Retrieval of the pregnant patient

Our medial retrieval service undertakes few true ‘obstetric’ transfers.

A review of 66 cases of pregnant or post-partum patients retrieved by GSA-HEMS, 33 had  obstetric conditions (mainly post-partum haemorrhage, some treated antepartum haemorrhage, and a few eclamptic patients). The other 33 had general critical care issues such as pneumonia and intracranial haemorrhage.

The only delivery we have had to conduct was a resuscitative hysterotomy (peri-mortem cesarean section) which was undertaken by retrieval registrar in the patient’s home during cardiac arrest. This is described here.

Most obstetric transport is undertaken by midwifery-trained flight nurses on fixed wing air ambulances. They deal with a lot of pre-term labour cases. Some general principles of obstetric retrieval include:

• Avoid transport in active labour.
• If labour is suppressed and the patient is ‘stable,’ transport can safely be carried out.
• If labour cannot be suppressed, the most appropriate course of action is for the baby to be delivered in the referring hospital and a specialist neonatal team mobilised (NETS).

The ABC of preterm labour is:

Antibiotics – penicillin 1.2 g iv (or clindamycin 600 mg)
Betamethasone – 11.4 g im (or dexamethasone 6 mg im)
Calcium antagonist – nifedipine 20 mg (up to 3 doses 30 mins apart if continued contractions)

In medical retrieval, we mainly focus on good general critical care of the pregnant patient.
In cases of obstetric haemorrhage, we need to consider general management of the bleeding patient:

• Turning off the tap (surgery, interventional radiology)
• General measures: avoiding hypothermia, coagulopathy, acidosis
• Blood product replacement: PRBCs, FFP, platelets, cryoprecipitate, maintaining normocalcaemia, considering tranexamic acid and in rare cases factor VIIa.
• Triage to the most appropriate facility: not just with an obstetrician, but with tertiary blood blank, theatre, intensive care, and interventional radiology services. This is invariably a trauma centre.

Guidelines for the management of post-partum haemorrhage are here. Remember the 4 T’s: trauma, thombin (DIC), tissue (retained products) and tone (loss of uterine tone).

Guidelines for the management of pre-eclampsia/eclampsia are here