In this section
Transport of any patient is potentially dangerous, and the risks of transport/transfer must always be taken into account when such decisions are being made. A planned and measured approach prior to a transfer should make the transfer uneventful.
PIPER Paediatric Infant Perinatal Emergency Retrieval
ARV Adult Retrieval Victoria
AV Ambulance Victoria
AAV Air Ambulance Victoria
ICU Intensive Care Unit
When the principal issue of concern is safe care of a medically unstable woman, it is anticipated that the Adult Retrieval Victoria (ARV) on-call retrieval physician will have been involved in the preceding consultative process, and if they deem it appropriate, will become the lead agency responsible for facilitating transfer. This includes, if necessary, provision of a medical retrieval team to support the paramedics in the care of a seriously unwell woman, who will usually be en route to an adult ICU bed.
An ambulance or an aircraft is not an appropriate place for a birth to occur. Transport may be appropriate once labour is suppressed. When it is considered likely that delivery is imminent, it is more appropriate not to attempt in utero transfer, but rather to deliver the baby locally and transport the mother and newborn subsequently and as required.
Accountability for the care of patients in transit rests with Ambulance Victoria (AV) and this includes monitoring, recording of clinical assessments and interventions. In nearly all cases, clinical care of the pregnant woman in transit is within the skill set of the attending paramedics. Therefore a midwife escort from the referring health service is not generally required to accompany in utero transfers.
Cardiotography (CTG) is not continued during transfer as there is no option to action any perceived abnormalities before arrival at the destination hospital.
If a public health service proposes that a midwife escort is required there should first be a discussion between the duty AV Clinician and the PIPER Perinatal consultant regarding the rationale for requesting a midwife escort, taking into account the skill set of the available AV staff as well as the impact on staffing at the referring hospital being asked to provide an escort. If agreement cannot be reached, the discussion should be escalated to the PIPER Perinatal Medical Director and the AV Regional Duty Manager
If there is agreement that a health service employee accompanies the patient, then the boundaries of their role during the transfer need to be clarified. Furthermore, there should be clear authorisation of the employee by an appropriate health service representative (executive or delegate) to undertake that role. The health service is responsible for the return costs of the accompanying staff member.
All patients must be adequately prepared and stabilised prior to transport, and in many cases this can be done prior to arrival of the transport team.
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. Formal handover from referring team to transport team, and from transport team to receiving team is essential. The transport team 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 needed infusions should be prepared prior to transport and labelled accurately. AAV 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 aerial 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 (eg. bowel obstruction). A nasogastric tube should be inserted prior to transport if active vomiting is not suppressed by the antiemetic.
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.