff considerations

    Accountability for the care of patients in transit rests with Ambulance Victoria (AV) with clinical support from the PIPER Perinatal Consultant Obstetrician. This includes the monitoring and recording of clinical assessments and interventions.

    In most cases, clinical care of the pregnant woman in transit is within the skill set of the attending paramedics.

    The referring clinician, AV or PIPER may propose that a midwife escort is appropriate. In rare circumstances an Obstetrician or GP Obstetrician accompanies the woman

    These discussions should take place at senior medical and AV Clinician/Duty Manager level.

    The primary determinants should be the well being of both the patient and staff, noting that it may be entirely appropriate to send a midwife or doctor to support the paramedics in high risk situations.

    It must be stressed that PIPER supports continual assessment and reassessment of the decision to transfer (or not to transfer) and does not support commencing if birth en route is likely.

    If agreement cannot be reached on the level of patient escort required the discussion should be escalated to the PIPER Perinatal Medical Director, the referring hospital Nursing/Midwifery Manager and the AV Regional Duty Manager.

    Health services should develop polices and processes that provide authorisation and guidance for staff who might be asked to accompany a patient for an interhospital ambulance transfer. The health service is responsible for the return costs of the accompanying staff member.

    Cardiotography (CTG) is not continued during transfer as there is no option to action any perceived abnormalities before arrival at the destination hospital.

    All patients must be adequately prepared and stabilised prior to transport. This should be completed in parallel with requesting ambulance transfer.

    Documentation is required by the transport team and by the receiving facility in order to provide appropriate ongoing care. The chain of responsibility must be clear throughout transfer with formal handover from referring team to the AV paramedics, and the paramedics to the receiving team. AV paramedics should communicate with the PIPER Perinatal Consultant if the clinical condition of the patient changes en route.

    Lateral tilt for supine pregnant women is critical over long journeys. Whilst maternity unit staff will recognise this need it is wise to reinforce such a need for careful patient positioning to non-obstetric non-midwifery personnel.

    All patients in whom intravenous access is likely to be required during transfer should have one or two (depending on the clinical situation) venous cannulae inserted and secured prior to transfer. Any required infusions should be prepared prior to transport and labelled accurately. Air Ambulance Victoria currently utilise syringe pumps for infusions with additives and any preparations should be drawn up into 50 ml syringes and labelled accordingly.

    All patients should be asked to empty their bladder prior to transfer; consideration should be given to inserting an indwelling catheter in the event of air transfer of patients with a significant anticipated intravenous fluid intake.

    Parenteral administration of an antiemetic should be considered if there is a past history of motion sickness, or if the current condition of the patient is associated with significant risk of vomiting.

    Anaemia reduces the oxygen carrying capacity of the blood; this is exacerbated at altitude due to the reduced partial pressure of oxygen. Patients with a haemoglobin concentration less than 7g/dL should ideally be transfused prior to transfer.