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FP-C High-Risk OB Transport Review
High-risk OB transports concentrate risk: two patients, time-sensitive pathology, and an environment (aircraft) where delivery is the scenario everyone is trying to avoid. The exams focus on a tight set of patterns — preeclampsia/eclampsia with magnesium infusions, obstetric hemorrhage, aortocaval compression, preterm-labor logistics, and the deliver-before-or-fly decision.
Doses and infusion management follow the sending orders and your protocols; what the exam tests is monitoring discipline (what does magnesium toxicity look like?), positioning physics, hemorrhage logic that respects pregnancy's altered physiology, and the humility to recognize imminent delivery on the ground.
Hypertensive disease and the magnesium watch
Preeclampsia — new hypertension after 20 weeks with proteinuria or end-organ signs; severe features: severe-range pressures (commonly cited ≥160/110), headache, visual changes, RUQ/epigastric pain, pulmonary edema, rising creatinine/LFTs, low platelets. HELLP (hemolysis, elevated liver enzymes, low platelets) can present subtly — the RUQ-pain patient with malaise is a tested trap. Eclampsia = seizures: protect, position left-lateral, oxygenate, magnesium per orders/protocol, and anticipate recurrent seizures. Severe-range blood pressures get antihypertensives per the sending plan — stroke is the maternal killer.
Magnesium sulfate transports: your monitoring triad is deep tendon reflexes (loss is the early toxicity flag), respiratory rate/effort (depression as levels climb), and urine output (magnesium is renally cleared — oliguria accumulates it); continuous cardiac monitoring throughout. Toxicity response: stop the infusion, support ventilation, and calcium (the antidote) per protocol/medical direction. The exam loves the toxicity-ladder question (reflexes vanish before respirations fail) and the infusion-discipline layer: pump-controlled, labeled, never bolused by gravity surprise.
Hemorrhage, positioning, and the delivery decision
Pregnancy rewrites shock assessment: blood volume expands ~40–50%, so a pregnant patient can lose well over a liter before classic vital-sign changes — and the fetus is the first organ hypoperfused (placental flow is sacrificed early). Treat mechanism and suspicion, not reassuring numbers. The bleeding patterns: placental abruption (painful, rigid uterus, often concealed bleeding — trauma association); placenta previa (painless bright bleeding — no digital vaginal exams, ever); uterine rupture (tearing pain, loss of station, fetal compromise — prior cesarean history); postpartum hemorrhage (the four T's: tone — most common, fix with fundal massage and uterotonics per orders; trauma; tissue; thrombin). Transport care: large-bore access, volume/blood per protocol, warmth, left-lateral or manual uterine displacement, and speed to obstetric/surgical capability.
Aortocaval compression: from roughly 20 weeks, supine positioning lets the uterus compress the inferior vena cava (and aorta) — dropping preload and pressure (supine hypotensive syndrome) and degrading CPR. Fix: left-lateral tilt (15–30°) or manual left uterine displacement — including during resuscitation, on backboards (tilt the board), and strapped to the aircraft litter. The delivery decision: imminent-delivery signs (crowning, bearing-down urge, multipara with rapid pattern) mean deliver before transport — a controlled delivery in a facility/ground environment beats one in a moving aircraft at altitude with no room; conversely, preterm labor without imminent delivery transports mother as incubator (with tocolytics/steroids per sending orders) because the best neonatal transport device is the uterus. Either way: neonatal resuscitation equipment checked and warm before wheels-up, because OB transports occasionally become two-patient transports despite the plan.
Practice questions with answers & rationales
Q1. Your magnesium-infusion patient's deep tendon reflexes have disappeared and her respiratory rate is drifting from 16 to 10. What's the sequence?
Answer: Magnesium toxicity, progressing in textbook order (reflexes lost first, then respiratory depression — cardiac effects beyond that). Sequence: stop the infusion immediately; support airway/ventilation as needed; administer calcium per protocol/medical direction as the antidote; reassess reflexes, respirations, and urine output (renal clearance — oliguria likely contributed); notify the receiving facility. The tested core is the toxicity ladder and the stop-support-calcium response.
Q2. Why is a 'normal' blood pressure falsely reassuring in a bleeding third-trimester patient?
Answer: Pregnancy's 40–50% blood-volume expansion lets her compensate through losses that would destabilize a non-pregnant adult — and compensation works by constricting the uteroplacental bed, so the fetus is in shock before the maternal vitals admit anything. Practical consequences: treat by mechanism/suspicion, trend subtle signs (rising HR, narrowing pulse pressure, maternal anxiety), establish access early, and remember fetal distress may be the first 'vital sign' of maternal hemorrhage.
Q3. A 34-weeker becomes hypotensive and lightheaded every time she's supine on your litter. Diagnosis and the two fixes?
Answer: Supine hypotensive syndrome — aortocaval compression: the gravid uterus pinches the IVC, gutting preload. Fixes: left-lateral tilt (15–30°, wedge/litter tilt) or manual left uterine displacement when tilt isn't possible (CPR, procedures, certain restraint configurations). This positioning rule survives everything — backboards get tilted as a unit, and arrest compressions in late pregnancy include continuous uterine displacement. It's the highest-yield two-handed intervention in OB transport.
Q4. Painless bright-red bleeding at 32 weeks versus painful rigid-abdomen bleeding after a car crash — name each and the one prohibition.
Answer: Painless bright bleeding = placenta previa (placenta over the os); painful rigid uterus with possible concealed bleeding = abruption (placenta shearing off — classic after trauma). The prohibition: no digital vaginal examination in third-trimester bleeding — a finger through a previa can convert spotting into catastrophe. Field/transport care for both: access, volume per protocol, left-lateral positioning, fetal-aware monitoring, and rapid delivery-capable destination.
Q5. The sending facility wants a 36-weeker in active labor flown 45 minutes; your exam shows crowning. What's the call?
Answer: Deliver before transport. Crowning means delivery within minutes — managing a birth (and a possible neonatal resuscitation) strapped into a vibrating, noisy, space-limited cabin at altitude is the worst available option. Deliver in the controlled environment with the sending staff, stabilize mother and newborn, then transport one or both as needed. The exam rewards recognizing imminent delivery as a no-fly trigger; 'mother as incubator' applies only when delivery is not imminent.
Q6. Why do preterm-labor transports often carry orders for corticosteroids and tocolytics, and what's your role with each?
Answer: Antenatal corticosteroids accelerate fetal lung maturation — the dose's value compounds with every hour gained before delivery; tocolytics aim to suppress contractions long enough to complete steroids and reach a NICU-capable center. Your role: administer/continue per the sending orders and protocol, monitor for agent-specific effects (and magnesium's toxicity ladder when it's the tocolytic), document contraction patterns and fetal status, and reassess the imminent-delivery question continuously — tocolysis failing mid-transport changes the plan.
Q7. Immediately after an in-transport delivery, the mother bleeds heavily with a soft, boggy uterus. First-line response?
Answer: Uterine atony — the most common postpartum hemorrhage cause (the 'tone' of the four T's). First-line: firm fundal massage (and encourage breastfeeding/nipple stimulation — endogenous oxytocin), uterotonics per protocol/orders, volume resuscitation, warmth, and rapid notification. Examine for trauma and retained tissue as alternates. The credited sequence starts with hands on the fundus — the mechanical fix precedes and accompanies the pharmacology.
Common mistakes to avoid
- Monitoring magnesium patients without the reflex–respiration–urine triad, or missing calcium as the toxicity antidote.
- Trusting maternal vitals in hemorrhage — the fetus is hypoperfused long before the numbers move.
- Performing or permitting digital vaginal exams in third-trimester bleeding.
- Transporting crowning patients 'because the NICU is better there' — imminent delivery is a deliver-first trigger.
- Forgetting left-lateral tilt/uterine displacement on litters, backboards, and during CPR.
- Launching without checked, warmed neonatal resuscitation equipment on any OB mission.