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Optimizing Outcomes in Regionalized Perinatal Care: Integrating Maternal and Neonatal Emergency Referral, Triage, and Transport

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Opinion statement

The purpose of integrating emergency maternal referral and triage capability into a neonatal retrieval service is to improve the effectiveness of regionalized perinatal care and to ensure opportunities for in utero transfer are maximized. Evidence for the effectiveness of regionalized perinatal care is presented, emphasizing the striking difference in survival of outborn extremely preterm (EPT) infants compared with inborn EPT infants. Barriers to achieving high rates of in utero transfer are identified and strategies to address preventable factors discussed. There is evidence of variation in rates of outborn extremely preterm births. As birth in transit is a rare event, this variation suggests there are opportunities for significant improvement in areas with high rates of outborn extremely preterm births. Variation in the level of risk aversion by triaging obstetricians and transport platform providers may be a significant preventable factor in deciding if a particular high-risk pregnant woman is deemed safe to transfer. Collaboration between obstetricians triaging these referrals and their neonatal retrieval colleagues within an integrated service is proposed as a model to address such issues. The integrated perinatal emergency referral and retrieval service is a key component of a system structured to support regionalized care. We propose this service should sit below the regional entity responsible for clinical governance that provides an imprimatur to ensure timely and equitable access to perinatal services for high-risk women and their newborn infants.

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Abbreviations

EPT:

Extremely preterm, < 28 weeks’ gestation

VPT:

Very preterm, < 32 weeks’ gestation

ELGAN:

Extremely low gestational age newborn

TPTL:

Threatened preterm labor

PPROM:

Preterm pre-labor rupture of membranes

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Marlow N, Bennett C, Draper ES, Hennessy EM, Morgan AS, Costeloe KL. Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study. Arch Dis Child Fetal Neonatal Ed. 2014;99(3):F181–F8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. •• Goh A, Browning Carmo K, Morris J, Berry A, Wall M, Abdel-Latif M. Outcomes of high-risk obstetric transfers in New South Wales and the Australian Capital Territory: The High-Risk Obstetric Transfer Study. Aust N Z J Obstet Gynaecol. 2015;55(5):434–9. This research identified that one third of in utero transfer for TPTL did not deliver and identified clinical characteristics of the group who did not deliver. Such information could be used to inform the development of a preterm birth prediction model.

    Article  PubMed  Google Scholar 

  3. Boland RA, Dawson JA, Davis PG, Doyle LW. Why birthplace still matters for infants born before 32 weeks: infant mortality associated with birth at 22–31 weeks’ gestation in non-tertiary hospitals in Victoria over two decades. Aust N Z J Obstet Gynaecol. 2015;55(2):163–9.

    Article  PubMed  Google Scholar 

  4. • Boland RA, Davis PG, Dawson JA, Doyle LW. Outcomes of infants born at 22–27 weeks’ gestation in Victoria according to outborn/inborn birth status. Arch Dis Child Fetal Neonatal Ed. 2017;102(2):F153–F61. This paper highlights the significant differences in mortality rates for outborn compared with inborn EPT infants in Victoria, largely because outborn EPT infant are less likely to be admitted to NICU (and die at the birth hospital) after livebirth compared with inborn peers.

    Article  PubMed  Google Scholar 

  5. The EXPRESS Group. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA. 2009;301(21):2225–33.

    Article  Google Scholar 

  6. Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. J Am Med Assoc. 2010;304(9):992–1000.

    Article  Google Scholar 

  7. Kollée LAA, Eskes TKAB, Peer PGM, Koppes JFP. Intra- or extrauterine transport? Comparison of neonatal outcomes using a logistic model. Eur J Obstet Gynecol Reprod Biol. 1985;20(6):393–9.

    Article  PubMed  Google Scholar 

  8. Fenton AC, Ainsworth SB, Sturgiss SN. Population-based outcomes after acute antenatal transfer. Paediatr Perinat Epidemiol. 2002;16(3):278–85.

    Article  PubMed  Google Scholar 

  9. Roberts CL, Henderson-Smart D, Ellwood DA, Group****** HRO, Perinatal Advisory W. Antenatal transfer of rural women to perinatal centres. Aust N Z J Obstet Gynaecol. 2000;40(4):377–84.

    Article  CAS  PubMed  Google Scholar 

  10. Badgery-Parker T, Ford JB, Jenkins MG, Morris J, Roberts CL. Patterns and outcomes of preterm hosptial admissions during pregnancy in NSW, 2001-2008. Med J Aust. 2012;196(4):261–5.

    Article  PubMed  Google Scholar 

  11. Reilly S, Brennecke SP, Smith J, Boland RA. An audit of pregnancies complicated by preeclampsia necessitating in-utero transfer. J Paediatr Child Health. 2017;53:84.

    Google Scholar 

  12. Roy ND, Kitchen AH. NETS: a new system for neonatal transport. Med J Aust. 1977;2:855–8.

    CAS  PubMed  Google Scholar 

  13. Zeitlin J, Papiernik E, Bréart G. Regionalization of perinatal care in Europe. Semin Neonatol. 2004;9(2):99–110.

    Article  PubMed  Google Scholar 

  14. Lorch SA, Myers S, Carr B. The regionalization of pediatric health care. Pediatrics. 2010;126(6):1182–90.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Swyer PR. The regional organisation of special care for the neonate. Pediatr Clin N Am. 1970;17(4):761–76.

    Article  CAS  Google Scholar 

  16. Kitchen WH, Ford GW, Orgill A, Rickards AL, Astbury BA, Lissenden J, et al. Outcome of extremely low birth weight infants in relation to hospital of birth. Aust N Z J Obstet Gynaecol. 1984;24(1):1–5.

    Article  CAS  PubMed  Google Scholar 

  17. Yu VYH, Dunn PM. Development of regionalized perinatal care. Semin Neonatol. 2004;9(2):89–97.

    Article  PubMed  Google Scholar 

  18. Yeast JD, Poskin M, Stockbauer JW, Shaffer S. Changing patterns in regionalization of perinatal care and the impact on neonatal mortality. Am J Obstet Gynecol. 1998;178(1):131–5.

    Article  CAS  PubMed  Google Scholar 

  19. Sanderson M, Sappenfield WM, Jespersen KM, Liu Q, Baker SL. Association between level of delivery hospital and neonatal outcomes among South Carolina Medicaid recipients. Am J Obstet Gynecol. 2000;183(6):1504–11.

    Article  CAS  PubMed  Google Scholar 

  20. Costeloe KL, Hennessy EM, Haider S, Stacey F, Marlow N, Draper ES. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ: British Medical Journal. 2012;345:e7976.

    Article  PubMed  PubMed Central  Google Scholar 

  21. McEvoy CG, Descloux E, Barazzoni MS, Diaw CS, Tolsa JF, Roth-Kleiner M. Evaluation of neonatal transport in Western Switzerland: a model of perinatal regionalization. Clinical medicine insights Pediatrics. 2017;11:1179556517709021.

    Article  PubMed  PubMed Central  Google Scholar 

  22. National Health and Medical Research Council. Clinical practice guidelines: care around preterm birth. Canberra: Commonwealth of Australia. 2000. p. 1–265.

  23. Bode MM, O'Shea TM, Metzguer KR, Stiles AD. Perinatal regionalization and neonatal mortality in North Carolina, 1968-1994. Am J Obstet Gynecol. 2001;184(6):1302–7.

    Article  CAS  PubMed  Google Scholar 

  24. Hein HA. Regionalized perinatal care in North America. Semin Neonatol. 2004;9(2):111–6.

    Article  PubMed  Google Scholar 

  25. Finnström O, Olausson PO, Sedin G, Serenius F, Svenningsen N, Thiringer K, et al. The Swedish national prospective study on extremely low birthweight (ELBW) infants. Incidence, mortality, morbidity and survival in relation to level of care. Acta Paediatr. 1997;86(5):503–11.

    Article  PubMed  Google Scholar 

  26. Tommiska V, Heinonen K, Lehtonen L, Renlund M, Saarela T, Tammela O, et al. No improvement in outcome of nationwide extremely low birth weight infant populations between 1996-1997 and 1999-2000. Pediatrics. 2007;119(1):29–36.

    Article  PubMed  Google Scholar 

  27. The Victorian Infant Collaboration Study Group. Changing outcome for infants of birth-weight 500-999g born outside of level 3 centres in Victoria. Aust N Z J Obstet Gynaecol. 1997;37(3):253–7.

    Article  Google Scholar 

  28. Chien L-YMPHS, Whyte RMF, Aziz KMF, Thiessen PMDF, Matthew DMF, Lee SKMP, et al. Improved outcome of preterm infants when delivered in tertiary care centers. [article]. Obstet Gynecol. 2001;98(2):247–52. - 0029-7844

    CAS  PubMed  Google Scholar 

  29. Hohlagschwandtner M, Husslein P, Klebermass K, Weninger M, Nardi A, Langer M. Perinatal mortality and morbidity. Comparison between maternal transport, neonatal transport and inpatient antenatal treatment. Arch Gynecol Obstet. 2001;265(3):113–8.

    Article  CAS  PubMed  Google Scholar 

  30. Harris BA Jr, Wirtschafter DD, Huddleston JF, Perlis HW. In utero versus neonatal transportation of high-risk perinates: a comparison. Obstet Gynecol. 1981;57(4):496–9.

    PubMed  Google Scholar 

  31. Thompson K, Gardiner J, Resnick S. Outcome of outborn infants at the borderline of viability in Western Australia: a retrospective cohort study. J Paediatr Child Health. 2016;52(7):728–33.

    Article  PubMed  Google Scholar 

  32. Sharp M, French N, McMichael J, Campbell C. Survival and neurodevelopmental outcomes in extremely preterm infants: 22–24 weeks of gestation born in Western Australia. J Paediatr Child Health. 2017. https://doi.org/10.1111/jpc.13678

  33. Lui K, Abdel-Latif ME, Allgood CL, Bajuk B, Oei J, Berry A, et al. Improved outcomes of extremely premature outborn infants: effects of strategic changes in perinatal and retrieval services. Pediatrics. 2006;118(5):2076–83.

    Article  PubMed  Google Scholar 

  34. Hutchinson FH, Davies MW. Time-to-delivery after maternal transfer to a tertiary perinatal centre. Biomed Res Int. 2014;2014:325919.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Boland RA, Davis PG, Dawson JA, Stewart MJ, Smith J, Doyle LW. Very preterm birth before arrival at hospital. Aust N Z J Obstet Gynaecol. 2017;1–7. https://doi.org/10.1111/ajo.12690

  36. McLelland GE, Morgans AE, McKenna LG. Involvement of emergency medical services at unplanned births before arrival to hospital: a structured review. Emerg Med J. 2014;31(4):345–50.

    Article  PubMed  Google Scholar 

  37. McLelland G, McKenna L, Archer F. No fixed place of birth: unplanned BBAs in Victoria, Australia. Midwifery. 2013;29(2):e19–25.

    Article  PubMed  Google Scholar 

  38. Musson RE, Harrison CM. The burden and outcome of in utero transfers. Acta Paediatr. 2016;105(5):490–3.

    Article  PubMed  Google Scholar 

  39. Akl N, Coghlan EA, Nathan EA, Langford SA, Newnham JP. Aeromedical transfer of women at risk of preterm delivery in remote and rural Western Australia: why are there no births in flight? Aust N Z J Obstet Gynaecol. 2012;52(4):327–33.

    Article  PubMed  Google Scholar 

  40. Kim EW, Teague-Ross TJ, Greenfield WW, Keith Williams D, Kuo D, Hall RW. Telemedicine collaboration improves perinatal regionalization and lowers statewide infant mortality. J Perinatol. 2013;33(9):725–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Hall RW, Hall-Barrow J, Garcia-Rill E. Neonatal regionalization through telemedicine using a community based research and education core facility. Ethn Dis. 2010;20(Supplement 1):136–40.

    Google Scholar 

  42. Marcin JP, Shaikh U, Steinhorn RH. Addressing health disparities in rural communities using telehealth. Pediatr Res. 2016;79(1):169–76.

    Article  PubMed  Google Scholar 

  43. McNamara PJ, Mak W, Whyte HE. Dedicated neonatal retrieval teams improve delivery room resuscitation of outborn premature infants. J Perinatol. 2005;25(5):309–14.

    Article  CAS  PubMed  Google Scholar 

  44. Truffert P, Goujard J, Dehan M, Vodovar M, Breart G. Outborn status with a medical neonatal transport service and survival without disability at two years: a population-based cohort survey of newborns of less than 33 weeks of gestation. Eur J Obstet Gynecol Reprod Biol. 1998;79(1):13–8.

    Article  CAS  PubMed  Google Scholar 

  45. Mohamed MA, Aly H. Transport of premature infants is associated with increased risk for intraventricular haemorrhage. Arch Dis Child Fetal Neonatal Ed. 2010;96(6):F403–7. https://doi.org/10.1136/adc.2010.183236

  46. Shlossman PA, Manley JS, Sciscione AC, Colmorgen GH. An analysis of neonatal morbidity and mortality in maternal (in utero) and neonatal transports at 24-34 weeks’ gestation. Am J Perinatol. 1997;14(8):449–56.

    Article  CAS  PubMed  Google Scholar 

  47. Towers CV, Bonebrake R, Padilla G, Rumney P. The effect of transport on the rate of severe intraventricular hemorrhage in very low birth weight infants. Obstet Gynecol. 2000;95(2):291–5.

    CAS  PubMed  Google Scholar 

  48. Gooi A, Oei J, Lui K. Attitudes of level II obstetricians towards the care of the extremely premature infant: a national survey. J Paediatr Child Health. 2003;39(6):451–5.

    Article  CAS  PubMed  Google Scholar 

  49. Mulvey S, Partridge JC, Martinez AM, Yu VYH, Wallace EM. The management of extremely premature infants and the perceptions of viability and parental counselling practices of Australian obstetricians. Aust N Z J Obstet Gynaecol. 2001;41(3):269–73.

    Article  CAS  PubMed  Google Scholar 

  50. Morse SB, Haywood JL, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of neonatal outcome and perinatal therapy use. Pediatrics. 2000;105(5):1046–50.

    Article  CAS  PubMed  Google Scholar 

  51. Martinez AM, Partridge JC, Yu V, Wee Tan K, Yeung C-Y, Lu J-H, et al. Physician counselling practices and decision-making for extremely preterm infants in the Pacific Rim. J Paediatr Child Health. 2005;41(4):209–14.

    Article  PubMed  Google Scholar 

  52. •• Patel RM, Rysavy MA, Bell EF, Tyson JE. Survival of infants born at periviable gestational ages. Clin Perinatol. 2017;44:287–303. This review reports the wide variation in approach to active management of EPT births in developed nations based on differences in national and institutional guidelines, which accounts for the wide variation in reported survival rates.

    Article  PubMed  Google Scholar 

  53. Boland RA, Davis PG, Dawson JA, Doyle LW. What are we telling the parents of extremely preterm babies? Aust N Z J Obstet Gynaecol. 2016;56(3):274–81.

    Article  PubMed  Google Scholar 

  54. Blanco F, Suresh G, Howard D, Soll RF. Ensuring accurate knowledge of prematurity outcomes for prenatal counseling. Pediatrics. 2005;115(4):e478–87.

    Article  PubMed  Google Scholar 

  55. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD. Intensive care for extreme prematurity—moving beyond gestational age. N Engl J Med. 2008;358(16):1672–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Lee HC, Green C, Hintz SR, Tyson JE, Parikh NA, Langer J, et al. Prediction of death for extremely premature infants in a population-based cohort. Pediatrics. 2010;126(3):e644–50.

    Article  PubMed  Google Scholar 

  57. Bolisetty S, Bajuk B, Me A-L, Vincent T, Sutton L, Kei L. Preterm outcome table (POT): a simple tool to aid counselling parents of very preterm infants. Aust N Z J Obstet Gynaecol. 2006;46(3):189–92.

    Article  PubMed  Google Scholar 

  58. Boland RA, Davis PG, Dawson JA, Doyle LW. Predicting death or major neurodevelopmental disability in extremely preterm infants born in Australia. Arch Dis Child Fetal Neonatal Ed. 2012;98(3):F201–4.

  59. Agency for Healthcare Research and Quality. The six domains ot health care quality Rockville, M.D: Agency for Healthcare Research and Quality 2016. Available from: https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html.

  60. Binder S, Hill K, Meinzen-Derr J, Greenberg JM, Narendran V. Increasing VLBW deliveries at subspecialty perinatal centers via perinatal outreach. Pediatrics. 2011;127(3):487–93.

    Article  PubMed  PubMed Central  Google Scholar 

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Contributors

Michael J. Stewart and Rosemarie A. Boland wrote the draft manuscript. Jacqui Smith reviewed and edited the paper. Each author has reviewed the manuscript and approved the submission of this version. The authors take full responsibility for the manuscript.

Funding

Rosemarie A. Boland currently holds a Postdoctoral Fellowship funded by the Murdoch Children’s Research Institute, Melbourne.

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Authors and Affiliations

  1. Paediatric Infant Perinatal Emergency Retrieval, Royal Children’s Hospital, Level 2, East Building, 50 Flemington Road, Parkville, Victoria, 3052, Australia

    Michael J. Stewart MBBS, FRACP, Jacqui Smith MB BS (Hons), FRCOG FRANZCOG FACLM & Rosemarie A. Boland PhD, RN, RM

  2. Clinical Sciences, Murdoch Children’s Research Institute, 50 Flemington Road, Parkville, Victoria, 3052, Australia

    Michael J. Stewart MBBS, FRACP & Rosemarie A. Boland PhD, RN, RM

  3. Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, 50 Flemington Road, Parkville, Victoria, 3052, Australia

    Michael J. Stewart MBBS, FRACP

  4. Department of Obstetrics and Gynecology, University of Melbourne, 7th Floor, Royal Women’s Hospital, 20 Flemington Road, Parkville, Victoria, 3052, Australia

    Rosemarie A. Boland PhD, RN, RM

Authors
  1. Michael J. Stewart MBBS, FRACP
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  2. Jacqui Smith MB BS (Hons), FRCOG FRANZCOG FACLM
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  3. Rosemarie A. Boland PhD, RN, RM
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Correspondence to Michael J. Stewart MBBS, FRACP.

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Michael J. Stewart declares that he has no conflict of interest.

Jacqui Smith declares that she has no conflict of interest.

Rosemarie A. Boland declares that she has no conflict of interest.

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Stewart, M.J., Smith, J. & Boland, R.A. Optimizing Outcomes in Regionalized Perinatal Care: Integrating Maternal and Neonatal Emergency Referral, Triage, and Transport. Curr Treat Options Peds 3, 313–326 (2017). https://doi.org/10.1007/s40746-017-0103-y

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