All right, so thanks very much for inviting me. I'm glad to be able to talk about this topic because A, I live this on a regular basis, this question, and B, of all the transport cases that I have to deal with, anything that has anything to do with obstetrics always gives me a little bit of heartburn because a lot of times you're racing against the clock in obstetrical emergencies or women that are in labor and still need to be transferred, so think about this a lot. So happy to share some insights with you. And so, yeah, so I'm an intensivist, I'm also a transport physician with Orange, it's our provincial area ambulance and critical care transport service in Ontario. And just to give you an idea of the kinds of distances we're talking about, I guess I should have put up some other thing so you could see how big Ontario is, but we've got helicopters, fixed-wing airplanes, and ground critical care transport units across the province, but as you get further and further north, you're getting into very isolated areas, very spread out population, particularly in the winter, subject to significant transport delays. And so we have a big jurisdiction and we have one provincial control centre, and when you're a transport physician, you're looking after everything for the entire province and guiding all our critical care transport paramedics and working with the sending and receiving facilities. So sometimes it's really easy, it's a 15-minute drive from one place to another, sometimes it's a four and a half hour flight. So lots of different scenarios that we deal with. So what I'd like to do in the next 10, 15 minutes or so, talk a little bit about three different things I'd like you to think about in parallel when you're thinking about cases that might need to move from your facility. Medical issues, obstetrical issues, and neonatal issues, and we're gonna talk about how they all work together and helping you think about what to do. A big part of this, fundamentally, it's a risk-benefit analysis about am I safer to keep this patient where they are or am I safer to move them? And that's always the question that you're asking, hopefully you're making sure you make the right one. Sometimes there isn't a perfect answer and you're trying to pick the best worst option knowing that sometimes there's always gonna be some risk. I'll talk very briefly about different modes of transport that we think about in terms of ground and different air types of transport and talk a little bit about staff and equipment during transport as well. So here's your three things I want you to think about and it is really kind of a Venn diagram-ish kind of thing. There are medical or surgical reasons for moving a patient, there's obstetrical reasons for moving a patient, neonatal reasons for moving a patient, and they intersect. And so what I'd like to do is we're gonna go through sort of the three different areas and think a little bit about how they intersect as we come up with a final plan for what we're gonna do potentially for a patient. We'll start off with medical and surgical. And so really this one's probably the easiest that if you have a patient who has a medical or surgical problem that you would normally be transferring out of your center and they happen to be pregnant, you're probably gonna send them out anyways, right? So that's actually pretty easy. The only thing is the addition of having to think about both obstetrical and neonatal support may impact on your referral patterns. So you have to think about this a little bit. So why would you usually send a patient out? Well, ECMO, right? So you gotta make sure if you're sending them to a place and they need ECMO, that they have ECMO. Trauma, if you're not a trauma center, you're gonna send them out. Maybe it's a surgical subspecialty that you don't have or a medical subspecialty or they need a cath lab, you don't have a cath lab. Whatever the reason is, you're gonna try to pick the right place. But you have to make sure that the right place that you normally send those patients to actually has the obstetrical and neonatal support to manage that patient. So I'll give you an example, true story. I'm in the helicopter, we got a call for a trauma and we hear on the sat phone as we're on the way, we've got a woman and she's 28 weeks pregnant and she's got some pretty critical injuries. Okay, no problem. You say, okay, well, we'll take the patient to the lead trauma hospital that manages multi-system trauma and has high risk obstetrics and has a level three neonatal capability. Well, for a little while in Toronto, we didn't have such a place. We had two lead trauma hospitals. One, they were, hopefully nobody from Toronto in here so I don't get in trouble. They merged with another hospital. They were called Sunnybrook and Women's Hospital. The only problem is that the Women's Hospital was downtown and they were uptown and they hadn't moved the obstetric services from that hospital yet. So Sunnybrook, which was our major trauma center in Canada had at that point, absolutely zero obstetrical support. And then the other lead trauma hospital, St. Mike's, they had sort of level two neonatal support, not really high risk obstetrics. So as we're flying in to pick up this patient, I'm going, holy crap, where am I gonna take this patient? That's been fixed, right? Good news. But I know of other jurisdictions where that's a problem. I still think in Toronto, one of the things we haven't worked out yet, all of our respiratory failure ECMO patients for almost always went to Toronto General Hospital. They're world experts on VV ECMO respiratory failure. Guess how much obstetric service they have there? Like pretty minimal, right? So it's a challenge, right? Trying to work this out. So my only advice on this one is think about these things in advance, because as you're landing the helicopter in the field, that's probably not the time you want to be thinking about this. Your system needs to think about how you're gonna approach this and think about this. And it's a challenge with regionalization of care in particular, because sometimes it's like a bit of a poker game. You get the cath lab, you have the trauma center, you have high risk obstetrics, you have neonatal. You kind of hope that things land in the same right place so you can get the patients everything they need in one center, but just something to think about. Let's talk about obstetrical stuff for a minute. So I kind of think of about six scenarios. I'm gonna go through these things quickly. This is not like super researchy scientific. This is just really being pragmatic at three in the morning when I get these calls and the things that I'm thinking about that I just want to share. This baby is delivering or needs to be delivered now, like right now, like it's happening right now, like there's a head there. This baby might be delivering almost now. This baby may deliver or needs to be delivered in the next few hours, or maybe in the next 24 hours, or maybe the patient's not in labor at all and doesn't require any kind of accelerated delivery plan, and then finally, postpartum complications. So kind of quickly work through all these scenarios for a second. So if you're in a sending facility and this patient has a problem and you're thinking about sending them out and the delivery is imminent, like literally the head is there, you're not putting them in an ambulance or a helicopter or a plane and sending them out. You're gonna deliver them and then you're gonna move them. And now the challenge is you may have two patients. You got the mom and now you have the baby, so you might need two transport resources now. Sometimes if the baby's healthy and the mom's not that bad, sometimes we'll transport the baby with the mom, but many times if the baby's got any issues, you have to transport that baby in like a separate incubator that you often can't put in the same transport resource. So sometimes we're sending two planes to the same place to pick up mom and baby separately. What if you have an indication for an emergency section? You're having like horrible decelerations. There's clearly something really bad happening. Yeah, maybe it's not a high-risk obstetrician. In fact, maybe you don't even have an obstetrician at all, but you have a general surgeon that knows how to do a C-section. Guess what? You're not transporting that patient, you're doing the C-section because by the time you get that mom to where they need to go, the baby's probably gonna be dead or be in horrible shape. So sometimes you have to make the decision it's not the right thing. They're calling me for transport. Like what you're right now is not a transport, you need somebody with a scalpel, right? So you gotta do what you need to do. The other thing too, particularly worrisome, let's say there's not an immediate reason to deliver the baby per se because there's not decelerations or some other problem, but the mom is in horrible shape to the point where the likelihood of them being transported without having a cardiac arrest during transport or horrible destabilization means you've gotta get that patient stable, that mother stable before you can move them. Because I'll talk about this a little bit more after, there are two things that are probably, they should be never events, they're never gonna be never, but one is delivering a baby in a helicopter while you're flying the woman from one place to another. And the worst case scenario is having a maternal cardiac arrest in a transport vehicle because 99.9999% of the time, there is nobody that's gonna do an emergency hysterotomy, to get that baby out and try to save the baby, which also usually helps the mom if you have any chance of getting them through that. So if you've got a patient who's on three pressers, who's really crashing, like sometimes whether they're pregnant or not, we just can't move that patient because they're just too unstable to move and you've gotta do your best to try to stabilize them where they are. We'll send crews to help, we'll send our critical care paramedics to help and they'll help work with the sending facility to stabilize the patient, but they're just too unstable to move. Okay, what about if the baby might be delivering almost now? So this is a big deal, getting inaccurate information about the state of labor and the progression of labor when we get the phone call asking us to send a resource, right? And so, okay, well, what was the cervix like? Okay, how long ago was that checked? Eight hours ago? Ooh, okay. How often are the contractions? Oh, okay. Have you checked to make sure there's not a head there? Right, so we get this a lot. Now, to be fair, sometimes we're getting calls from places that, honestly, they have very little obstetrical experience. We're getting calls from these northern nursing stations where it's great that we can find a nurse that's willing to go up and actually do that. There's no doctor, there's a nurse up there managing all sorts of crazy things. Very limited obstetrical experience and if you wanted to test like inter-rater reliability of some of those cervical exams, not so good, right? So we've certainly been burned a number of times and we do often insist on an updated exam unless there's a contraindication while we're on the way. So that's something to really think about because, again, you don't want them delivering during transport and so you really want to make that decision should I stay or should I go, right? You need to have some updated information about where you are in the labor and what's the risk of delivery. You also want to think about what are other risk factors for precipitous labor? So is this sort of a grand multiple who has a history of like going from zero to 100 in terms of their labor and popping up that baby really fast and especially if it's a more preterm baby that's gonna be small with those other things, you add all those factors together and you know this accelerates very quickly and so you need to be prepared for that as far as reassessment of the exam and knowing where you are and making that decision whether you're gonna go or not. So we often ask for an update while we're launching our transport teams and we often will ask for another reassessment before we leave the facility if you can just to make sure, because we're always asking ourselves should we stay, should we go and we need updated information to help sort that out. And then you're really always doing this risk benefit assessment so you're close to delivery but you're not quite there yet and so if you know that you're early and you're also taking into account how long is the transport and do you think you can make it or not, these are complex decisions that require discussions with your sending facilities team, the receiving obstetrician, plus or minus neonatology and your transport experts to make a decision do you stay or do you go and that's really important. And so sometimes though the limitations and what you have in the sending facilities do impact on this. So you have a very complicated obstetrical situation where you think it's gonna be almost impossible for that baby to be delivered vaginally but there's nobody at that facility that can actually do a C-section like you hope that they plan for this because there are women living in most communities and women get pregnant and every once in a while they need a C-section so even if you're in a small hospital like you really hope you've got, you've thought a plan through in this one in case there's an emergency but lots of times it doesn't happen and they say Fred's the only surgeon, right, he's the only one who does C-sections, he's off in Cuba on vacation or something and you're like okay. So that sometimes is taken into account as well. Now those were sort of like red light sort of scenarios. Let's talk about kind of a yellow light scenario in the middle. We're talking about hours, we're kind of more into early labor or maybe mid-labor and you're saying you're still assessing whether they deliver during transport so you start to ask yourself a few other questions. So is this an uncomplicated term pregnancy, right, and the transport time's reasonably short and there's a chance but there's whatever reason risk-benefit wise you think that patient needs to go, maybe for the other medical or surgical reasons you need to transport them. If you've got the right transport team that's used to uncomplicated deliveries and you're not expecting a problem and they can also do neonatal resuscitation, you might say okay, maybe we'll go and if she does deliver we've got a team that can actually manage that, that's okay. Still not a good idea, like you don't want to deliberately plan for that but it may weigh into things a little bit. If you think you've got enough time, once in a blue moon you're gonna be wrong. And then so again, what's that expected inter-facility transport time? So if it's an hour helicopter ride and you're thinking where are they in their labor and you're like yeah, I think they'll make it, it's a pretty good chance they're gonna be okay. Whereas if it's one of these four and a half hour flights from very rural northern area, you're like I'm not sure. But then you're also taking into account well what resources do they have to actually manage the patient? And so these are complicated discussions that you've got to have. The most important thing is it's got to be a dialogue between receiving and sending and the transport folks to figure out what's the best way to go. What if you actually think you've got actually a bit more time? So in the next 24 hours, it's often things like premature rupture of membranes is probably one of the commoner scenarios. And then you're always asking yourself, okay, if the mom is stable enough to transport, ideally sounds like you got some time, just transport them. That's probably the easiest thing to do. Sometimes again, the mom is too unstable to transport because we're talking about potentially critically ill patients, right? And so if that's the case, there's a very important rule, right? The best transport incubator is called a uterus, okay? Not one of those plastic thingies, okay? So if you can move the mom with the baby in utero, that's the best strategy. And I'll show you a little bit of data just very quickly. So classic data that it's much better to deliver particularly a preterm baby or a low weight baby in the facility that's got the advanced neonatal capability than to deliver them someplace else and then move the mom and the baby separately. Now, if you can't do it because the mom's too unstable and you think the baby's gonna be delivered there, then your second best option is sending an expert neonatal transport team to be there when the delivery happens, that's the ideal state, or at least get them on the way so that as soon as possible after the delivery, the neonatal team is there to help resuscitate, stabilize the baby, and then you've got these two patients that you potentially have to move. So that's the question. Hopefully you can move them, but your backup strategies, get the neonatal team there if you can't, but the best strategies, get them there. And then finally, the patient's not in labor, doesn't require any accelerated delivery plan. And if you're comfortable, you can manage that patient, and you do have some obstetrical services, maybe you don't have to move them right away. And so that's, again, a complicated conversation that you're gonna have between sending and receiving. But if one of your questions is, well, how likely is it that this patient's gonna deliver in the very near future? And so there are ways to help predict that, and you look at a cervical ultrasound and febrile fibronectin and ways to at least rule out the likelihood that there's gonna be an imminent delivery that you're gonna have to worry about. So you may have some more time to stabilize the mom, maybe get them extubated to the point where they're better. They may still need to go get transferred somewhere, but if you can avoid having to transfer them when they're critically ill, then that's ideal. You're gonna look at fetal status as well, and you have to be able to monitor at the sending facility to make sure you keep an eye so that if there are any signs that there's fetal or maternal trouble that you actually get them out and accelerate the plan to get them out. But you always have to be prepared that things can happen fast in these patients. As you heard from both of our previous speakers, there's not a lot of reserve, as they can go from being fine to not fine very quickly and then get sick very quickly. And so you need to have a plan both to get them out faster if things change, but also whenever I've got a pregnant patient in the ICU, we're always thinking about having that delivery set up and neonatal resuscitation set up right nearby, like in the adjacent ICU room, because if things happen and they happen fast, you wanna be prepared to do that and working with your obstetrics and pediatrics teams so that they're ready and they know about the patients that they get called and you're keeping them for the next little bit that they're gonna come and help you. And then finally, one of the things that it's always there is postpartum complications. And so postpartum hemorrhage is a big deal. When I used to work in my center that didn't have trauma, I used to refer to the postpartum hemorrhage transfers in as trauma because it was like the 20-pack cells later by the time they get to me and that sort of thing. And so in this case, you're gonna send these patients because they're gonna need maybe a surgical intervention, interventional radiology for postpartum hemorrhage and other things. So there's certainly reasons for sending them, but again, you wanna try to stabilize them before you get them out. And then finally, neonatal, just as a reminder, there's different levels of neonatal support, level one, level two, level three, and level four. And it's really based on sort of gestational age and presumed fetal weight. And so basically if they're above 35, 36, 37 weeks, you're probably in good shape with a fairly minimal neonatal support. But as you're dealing with lower gestational age and smaller babies, you need more support as you go through. And so what you really wanna do is make sure you're matching where the baby's delivered when you can to make sure they have the appropriate neonatal support. And there's data that shows that the mortality is reduced. Outcomes are better if the baby delivers, for like a small or early gestational age baby or a low birth weight baby, if they deliver in an appropriate neonatal facility that matches their needs, particularly a level three for those who are early gestational age or below 1500 grams. And so finally, just to sort of wrap it up, if you got the green light that everything's fine, the patient's stable, you decide that they're gonna go to tertiary care facility, you don't think they're gonna deliver, they're stable enough to transport, no problem, you move them, that's great. What if you think you can manage them from an ICU perspective and they're pregnant, but the pregnancy seems to be going fine and there's no imminent need for delivery or any other issues, maybe you're able to stay. Let's say that you have, let's say a level two NICU, right? And so maybe if they can stabilize a little bit longer, let that baby cook a little bit longer in there and get a little older, a little bigger, maybe they don't necessarily need to be transferred because you're sort of on the brink, you're really close to being able to support them. You might be able to buy a little bit of time and then avoid that transfer. So that's kind of a discussion that you're gonna have. Maybe you're gonna deliver them at the sending facility and send that neonatal transport team and then kind of the less optimal scenario is delivering them before the neonatal transport team gets there, but you might have to do it. And again, worst case scenario is delivering the fetus during transport. And so the last thing I just wanna mention is the teams. You wanna make sure you have a team that's gonna be able to handle this. So a lot of times you try to have a specialized transport team that's got the obstetrical and neonatal resuscitation expertise, but sometimes you have to send staff from the sending facility to do that along with your transport team because they just don't have it. Ground versus rotor versus fixed wing, just a basic rule, ground for shorter distances, rotor a little bit longer distances and fixed wing aircraft for much longer distances. Fixed wing rotor wing helicopters are more susceptible to weather and they also need helipads. So sometimes it's just faster to drive from one hospital to another, then fly them because you need to go to an airport, put them in an ambulance, move them, go to another airport, put them in another ambulance, ends up being longer. So rely on your transport experts to tell you sort of what makes sense. Good communication, good monitoring of the patient. Tocalytics is one thing just to mention. For term babies, generally we don't do tocalytics because it's not something that's gonna help, right? The one exception is if you have a five-hour flight and you don't want them delivered in transport and you have to move them. Sometimes people will use a tocalytic just to slow things down a little bit to try to get them there. If they're already in labor, you don't want it to progress. And you heard about airway issues and so you wanna make sure you prepare these patients that they need to be intubated, intubate them before transport because you don't wanna have a difficult airway en route. If they're bleeding, make sure you bring blood products. So just being prepared. And just having the usual equipment to manage a critically ill patient when you transport them but thinking about, is it possible they're gonna deliver? Is there a way that I can monitor fetal heart rate during transport? Although it's hard in a helicopter, it's kind of loud. Thinking about having the right drugs to manage obstetrical-related complications and issues. Having a checklist can really help you when you're speaking between sending and receiving the transport teams, making sure you have all the right information and you haven't missed it. So there's a reference that's up there. It's a great checklist that you can look at. It's also in the FCCSOB textbook, the new version of it, if you are interested. And the last thing I'm gonna mention, one is fetal viability and decision to transport. So when you're on that very early brink of viability and depends on how many weeks you want that to be, but sometimes what's considered viable at a tertiary, quaternary obstetrical center with advanced neonatal services is not the same cutoff that other places might think is viable. So when you're on that sort of brink and we keep pushing the technology to decide what's the cutoff between saying a pregnancy is viable or non-viable, those are sometimes some complicated logistical and ethical discussions that can't get into here. And then I mentioned that whole issue about having to do a resuscitation histerotomy during transport. It's just, it doesn't happen. So if you think there's a high risk that they're gonna arrest, don't send them in an aircraft or an ambulance. All right, so I'll stop there. Thanks very much. Kind of sum up, right? Medical surgical reasons why you transfer, obstetrical reasons, neonatal. Think about how they intersect and work with your sending, receiving facilities and your transport teams together and you'll make the right decision. Thank you.

transporting obstetrical patients

challenges

considerations

risk-benefit analysis

coordination

communication