Episode 123 Transfer
Florence Wilcock: [00:00:00] Hello, my name's Florence. Welcome to the obs Pod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy, call the midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth.
Perhaps you work in maternity and want to know what makes your obstetric colleagues tick or you want some fresh ideas and inspiration, whichever of these is the case, and for that matter, anyone else that's interested, the Obs Pod is for you.
Episode one 20. Transfer this week is World Prematurity Day, the 17th of November, [00:01:00] a day where every year we think about, and remember those babies that are born prematurely. I've touched on premature babies in some of my other episodes. Might like to look back to the episode detour where I worked in a neonatal unit for a time, or possibly one of my baby loss episodes about signs of life, about very extreme prematurity.
Today in honor of world prematurity day, I'm going to talk about transfer. Imagine for a moment you're pregnant, you're excited, you're looking forward to having a baby. You're in the middle of your pregnancy. You've had your 20 week scan a few weeks ago. You've found out what sex [00:02:00] you're having. Maybe it's a boy, maybe it's a girl.
But you've started to imagine in your mind's eye this baby and start to plan for its arrival. Maybe you have a few twinges, Maybe you've got a bit of tummy pain. Maybe you've got an increase in vaginal discharge. You've decided to pop into the hospital, have a bit of a checkover. Suddenly you are whisked to the labor ward.
You're told to call your partner. You're told this could be premature labor. Maybe your baby's going to arrive soon. You're in shock. It's far too early for your baby to arrive. Maybe you are 25 or 26 weeks pregnant. You're scared, you're [00:03:00] not prepared, and you're worrying. How might this tiny baby survive?
You're in shock. You're trying to get your head around the fact that this baby might be going to arrive months ahead of schedule, and then a doctor or midwife walks in and starts to explain to you that they're going to need to send you to another hospital, not the hospital that's close to your home, not the hospital that you chose to have your care.
Not the hospital that you know and have become familiar with the staff, but a completely different hospital you're at possibly one of the most stressful times of your life and they're telling you they can't care for you. [00:04:00] What's this all about? So this is what's called an in utero transfer. And the point of it all is that the most preterm and smallest babies need to ideally be born in what's called a tertiary level neonatal unit.
So neonatal units have different grades depending on the skill of their staff and the equipment and facilities They have special care baby unit is where babies born from 30 to 32 weeks of pregnancy will receive their care. They might have some minor help with feeding, perhaps treatment for jaundice. It's neonatal care.
That's a level above what your baby might receive on the postnatal ward, but, [00:05:00] Minimal. Then you have what's called a local neonatal unit or level two. These units can look after babies that have some special care needs, and they may need some help with breathing support. Babies born after 27 weeks will often receive their care in this local neonatal unit, and that is the level of the neonatal unit in my hospital.
Then there's what's called a level three neonatal unit or neonatal intensive care. This can provide all bells and whistles, every aspect of care a baby might need, and babies that are likely to be, born before 27 weeks or a less than 800 grams in birth weight. Should ideally start their care at a neonatal intensive care [00:06:00] or level three unit.
So the difficulty is that not all units will have a level three neonatal unit. We've got to consolidate our staff, our equipment, our expertise in those level three units. Most local hospitals will have a level. Or a level one unit, Hence the problem we want, ideally, those babies born before 27 weeks, or estimated to be less than 800 grams birth weight to be born in that level three unit.
Why , Well, the statistics are actually incredible. If we can have all the babies. Of less than 800 grams or less than 27 weeks, born in a tertiary unit, [00:07:00] one more baby will survive for every 20 women transferred. And if a baby is not born in a tertiary unit, so it's born in the wrong place, it has a two to three times higher chance.
Of intra ventricular or per ventricular hemorrhage, that's a hemorrhage, a bleed in its brain that may result in some form of brain damage and a 1.3 times higher risk of death. So being born in the right place is crucial in improving not only the survival of your baby , but it's long term health. Place of birth of course, is not the only thing.
There are other things we are going to do to try and [00:08:00] optimize the health of your baby, such as giving steroids to try and help improve the baby's lungs, magnesium to try and reduce the risk of brain damage, and then antibiotics. To prevent infection. But where a baby is born is a crucial component. One of the four crucial things we can do that improves clinical outcomes for preterm babies.
And it kind of makes sense logically. So if you imagine we can either move you the woman you can get up and walk, or you can be in a wheelchair and your baby is transported, cushioned in the womb in its amniotic fluid, receiving blood supply from the placenta, [00:09:00] beautifully protected, or, if the baby is born in the wrong place.
Then we have to do what's called an ex utero transfer. So that is your very fragile, very preterm baby being put in an incubator, probably with some ventilation or breathing support with drips, with an intensive care nurse, with an intensive care doctor being put in an ambulance and sent to another place. So it's common sense that really the best thing to do, if at all possible is to transfer you.
Okay, Makes sense. Makes a big difference to outcomes. Why is it so difficult? Well, the reality is we have to try and decide who might be about to give birth to a very premature or [00:10:00] very small baby. And then we've got to balance that with is it safe to transfer you? Ideally, we want to be doing things early enough that we've got time to safely transfer you.
We don't want your baby born in an ambulance that's not good for you or your baby, but equally we don't want to transfer too many women because actually we thought they were about to deliver, but they weren't. And then we've potentially had a neonatal unit that had cots who's received a woman, and they're keeping a cot for that woman.
But actually, if we've made the wrong call and she wasn't likely to give birth, we've wasted a cot. So it's very difficult. Fortunately for us, there've been quite a few modern [00:11:00] developments that can help us decide which women might be the right women to transfer. So we can take a history, find out what are your symptoms, how are you feeling, what's been happening, and also look at your examination.
But we can also use something called Quip app, which looks at predictors of preterm birth. This might be the length of the cervix, the neck of the womb, or a quantitative fetal fibronectin. That's something that your cervix releases when it's likely to go into labor. These can be keyed in to the Quip app, website, by a doctor, or midwife, and it helps give us an idea about the likelyhood, Of going into labor prematurely in the next week.
It can't absolutely tell [00:12:00] us who's going to birth their baby very preterm, but it can give us a picture of who might not and therefore less need to transfer and move these women around. Whereas if you've got a higher percentage chance, we may then institute some of the treatments I mentioned. Such as steroid injections and magnesium sulfate, and we are more likely to want to move you to a tertiary neonatal unit so that you are ready just in case.
So once we've tried to decide if you are the person that's going to give birth very prematurely, then we've got to work to try and find somewhere for you to go , and this isn't easy. I work in London. There's masses of hospitals and [00:13:00] eight tertiary level neonatal intensive care units, so you'd think it would be easy.
I'm spoiled for choice. The reality is that you've got to find a unit that has a cot that is free, that has the right staff ready to care for that baby. They're not short staffed or having lots of people off sick, and then because you are being transferred and the baby is still in the womb, as well as making sure the neonatal unit have availability in staffing.
I've also got to make sure that the obstetric unit. Probably the labor ward also has space for you and appropriate staff. This can be a bit of a minefield. We can spend hours ringing round different neonatal units only to find, yes, the neonatal unit has a cot and can accept no. The labor ward's got a shortage [00:14:00] of midwives, or they're overflowing with women in labor.
Yes, this labor ward they can take, That's okay. Yes, The neonatal unit can take, Oh no, actually someone's just turned up and taken that cot so we have to make a series of phone calls and it can be very difficult to coordinate and all this while. We're also trying to look after the woman at the center of all this, because if her cervix is dilating more and she is laboring, then we've got a finite amount of time in which we can safely do the transfer.
Yes, we're gonna send a midwife or nurse with her in the ambulance, but we absolutely do not want this baby to be born in the back of an ambulance. This baby is vulnerable. This baby, yes, it would be better to be born in a tertiary unit [00:15:00] or a level three unit, but it definitely would be better to be born in a level two unit than on the road in the back of the ambulance.
So it can be quite a challenging juggling act because of this. Some places, including London, have really worked hard to try and improve the way we do an in utero transfer to try and coordinate better the phoning so that you have to phone one place with just one phone call, and this is the emergency bed service.
And the idea of this is to try and improve and reduce the number of babies that are born outside of the level three neonatal units who really should be born there. So there's been lots of work going on in London in [00:16:00] the last few years to try and streamline the process, make sure conversations are happening at a senior level
consultant to, consultant or senior midwife to senior midwife and better coordination so that you are making less phone calls and because the emergency bed service is run by ambulance control also, then ensuring that when you have located a cot, And located a maternity unit and you get the green light with much relief, you can then safely transfer the woman with a member of staff accompanying her in an ambulance in a time efficient way.
There's nothing worse than finally getting agreement from a neonatal unit and a labor ward and then having to wait a long time for the ambulance transfer. . [00:17:00] There's been a lot of improvement in the last few years, but it's still far from a perfect system. There's a lot to coordinate and a lot to think about, let alone explaining to the woman, her partner, her family.
Why? Why is that? You just can't look after them where they. And as a doctor or a midwife, it feels really difficult to have those conversations. It feels almost like you're rejecting that family. You're saying, We can't care for you here, but we really are doing it with the best of intentions.
A few years ago when we did the project, nobody's patient, I was inspired to write a poem. My perspective, the obstetric perspective of an in utero transfer. [00:18:00] So I'm going to read it to you now. The transfer dilemma, In utero , ex utero it seems very simple to me. Surely we know in utero is much the safest. Why is this decision always made so late in the day?
Those pesky obstetricians, they're so slow to decide. In the meantime, the neonatal team are taken for a ride. Please, let's not start an argument. Can I instead explain what may be going on in the obstetrician's head first for a start? I have to break a woman's heart. There's no easy way to say, I have to send you away.
The relationship and trust is shattered into [00:19:00] dust. Her views don't hold sway. It's just going to be this way. We can't care for you. Here are the last words she wants to hear. The reasons her baby needs care are quite another. , depending on the underlying condition, transfer can be a dangerous mission. It can be hard to predict what happens next, and therefore to think through what may be best.
We have to measure up and weigh the possible outcomes, or if we let her stay a birth, bleeding, or collapse on route are just a few of the risks we must compute. Whilst we are ringing to plan her care, checking for cots here and there, we can think its settled and arranged only to find the situation has suddenly [00:20:00] changed, ready to go.
Suddenly the answers no
now for my zesty bit , my zesty bit for parents is to understand if your baby arrives very preterm, we may well move you and it will be potentially inconvenient, further from home, more difficult for family to visit and not where you chose to have your maternity care. But this will be with good reason. Your baby, should it arrive early, will really benefit from the expertise of those staff who regularly look after such vulnerable and tiny or very preterm babies.
So whilst it's a shock [00:21:00] and you're gonna find it really difficult, hopefully you'll be transferred. Your baby will stay in the womb and you'll go home and it will all become a distant memory. But should the worst happen, should your baby need to be born so early on in pregnancy or so small, your baby is in the absolute best place for your baby to have the best chance of not only survival, but good health in the future
if you are a health professional listening. Then do explore the Quip app website. I've put a link in the notes and also the implementation guidance for In utero transfer, whether you are in London or not. There's some really helpful flow charts to think about the steps we go through. I've [00:22:00] attached the bpam antenatal optimization guidance, the things that we can.
As doctors and midwives that may have a big impact and benefit those babies that are born preterm, those that need that level three neonatal care and those that don't, that need less intensive care.
I very much hope you found this episode of the obs Pod. Interesting. If you have, it'd be fantastic if you could subscribe.
Rate and review on whatever platform you find your podcasts, as well as recommending the obs pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalog from clinical topics, my career and journey as an obstetrician and life in the [00:23:00] nhs. More generally, I'd like to assure women I care for.
That I take confidentiality very seriously and take great care, not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary. If you found this episode interesting and want to explore the subject a little more deeply, Don't forget to take a look at the program notes where I've attached some links.
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