Dr. Tanya Goodwin concludes her two-part series on NICU designations and transfer of the OB patient. Excellent information for any author writing this scenario. You can find Part I here.
Welcome back, Tanya!
Typical blood work would include a complete blood count (for evidence of infection, anemia, or clotting problem) electrolytes (blood chemistry), type and screen (in case blood transfusion necessary or injection for blood type – Rhogam). If the woman is contracting then medications to stall labor are started (Magnesium Sulfate IV, Procardia orally).
Before the OB or labor nurse performs a vaginal exam to assess cervical dilation, a sterile speculum is inserted into the vagina and a special swab called fetal fibronectin is done (a positive result increases the risk that the woman will deliver pre-term). If ruptured membranes are suspected then a sample of fluid is evaluated for amniotic fluid. If the water hasn’t broken pre-term, then the OB does an internal exam to check for cervical dilation.
Antibiotics may be given to decrease the risk of neonatal Group B Streptococcal sepsis (severe and life threatening bacterial infection) Also a corticosteroid injection may be given to the woman between 26 – 32 weeks gestation to help accelerate fetal lung maturation.
Once the woman is assessed for labor, the OB must make a decision as to the probability that his/her patient will make it to another facility without giving birth en route or encounter a medical complication. The OB’s first obligation is to the mother, and then fetus. Stabilizing the pregnant woman is paramount. The fetus depends on the health of the mother.
A U.S./governmental code called EMTALA or Emergency Medical Treatment and Active Labor Act forbids rejection of care and transfer of an unstable patient to another facility. This applies to all hospitals that participate (or receive payment) from Medicare/Medicaid, which is virtually every U.S. hospital. Its original intention was to prevent hospitals from “dumping” indigent patients into “charity hospitals”.
The OB explains the situation to the woman and any family she consents to relay medical information to. This is typically the father of the baby. Risks and benefits of transfer are discussed with the woman and “family” and the woman must give consent to be transferred.
The OB then calls a “transfer center” relaying information regarding the woman’s status and the necessity for transfer to a higher level of care. The transfer center finds the nearest suitable facility and connects the admitting OB to the receiving/accepting OB. Medical information is exchanged. Once the patient is accepted, then depending on distance or urgency, the woman is transported via helicopter (weather permitting) or ambulance. If this is a neonate, then the pediatrician is in charge of obtaining appropriate transport. Nurses also give nurse-to-nurse report. Medical records generated are copied and go with the patient. Everyone involved keeps one another updated as to the outcome, hopefully a happy ending but unfortunately not always that way.