Destination and Bypass - Maternity

[flightmedic608]

Such different approach on transporting these patients. Yes, I may not have been clear enough in my post, there is a difference between 3rd trimester and imminent delivery, I wasnt trying to infer that they were similar I apologize. Where I work, we have guidelines regarding air transport of OB patients and try to take every aspect into account. Good luck though sounds like a very tough situation you are facing, I can forward you a link to our protocols as an example if you think that would help.

Edited May 2, 2012 by flightmedic608

[mikeymedic1984]

If they have no delivery equipment at all, then it would be a bad decision to take any pregnant patient there, regardless of complaint, you never know when a complication would set in, so I would write it as all go to the distant facilities that are most appropriate (whichever their OB doc practices at), you would only stop at the local if the mother or baby is in arrest (or a severe complication - Low heart rate). Might be time to ask the hospital for a little financial contribution to both ambulance services so that you can stock up with more neonatal equipment.

[Arctickat]

Thanks for the input guys, I appreciate your thoughts and views. Flight, I'd love a peek at that protocol.

[flightmedic608]

No prob Arc can you email me at flightmedic608@comcast.net so that I can forward you a copy?

Edited May 2, 2012 by flightmedic608

[ERDoc]

I don't have much else to add other than suggesting you change your gestational age cutoff. Go with 20 weeks since that is considered the age of viability. Anything under can go to the local ER, anything above needs to go to the other place.

[croaker260]

Here is our hospital destination protocol. It covers a wide variety of situations. I hope it helps.

http://www.adaweb.net/LinkClick.aspx?fileticket=eJD2Vbo%2f46Q%3d&tabid=798

REGARDING Pregnant Patients

I. Pregnant Patients:

• A pregnant woman who has received pre-natal care and has an established physician may be transported to the hospital of choice
  
• A pregnant woman who has a history of high-risk pregnancies should be transported to St. Luke’s Regional Medical Center, St. Luke’s Meridian Medical Center or Saint Alphonsus Regional Medical Center. These hospitals have Neonatal Intensive Care Units.
  
• Complicated imminent deliveries from home, medical facility or birthing center will be transported to the closest appropriate facility
  

　

This note is important too:

If the patient or attending physician requests transport to a facility not consistent with the above guidelines, the request will be honored only after informing the patient, responsible person, or physician of the unavailability of certain services at that facility. If the patient demonstrates impairment of judgment related to injury, shock, drug effects, or emotional instability, the Paramedic will act in the patient’s best interest and transport to the most appropriate facility.

This protocol shall not relieve Ada County Emergency Medical Services System (ACEMSS) personnel of the responsibility to determine the patient’s destination preference. Where question exists concerning the appropriate patient destination, Medical Control shall be consulted.

ACEMSS personnel have the option to transport patients with immediate life-threatening conditions to the closest appropriate facility.

[Arctickat]

If the patient or attending physician requests transport to a facility not consistent with the above guidelines, the request will be honored only after informing the patient, responsible person, or physician of the unavailability of certain services at that facility.

This kinda bugs me. Why is it your responsibility to know what is or is not available at every hospital? How are you to know if the part time on call obstetrician at hospital ABC is currently available?

Edited May 8, 2012 by Arctickat

[Asysin2leads]

Artickat, I can speak about some EMS and ER practices in the Northeast US, but I'm confused a little. Is your local podunk place like a medical clinic or is it an Emergency Room? According to my old medical directors, not only should any Emergency Room in the US be able to perform non-complicated delivery, any EMT-B in the United States should be able to able to do it to. This came about because of an issue with a BLS crew. The BLS crew had a woman who was crowning in the back of the ambulance. She requested to go to St. Not-the-closest where she had all of her prenatal care done. The crew on the other hand elected to go to the Our Lady-of-around-the-corner hospital. The baby was delivered in the ER of the hospital they diverted too, and was fine and healthy, but the mother still lodged a complaint. They found the crew to be at fault, as imminent childbirth, despite reasonable objections, is not a reason to divert to the closest hospital, as childbirth is something that an EMT-B is fully trained and certified to perform. I took a neo-natal resuscitation class shortly after I became aware of the incident, because as Kiwi mentioned, four hours doesn't cover very much.

So, what I would need to know is do the standards of care of your area dictate that your neighborhood emergency joint be able to handle simple childbirth? I would be very surprised if they weren't, because as I said delivering a child when birth is imminent is seen in many areas as a basic skill.

If that's the case, then you run into another complicated matter. On one hand, if you brought the mother to the ED, they should be able to handle it, and there would be no good reason to bypass it, but by the same token, the crew should be able to handle the childbirth, in the back, while moving, and imminent childbirth is not necessarily a reason to divert to the closest.

[Arctickat]

You've pretty much described our situation. I even got my fingers slapped about 15 years ago because we were running L&S to the L&D with a maternity and the Ministry of Health told me that I am trained in childbirth and there is no need for us to be in a rush. Here's the problem, the only way to determine if birth is imminent (besides the obvious crowning and other external signs) is an internal exam. Not even our ALS providers have that in their scope. Our local hospital can do imminent childbirths and will keep the patient in the hospital if it appears the mother will deliver within the hour, but, 95% of the time the labour has just started and might be 2 - 3 cm, basically, the ambulance is a taxi ride to the L&D. Our local docs are being over taxed with unnecessary ER visits and are seeking ways to reduce being phoned at home in the middle of the night. In the case of a maternity, they come down, assess the patient, and send her to an obs. Waste of time for the mother and ruins his night. What he would like is for us to take these maternity patients direct to the obs instead.

I'm fine with the idea, but he and we both answer to the public via the health region board of directors and the Ministy of Health. It is they whom we need to persuade to permit this bypass. Our Emerg can handle childbirth, but there are two types, elective and emergent. Our ER doesn't do Elective Childbirths and will only do Emergent (imminent).

I hope I didn't muddy the waters any more.

[Asysin2leads]

No, it's pretty clear now. It's pretty clear that's it's a toughy. I think the best protocol would be to transport to the women's center unless there are exigent circumstances. I think in this case the balls in our court, and you should only divert to the local place if you can justify it. I think though that if you are going to be transporting and risk childbirth, you should make provisions to have an extra set of hands with you in the back, even if it's just someone with FR training. Can your local ED do a breech birth or a placentia previa? If you suspected that this might be occuring could they intervene appropriately?