Inter-Hospital Transfer of the Pregnant Woman: 2/2

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!

Prior to any transfer, the woman’s pre-term labor must be assessed. The OB performs a history and physical examination while the nurses attach a fetal Doppler and a Tocometer to record fetal heart beat and uterine contractions respectively, start an IV, and they or a lab tech draw blood.

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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.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Inter-Hospital Transfer of the Pregnant Woman: 1/2

I’m pleased to host Dr. Tanya Goodwin as she discusses the difference between NICU’s and their designation. This will be Part I of her post. Part II covering transfer specifics will be on Wednesday.

One thing I want to point out is the Trauma Center designations run opposite of NICU’s. A Level I Trauma Center is where the most critical patients are taken if possible. Level II and Level III can always stabilize but may need to transfer the patient out.

Welcome back, Tanya!

Most pregnant woman will happily deliver their babies in a comfy hospital maternity unit. But for a few, their labor and delivery may need to be at a more specialized facility, or their infants may need to be transferred to an appropriate NICU or Neonatal Intensive Care Unit.

So how does this all happen?


Aside from a rare, life threatening maternal illness or a pregnant woman involved in a traumatic accident, transfer of the pregnant woman is usually based on the neonatal need.


A woman between 36 and 40+ weeks gestation (last month of pregnancy) can stay at a level I facility. Their babies will do quite well in a regular newborn nursery. Occasionally, a full-term baby may not adjust well to extrauterine life or have breathing problems or unforeseen medical or surgical issues that requires prompt transport to level II or III NICU (usually level III).


A level II nursery or special care nursery can accommodate those infants between 32 and 35 weeks. A 35 “weeker”, if doing well can stay at a level I /newborn nursery. Infants in a Level II are mainly there to feed and grow or receive a course of antibiotics.


Level III NICU’s are for babies that need long term care such as assistance with respirations via ventilators, medical or surgical issues. They may need to be fed through special nutritional intravenous fluids. These are the NICUs you usually see on TV.


A newer level, IV, has been touted as the place for extreme pre-term babies, between 22-25 weeks. Level III/IV are in urban centers (tertiary centers or teaching hospitals) where there are 24 hr neonatologists/sub-specialty neonatologists, physicians, surgeons, anesthesiologists, fellows, residents, and medical student. A very busy place!


Two of the most common scenarios requiring maternal transfer are pre-term labor (labor before completed 36 weeks pregnancy) and premature rupture of membranes (water breaking before 36 weeks). These conditions frequently co-exist, but not necessarily. If the OB is in a level I unit, then transfer of the woman is considered. If the OB is in a level II unit then depending on the gestation, the woman may stay or may be transported. No problem if already in a tertiary hospital.

More on this topic Wednesday.
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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com