Emergency rural obstetric transfers in South Australia: a review of the clinical and precipitating factors.

Abstract

The provision of critical management of obstetric emergencies is a vital service for rural women and their families. Emergency obstetric transfers are indispensable to reduce maternal and neonatal mortality and morbidity because local rural hospitals often do not have the resources or expertise to manage both maternal and neonatal outcomes. However, the transfer of a rural pregnant woman to a higher level, tertiary perinatal centre (TPC) is often stressful for the patient and costly for health services. Currently, little is known about the main reasons for obstetric transfers in rural South Australia, and there is even less information about the management of mothers and babies once they arrive at their destination. The present guidelines for informing the necessity of transferring from a rural or remote area to a TPC are unclear. This study aims to describe the clinical reasons for obstetric transfers from a rural area in South Australia and explore predictive factors of likelihood of delivery on transfer. Additionally, this study aims to determine the outcomes of transfers in terms of location of delivery, timing of delivery and to explore the association between delivery after transfer and clinical reasons for transfer. All women from the Riverland region of South Australia who were transferred antenatally at >20 weeks gestational age for an acute admission to a TPC over a 5-year period were included in a retrospective review. Participants were determined from hospital coding data, and medical case notes were retrieved for all participants. The demographic and clinical data, including details of the emergency presentation and outcomes of women transferred to a tertiary hospital, were analysed with descriptive statistics (mean, standard deviation). A logistic regression was performed for predictive factors associated with delivery on transfer. A total of 160 patients were transferred antenatally. A minority of participants delivered on admission (35%). Of the women who were discharged undelivered, 43% eventually delivered at their rural hospital and the remainder delivered later in a tertiary hospital as part of a planned admission. The most common diagnoses for transfer were preterm labour, premature preterm rupture of membranes, antepartum haemorrhage and placental disorders. Delivery on transfer was associated with preterm premature rupture of membranes and pre-eclampsia. Likelihood of delivery on transfer was not increased with preterm gestation, cervical dilation or other presenting diagnosis. There was not an association of increased number of indications for transfer and likelihood of delivering after transfer. This study suggests that the rural doctor workforce in the Riverland region appears to be well skilled at identifying obstetric emergencies despite the lack of guidance around what constitutes a high risk perinatal situation. Furthermore, this study quantifies the number of women who would potentially require support services associated with rural perinatal transfers from this area. There was a comparatively lower rate of delivery on transfer and, as such, these women eventually delivered their babies either at their hospital of origin or returned to a metropolitan hospital as part of a planned admission for delivery. Further research is needed about the practical implications of transferring pregnant women to tertiary centres and clinical decision-making tools to improve this process.