If a POC HGB and vital signs are stable this patient may go to the ER in Bethel on the next available flight. She should be warned that she may in be in Bethel for at least 2-3 days as part of the evaluation. There is also a risk she may bleed to death if she remains in the village.
Preterm and term vaginal bleeding evaluation Assess amount of hemorrhage by “pad” count and POC Hgb and transport commercial to Bethel OB Triage (if EGA > 20 weeks, otherwise to the ER) if vital signs stable and hemorrhaging allows. Consider IV fluids as needed.
Labor in the Village
- Chief complaint: Contractions, vaginal bleeding or other suggestive of labor
- Ascertain gestational age, parity and Be-in-Bethel (BIB) date (should be documented on Problem List).
- Get clear history of contractions—duration, frequency, strength.
- Get history of complications—review OB chart to review placental location, prenatal course.
- Find out when last had sex or pelvic exam.
- Make sure health aides dip a urine, get blood pressure and continue to accurately record contractions. Have them assign someone to palpate uterus.
- There is no availability of continuous monitoring—just a Doppler and manual palpation.
- If the CHA has not sent you an RMT in RAVEN, start a RAVEN alert note or a word document that you can copy and paste into a RAVEN alert note. Use this to document the frequent call backs.
- If the CHA has sent you a RAVEN RMT be sure to document your advice and call back information.
- If seems like preterm labor is a possible diagnosis—
- Start IV fluid, give Motrin 800 mg if not allergic, give terbutaline, give dexamethasone.
- Repeat terbutaline q 30 min for up to 3 additional doses if contractions continue and patient tolerates. .
- Can repeat IVF if seems dehydrated.
- If contractions do not stop and it is before the BIB, activate a medevac.
- If it is after the BIB and there is a compelling reason such as possible breech or transverse presentation or hypertension, consult HROB and consider a medevac.
- If contractions stop, can monitor in village until they can come in commercial.
- Do not fly someone commercial who could deliver en route regardless of gestational age.
- You really cannot tell who is or is not in labor over the phone— do not hesitate to consult HROB for these patients.
Do not medevac an uncomplicated pregnancy in labor who missed her BIB. The CHA will need to deliver in the clinic with your support over the phone. Have them come in commercial ASAP after delivery unless a problem arises.
- Phone * 96 to activate medevac—let them know 2 physicians will fly; get ED to fax face sheet and PTO, which you have filled out.
- Do not send the resident as the FP. This is a potentially difficult situation.
- Contact peds on call to prepare to come if preterm infant expected.
- Notify back-up that a physician with delivery privileges needs to go on medevac—back-up will either fly or come in to cover the hospital depending on time of day or other considerations. During the day it is your partner on wards.
- Back-up physician needs to know what you have done and what you are thinking since they will be managing the RMT with the village while you are in flight. Have them assume your role in Tiger Text. Please make sure the backup physician also assumes the peds wards on call role while the pediatrician is out. If a delivery is imminent, make sure the CHAs know to get the clinic or delivery room VERY warm (sweaty warm), get out a baby or premie bag and mask, plus clean towels and blankets on a surface with a lamp or other heating source, baby hat and saran wrap if needed..
- Notify ED, L&D, Northwing and the operator, so everyone knows who will be covering FP and Peds roles for the duration of the medevac.
- Gather needed supplies in L&D. They have a med pack and an equipment pack. Check to be sure there is betamethasone, toradol, antibiotics and nefedipine.
- Bring FFN; GC/CT, GBS swabs, be sure they are not expired
- Make sure there is sterile speculum
- The pediatrician will bring their own meds and supplies
- Wear appropriate gear—warm clothes, consider a space blanket and small food cache for your pocket
- Arrange transportation to hangar—Take a cab or your car to LifeMed Hanger at 3600 Tower Road (next to ACE Hanger). If you take your car you may have to get the car later. You may need to remain with the mom or baby in the ambulance to the hospital. Ensure the entire team is on the same page as to who is going on the medevac and how they are getting to the hanger. Dispatch can contact crew if issues arise while preparing to go or if you anticipate delays of more than 20 minutes to get to hangar.
- Don’t get in the flight crew’s way—ask where they need you to sit and what you can do to help.
In the village
- Ask what you can do to help get gear to clinic
- Medevac crew will get VS while you assemble supplies
- Make sure there is clear communication with everyone as to plans
- Clear the room of extraneous people
- Set up to do sterile spec, obtain FFN and cultures
- You might not have a lithotomy table-speculum can be inserted stem up or patient can be placed on some kind of lift. The health aide can hold an otoscope or flashlight if no gooseneck available for illumination.
- Check cervix after obtaining samples if no concern of previa
- Radiate calm and be decisive
- Make decision on disposition
- Imminent delivery—stay and deliver in clinic—Pediatrician will prepare for and manage the infant(s)
- Cervix closed—go to Bethel
- Cervical change but delivery not imminent—talk to high risk OB and ANMC about Bethel versus ramp transfer to ANMC.
- Cervix open but undeliverable lie—consult as to Bethel vs. ANMC for management
- Notify L&D prior to leaving clinic of plans so they can prepare
On flight home
- Monitor for resumption of contractions. Can give additional Terb, tordadol, nifedipine
- Crew will watch, but sit where you can be consulted or help if needed.
Back in Bethel
- Take patient to L&D and manage as needed
- Complete assessment—send FFN and cultures
- Do paperwork, write up events in village
- Let your back-up go home to sleep and notify everyone that you are back and available
- Let nursing know what meds and equipment need to be restocked
- See Village OB Patient in Possible Labor for printable version of above.
- See the Pediatric Village Delivery Orientation for more information about Delivery in the Village
- Village Labor Patient YKHC Clinical Guideline