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12 Neonatal Physiology and Transport

that must be done as part of stabilisation before transport. The critical Mothers should accompany their babies whenever they are fit
importance of temperature maintenance is demonstrated in the higher enough to do so. If they are unable to do so, it helps if a clotted
mortality of babies who are hypothermic on arrival at a tertiary centre. specimen of the mother’s blood is made available to allow a safe
Gastric decompression is a vital intervention. By keeping the stomach matching of blood in case a transfusion becomes necessary.
empty, the risk of vomiting and aspiration is reduced. It can be reduced The principles involved in safe neonatal transfer are outlined in
still further by nursing the baby in the lateral position, or prone, during Table 2.2, which presents the mnemonic TWO SIDES as a memory aid

transport. Gastric decompression also relieves pressure on the diaphragm, for those whose exposure to neonatal transfers is limited.
reducing the work of breathing. It reduces the diameter of the bowel, thus Table 2.2: Checklist for neonatal transfer.
reducing tension in the bowel wall and allowing greater mucosal blood
flow. All of these effects are beneficial, but can be assured only if the Tube Orogastric, maintain gastric decompression; prevent
aspiration; improve diaphragmatic excursion; maximise
nasogastric or orogastric tube is supervised and regularly checked for bowel perfusion
blockage. None of the benefits of gastric decompression are achieved if Warmth Conserve energy stores by reducing energy required for
the nasogastric tube becomes blocked or displaced. thermogenesis
Pretransport stabilisation should ensure that the baby does not start
on a journey with a fluid deficit. Nonetheless, fluid replacement during Oxygen Maximise O delivery to the bowel, brain, myocardium
2
transport remains essential to replace ongoing losses, particularly Sabilisation Fluid volume restored, rewarmed, before transfer
nasogastric losses, and to provide maintenance fluid for the duration Intravenous fluids Ringer’s lactate through cannula
of the journey. Isotonic fluid losses should be replaced with isotonic Documentation Referral letter including pre-referral history and progress
fluid, not paediatric maintenance fluids. Modified Ringer’s lactate is a Escort The most skilled nurse or paramedic available
reasonable choice. It is overly optimistic to expect a needle to remain
in a vein during transport, and fluid will inevitably extravasate if this Specimens X-Rays, mother’s clotted blood
is attempted. An intravenous cannula should be placed at a site that is
accessible for checking during transport. Evidence-Based Research
The amount of fluid required to correct a preexisting deficit can
be answered simply. Give enough! “Enough” means that the baby has Table 2.3 presents a study on postnatal transfer of preterm infants
well-perfused peripheries, adequate urine output (at least 1 ml/kg per between hospitals.
hour) signifying adequate renal perfusion, and appropriate cerebral Table 2.3: Evidence-based research.
function. If this has not been achieved, “enough” has not been given. Title Moving the preterm infant
Resuscitation is best achieved by aliquots of 10 ml/kg of Ringer’s
lactate repeated until the desired clinical parameters have been met. Authors Fowlie PW, Booth P, Skeoch CH
Additionally, patients will require maintenance fluids determined by Institution Aberdeen Maternity Hospital, Aberdeen, UK; Princess Royal
their age and degree of prematurity. Maternity Hospital, Glasgow, UK
Oxygen administration by mask or by head box supports the baby Reference BMJ 2004; 329(7471):904–906
through any respiratory embarrassment and improves oxygen delivery, Problem Newborn infants and pregnant mothers may have to
particularly to the bowel. Along with the increased mucosal flow move between hospitals for appropriate care because of
prematurity or the threat of preterm delivery. Sometimes
following gastric decompression, oxygen administration may play a this move means that the infant and family have to travel
role in reducing bacterial translocation through a compromised mucosa. hundreds of miles.
Stabilisation is the sine qua non of transportation. If a baby cannot Intervention This article focuses on the postnatal transfer of preterm
be resuscitated in a primary care facility, it is unlikely that this can infants between hospitals.
be achieved in a moving vehicle. Stabilisation includes restoration of Comparison/ When no regional transport service is available, medical and
circulating blood volume with an appropriate fluid, ensuring that there control nursing staff from either referring or receiving units
is a clear and sustainable airway, treating hypoglycaemia, and ensuring (quality of undertake the transport on an ad hoc basis. The staff will
have variable experience in neonatal transport and the
that the patient is warm. evidence) equipment used, and the vehicle may not be dedicated
Whenever possible, the child should be escorted by the most for neonatal use. Running these ad hoc teams often puts
experienced staff available. Successfully supervising the care of resources under strain because there will be fewer staff on
site in the unit that carries out the transport.
a surgically ill neonate during transport is the pinnacle of nursing
achievement, and should be recognised as such by medical staff and Outcome/ Anticipating the need for transfer early, appropriate
preparation for transfer, and ongoing high-quality care
nurse administrators. To maintain high standards of professionalism effect during transfer are the cornerstones of good neonatal
in the cramped conditions of a vehicle with a patient who, in the best transport. To achieve this, staff need to be trained
of circumstances, is a nursing challenge deserves the plaudits of the appropriately, all equipment and vehicles must be fitted out
for the purpose, and lines of communication must be well
entire team. Unfortunately, escorting ill babies is often left to the most established.
junior and inexperienced staff member because this impacts the least Historical Some newborn infants will always need to be moved
on the functioning of the referring institution. The mother alone is significance/ between hospitals. Neonatal transport services must be well
never a suitable escort. Rarely do mothers have intensive care nursing comments organised and should aim to provide clinical care to a high
experience, and the emotional turmoil of giving birth precludes the standard. The service should be staffed by professionals
trained in neonatal transport medicine and in using
required precision and objectivity. appropriate equipment.
Documentation, including a letter of referral outlining the pre-
referral progress of the patient and management provided at the
primary care facility, must accompany all transported babies. This
should augment the telephone discussions with the referral hospital that
preceded the decision to transfer the baby. Likewise, any x-rays taken
to support the diagnosis should be included with the documentation,
or patients will have to endure a repeated radiological examination on
arrival, which is a waste of time and money.