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CHAPTER 2 Prenatal Environment: Effect on Neonatal Outcome
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39
evaluation of the fetus. Although there are several
different BPP scoring systems, the one most generally accepted assigns a numerical score of 0 or 2
for the absence or presence, respectively, of five different parameters: fetal movement, tone, “breathing”
movements, amniotic fluid volume, and the NST.
One advantage to evaluation of several different
fetal biophysical variables is enhanced specificity
of testing with a diminished incidence of delivery
for false-positive results. The presence or absence
of acute markers (movement, tone, breathing, and
NST) helps reflect fetal status at the time of testing.
However, the absence of a given marker may be
difficult to interpret, because it may simply reflect
normal periodicity.
The biophysical activities that mature first in fetal
development disappear last as acidosis worsens. Fetal
tone (flexion and extension) is present at 7½ to 8½
weeks after the last menstrual period. This activity,
as well as gross body movement, is mediated in the
cortex and nuclei of the CNS. Fetal movement is
present by 9 weeks. Fetal breathing movements (i.e.,
rhythmic breathing movements of 35 seconds or
more) can be seen by 20 weeks of gestation. The
CNS center responsible for control of this activity is
the ventral surface of the fourth ventricle. The final
acute marker to mature is fetal heart rate acceleration in response to movement (reactive NST) seen
in the later second trimester. The posterior hypothalamus and medulla control this activity. Given
that the first marker to appear in development is
the last to disappear with worsening fetal acidosis,
the absence of fetal tone has been found to be associated with high perinatal morbidity and mortality
rates. Chronic sustained fetal hypoxia or acidosis
may produce a protective redistribution of cardiac
output away from less vital fetal organs (e.g., kidney,
lung) toward the essential organs (e.g., brain, heart,
adrenal glands). Redistribution of fetal blood flow
may be so profound that renal perfusion decreases to
the point that oligohydramnios is established. When
the largest vertical amniotic fluid pocket within the
uterus is less than 1 cm, the perinatal mortality rate
is as high as 110 per 1000.
42,78
A BPP score of 8 or 10 is normal; a score
of 6 is equivocal, and the profile should be
repeated in 12 to 24 hours. A score of 4 or less
is abnormal. Management in the presence of an
abnormal BPP depends on the gestational age
and the maternal and/or fetal factors contributing to the altered state.
The BPP employs the advantages of real-time
ultrasonography to observe fetal behavior.51 One
of its major advantages is as an intermediate step
in the evaluation of a fetus with a nonreactive
NST before a time-consuming CST is performed. It is also a useful tool for patients with
contraindications to the CST, such as premature
labor, PROM, placenta previa, malpresentation,
unexplained vaginal bleeding, or multiple gestation. The modified BPP, which combines an acute
marker (NST) with the chronic marker of fetal
well-being (amniotic fluid index [AFI]), has been
shown by some centers to be as predictive of fetal
well-being as the full BPP. Because evaluation of
the AFI is less time-consuming and requires less
technical skill, this may be an acceptable alternative for many centers. Finally, it should be noted
that though widely used, there is insufficient
evidence from RCTs to support the use of BPP
as a test of fetal well-being in high-risk pregnan-
10,51
cies.
No matter which of these testing modalities is
used, the patient should be counseled as to the predictive value of a “normal” test. The incidence of
stillbirth within 1 week of a reactive NST is 1.9 per
1000; for a negative CST, it is 0.3 per 1000; and for
a normal BPP, it is 0.8 per 1000.10 Although some
investigators have reported a decreased incidence of
fetal mortality after initiation of a fetal movement
counting program for “low-risk” patients,
141
more
recent studies have found no difference in perinatal
outcomes with fetal movement counting.54 More
controlled studies are needed.
54,104
The role of Doppler flow assessment of the
fetal arterial and venous systems in the prediction of in utero well-being is also accepted.
Measurement of umbilical artery velocity is used as
a method of fetal surveillance for growth-restricted
fetuses. Specifically, decreased or absent end-diastolic
flow may appear days before conventional antenatal
tests become abnormal. In cases such as these, at a
minimum, intensive fetal surveillance is advised.51
Reversal of diastolic flow is highly predictive
of in utero fetal demise within 24 hours and
warrants immediate intense investigation or
delivery.
51
The dramatic improvement in ultrasound image
quality over the past 15 years also has made it
possible to directly sample fetal blood and tissue.
The technique of percutaneous umbilical blood sam-
pling (PUBS) has given the obstetrician access to
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the fetal circulation with relative safety for both
the fetus and mother. In this procedure, real-time
ultrasonography is used to guide the insertion of
a needle into the umbilical vein or artery. Samples
of fetal blood can be obtained, or, as in the case
of red cell isoimmunization, transfusions can be
carried out. The fetal loss rate is generally quoted
as 1% to 2%.
143
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PERINATAL TRANSPORT
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3
AND LEVELS OF CARE
MARIO AUGUSTO ROJAS, AMANDA FLAHERTY, HEATHER FURLONG BROWN, AND TAMARA RUSH
erinatal transport is the timely and appropriate transfer of high-risk pregnant moth-
P
ers to health care facilities in which expertise and resources for optimal care are available
to improve mortality and morbidity of both the
mother and her fetus. If transfer of the mother is
not possible because of risk outweighing potential
benefit, the objective then shifts to optimizing delivery, and birth of the high-risk infant. In the latter
situation, it is necessary to have adequately trained
professionals to resuscitate and stabilize the infant
before his or her transfer to a medical center that
has the appropriate expertise and resources.
For perinatal transport to effectively support highrisk mothers and their fetuses, as well as sick newborn
infants, each country, state, or region must identify
its perinatal resources with respect to physical and
human capabilities. This review should include classification of levels of care and expertise, as well as
mapping of resources as they exist within specific geographic areas. Classification of perinatal resources
according to the different levels of care as recommended by the American Academy of Pediatrics
and the American College of Obstetricians and
Gynecologists (ACOG) in their Guidelines for
Perinatal Care4 will direct organization, identifi-
cation of resources, and roles of patient referral
and retrieval centers, as well as reveal the natural
elevation of care within the geographic area of
question (Table 3.1). Historically, regionalization has
been recommended as the most effective and costefficient use of perinatal resources.* The implementation of this important strategy is subject to qualitative
variance depending on the characteristics of the
*
References 9, 11, 17, 19, 52, 67, 86.
health care system and resources where it is applied. In
countries in which universal health care is the norm,
regionalization is more easily implemented, whereas in market-driven health care systems in which
de-regionalization is predominant, these provisions
for care become more challenging.† Whatever the
circumstances, perinatal providers must use innovative
strategies to maintain regionalization of services and
high-quality perinatal transport systems.
Because all hospitals cannot provide all levels
of perinatal care, interhospital transport of pregnant women and neonates is an essential component of any regional perinatal effort. Women who
are at risk for complications and pose significant risk
for adverse outcomes or whose neonates are likely
to require intensive care support should be considered candidates for referral during the antepartum
period.32 Similarly, it is accepted medical practice to
transfer a neonate to a hospital that can provide the
services needed or anticipated to be needed if the
birth hospital cannot provide that level of sevice.
Once resources are identified and classified, a
model for integration of perinatal services may be
constructed. Strategic planning at this level will direct
the design of the organizational structure of the
perinatal transport system, including identification of
leadership functions, the different member nurseries/
units and their roles, and the definition and process for
perinatal elevation of care. This integration will then
allow for the creation of a system for continuous data
collection and analysis, facilitating a systems approach
to problem solving and the implementation of quality
improvement strategies within the system.
†
References 11, 21, 25, 28, 42, 48, 70.
‡
References 9, 13, 14, 21, 28, 35, 36, 42, 48, 53, 70, 84, 86.
25,31
‡
78
BLUE type highlights content that is particularly applicable to clinical settings.
45
46 UNIT TWO Support of the Neonate
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TABLE
3.1
Birth Center:
Peripartum care of low-risk women with
uncomplicated singleton pregnancies with
a vertex presentation who are expected to
have an uncomplicated birth.
Example: Term, singleton, vertex
presentation
Level 1: Basic Care
Careofuncomplicatedpregnancies
withtheabilitytodetect,stabilize,and
initiate management of unanticipated
maternal-fetal or neonatal problems that
occur during the antepartum, intrapartum,
or postpartum period until patient can be
transferredtoafacilityatwhichspecialty
maternal care is available.
Examples:Anypatientappropriatefor
a birth center plus capable of managing
higher-risk conditions such as:
• Termtwingestation
• Trialoflaboraftercesareandelivery
• Uncomplicatedcesareandelivery
• Preeclampsiawithoutseverefeatures
Level II: Specialty Care
LevelIfacilitypluscareofappropriate
high-risk antepartum, intrapartum, and
postpartumconditions,bothdirectlyand
admitted and transferred from another
facility.
Examples:Anypatientappropriateforlevel
I care, plus higher-risk conditions such as:
• Severepreeclampsia
LEVELS OF PERINATAL AND NEONATAL CARE AND THEIR EXPECTED CAPABILITIES*
PERINATAL CARE PERSONNEL
All institutions providing perinatal care should
be capable of neonatal resuscitation and
stabilization
• Capabilityandequipmenttoprovidelow-risk
• Anestablishedagreementwithareceiving
• Datacollection,storageandretrieval
• Abilitytoinitiatequalityimprovementprograms
• Medicalconsultationavailableatalltimes
Abilitytobeginemergencycesareandeliverywithin
a time interval that best incorporates maternal
andfetalrisksandbenetswiththeprovisionof
emergencycare
• Availablesupportservices,includingaccessto
• Protocolsandcapabilitiesformassivetransfusion,
• Abilitytoestablishformaltransferplansin
• Abilitytoinitiateeducationandqualityimprove-
at term
LevelIfacilitycapabilitiesplus
• CTscanandideallyMRIwithinterpretation
maternal care and a readiness at all times to ini-
tiateemergencyprocedurestomeetunexpected
needs of the woman and newborn within the
center, and to facilitate transport to an acute
settingwhennecessary
hospitalwithpoliciesandproceduresfortimely
transport
thatincludeeffortstomaximizepatientsafety
obstetricUS,laboratorytesting,andbloodbank
support supplies at all times
emergencyreleaseofbloodproducts,and
managementofmultiplecomponenttherapy
partnershipwithahigher-levelreceivingfacility
mentprogramstomaximizepatientsafety,
and/or collaborate with higher-level facilities to
do so
available
• Everybirthattendedbyatleasttwopro-
fessionals:Primarymaternalcareproviders
CNMs,CMs,CPMs,andlicensedmidwives
whoarelegallyrecognizedtopracticewithin
thejurisdictionofthebirthcenter;MDs(FPs:
Ob-Gyns)
• Availabilityofadequatenumbersofqualied
professionals with competence in level I
criteriaandabilitytostabilizeandtransfer
high-risk women and newborns
Birth center providers plus
• Continuousavailabilityofadequatenumber
ofRNswithcompetenceinlevelIcare
criteriaandabilitytostabilizeandtransfer
high-risk women and newborns
• Nursingleadershiphasexpertiseinperinatal
nursing care
• Obstetriccareproviderwithprivilegesto
performemergencycesareanavailableto
attend all deliveries
• Anesthesiaservicesavailabletoprovidelabor
analgesia and surgical anesthesia
LevelIfacilityprovidersplus
• Continuousavailabilityofadequatenumbers
ofRNswithcompetenceinlevelIIcare
criteriaandabilitytostabilizeandtransfer
high-risk women and newborns who exceed
level II criteria
TABLE
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3.1
• Placentapreviawithnoprioruterine
Level III: Subspecialty care
LevelIIfacilitypluscareofmorecomplex
maternal conditions, obstetric complications, and fetal conditions.
Examples:Anypatientappropriateforlevel
II care, plus higher-risk conditions such as:
• Suspectedplacentaaccretaor placenta
• Suspectedplacentapercreta
• ARDS
• Expectantmanagementofearlysevere
LEVELS OF PERINATAL AND NEONATAL CARE AND THEIR EXPECTED CAPABILITIES*—cont’d
surgery
previawithprioruterinesurgery
preeclampsia at less than 34 weeks of
gestation
CHAPTER 3 Perinatal Transport and Levels Of Care
PERINATAL CARE PERSONNEL
• BasicUSservicesformaternalandfetalassess-
ment
• Specialequipmentneededtoaccommodatethe
care and services needed for obese women
Level II capabilities plus
• Advancedimagingservicesavailableatalltimes
• AbilitytoassistlevelIandIIcenterswithquality
improvementandsafetyprograms
• Provideperinatalsystemleadershipifactingasa
regional center in areas where level IV facilities
are not available
• MedicalandsurgicalICUsacceptpregnant
women and have critical care providers onsite to
activelycollaboratewithMFMsatalltimes.
• Appropriateequipmentandpersonnelavailable
onsite to ventilate and monitor women in labor
anddeliveryuntiltheycanbesafelytransferred
totheICU.
• Nursingleadershipandstaffhaveformal
training and experience in the provision of
perinatal nursing care and should coordinate
with respective neonatal care services
• Ob-Gynavailableatalltimes
• Directorofobstetricservicesisaboard-cer-
tiedOb-Gynwithspecialinterestand
experience in obstetric care
• MFMavailableforconsultationon-site,by
telephone,orbytelemedicine,asneeded
• Anesthesiaservicesavailableatalltimes
to provide labor analgesia and surgical
anesthesia
• Board-certiedanesthesiologistwithspecial
training or experience in obstetric anesthesia
available for consultation
• Medicalandsurgicalconsultantsavailableto
stabilize obstetric patients who have been
admittedtothefacilityortransferredfrom
other facilities
• LevelIIcareprovidersplus
• Continuousavailabilityofadequatenumbers
ofnursingleadersandRNswithcompetence
inlevelIIIcriteriaandabilitytotransferand
stabilize high-risk women and newborns who
exceed level III care criteria, and with special
training and experience in the management
of women with complex maternal illnesses
and obstetric complications
• Ob-Gynavailableon-siteatalltimes
• MFMwithinpatientprivilegesavailableat
alltimes,eitheron-site,bytelephone,orby
telemedicine
• DirectorofMFMservicesisaboard-certied
MFM
• Directorofobstetricserviceisaboard-cer-
tiedOb-Gynwithspecialinterestand
experience in obstetric care
• Anesthesiaservicesavailableatalltimes
on-site
• Board-certiedanesthesiologistwithspecial
training and experience in obstetric anesthesia in charge of obstetric anesthesia services
• Fullcomplementofsubspecialistsavailable
for inpatient consultations
47
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48 UNIT TWO Support of the Neonate
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TABLE
3.1
Level IV: Regional Perinatal Health Care
Centers
LevelIIIfacilitypluson-sitemedicaland
surgical care of the most complex maternal
conditionsandcriticallyillpregnantwomen
and fetuses throughout antepartum,
intrapartum, and postpartum care.
Examples:Anypatientappropriateforlevel
III care plus higher-risk conditions such as
• Severematernalcardiacconditions
• Severepulmonaryhypertensionorliver
• Pregnantwomenrequiringneurosur-
• Pregnantwomeninunstablecondition
LEVELS OF PERINATAL AND NEONATAL CARE AND THEIR EXPECTED CAPABILITIES*—cont’d
PERINATAL CARE PERSONNEL
LevelIIIfacilitycapabilitiesplus
• On-siteICUcareforobstetricpatients
• On-sitemedicalandsurgicalcareofcomplex
• Perinatalsystemleadership,includingfacilitation
failure
geryorcardiacsurgery
and in need of an organ transplant
maternalconditionswiththeavailabilityofcritical
careunitorICUbeds
of maternal referral and transport, outreach
education for facilities and health care providers
intheregion,andanalysisandevaluationof
regional data, including perinatal complications
andoutcomesandqualityimprovement
Level III health care providers plus
• MFMcareteamwithexpertisetoassume
responsibilityforpregnantwomenand
women in the postpartum period who are in
critical condition or have complex medical
conditions. This includes co-management
ofICU-admittedobstetricpatients.An
MFMteammemberwithfullprivilegesis
available at all times for on-site consultation
andmanagement.Theteamisledbya
board-certiedMFMwithexpertiseincritical
care obstetrics.
• MDandnursingleaderswithexpertisein
maternal critical care obstetrics
• Continuousavailabilityofadequatenumbers
ofRNswhohaveexperienceinthecare
of women with complex medical illnesses
and obstetric complications; this includes
competence in level IV care criteria.
• Directorofobstetricserviceisboard-certied
MFM,orboard-certiedOb-Gynwith
expertise in critical care obstetrics
• Anesthesiaservicesareavailableatalltimes
on-site
• Board-certiedanesthesiologistwithspecial
training or experience in obstetric anesthesia
in charge of obstetric anesthesia services.
• Adultmedicalandsurgicalspecialtyand
subspecialtyconsultantsavailableon-siteat
alltimestocollaboratewithMFMcareteam
Level I: Well Newborn Care
NEONATAL CARE PERSONNEL
• Provideneonatalresuscitationateverydelivery
• Evaluateandprovideneonatalcaretostable
term newborn infants
• Stabilizeandprovidecareforinfantsborn
at 35–37 weeks of gestation who remain
physiologicallystable
• Stabilizenewborninfantswhoareillandthose
born before 35 weeks of gestation until transfer
to a higher level of care
• MDs:(FPs,pediatricians)
• Advancedpracticenurses(NNPs,PNPs,
FNPs)
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