When to Transport
When to transport a pregnant patient to a hospital
Jails must be able to determine when a pregnant patient with (or without) OUD should be transported to a hospital for a higher level of medical care either for MOUD (also referred to as MAT) dosing or other evaluation.
HOW
In general, jails should have a LOW threshold for transporting pregnant people in custody, especially those with OUD, to the hospital.
We know transports are a hassle; we know that some jail staff might think that pregnant patients might be exaggerating labor symptoms. Regardless, no jail wants to have a woman give birth to a baby in their facility or have another complication, so transport is best when a pregnant patient has signs of labor (unless you have an Ob/Gyn, family physician, midwife or other clinician with Ob training on site!)
What pregnant patient situations necessitate hospital transport offsite?
Some patient situations that require hospital transport in pregnancy include but are not limited to:
- “Unwell”: Individuals who appear unwell are referred for immediate clinical assessment conducted by a qualified healthcare professional. See the BJA training video (7 mins) on how to identify if someone in jail is unwell. Broadly defined, “appears unwell” encompasses observed signs and symptoms obvious to a layperson that:
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- An individual may be sick (physically or psychologically), which includes signs of or self-reported intoxication or substance withdrawal. Symptoms of the latter may present at any time (including upon arrival to the facility); typically, they emerge within 72 hours of arrival.
- The condition of a patient who has already been assessed by a qualified healthcare professional is worsening, becoming unstable, or becoming a danger to the patient or others.
(This definition is taken from the Bureau of Justice Assistance’s Guidelines for Managing Substance Withdrawal in Jails)
- Urgent maternal warning signs: These are signs or symptoms in a pregnant (or
postpartum) patient that can be signs of dangerous conditions that are specific to or have higher risks in pregnancy such as pre-eclampsia (high blood pressure with other complications) or blood clots in the legs/lungs. If a pregnant patient experiences these, they need urgent evaluation by a qualified health care professional with pregnancy care training. Use the MOMCARE Recognizing Urgent Maternal Warning Signs in Custody 1-pager to educate jail staff on what to look out for.
How do I know if the jail medical staff are suited to care for an unwell pregnant patient?
- For a pregnant patient, a qualified health care professional is a physician (usually Ob/Gyn or family medicine physician), physician assistant, nurse practitioner, certified nurse midwife, or another who by virtue of their education, credentials, experience, and licensure can competently and legally execute the clinical activity at hand for a pregnant patient.
- Medical staff should assess how urgent the situation is, which determines whether transport should be by ambulance (911) or jail vehicle.
- If your jail does not have 24/7 in-person coverage by a nurse or other qualified health care professional, then onsite custody staff must call the on-call clinician. If there is no on-call clinician, the onsite custody staff must arrange for transport by ambulance or jail transport vehicle.
When does a pregnant patient need to be transported offsite for MOUD initiation?
You should transport a newly arrived pregnant patient with OUD offsite to be evaluated to start MOUD if:
- They appear unwell, if they have urgent maternal warning signs, or if they have labor signs (if in 2nd or 3rd trimester)
- Your jail does not have 24/7 access to a clinician with expertise in pregnancy and opioid withdrawal management
- Your jail does not have the ability to dose and titrate buprenorphine/methadone on-site
- Your jail staff have not been trained to recognize when a pregnant patient needs a higher level of care.
Do pregnant patients who undergo opioid withdrawal (for patients who decline MOUD) need to be transported offsite?
You should transport a newly arrived pregnant patient with OUD offsite for withdrawal management if:
- They appear unwell, if they have urgent maternal warning signs, or if they have labor signs (if in 2nd or 3rd trimester)
- Your jail does not have 24/7 access to a clinician with expertise in pregnancy and opioid withdrawal management
- Your jail does not have medications onsite that are safe in pregnancy that can be used to manage withdrawal symptoms.
- Your jail staff have not been trained to recognize when a pregnant patient needs a higher level of care.
- For patients who also take benzodiazepines or alcohol, withdrawal from these substances, especially with opioid withdrawal, can be especially unsafe and these patients should be transferred.
What do jail staff need to know about transporting offsite for contractions and labor?
- It can be hard, even for obstetricians and midwives, to diagnose exactly when someone is in labor! So jail staff should not be expected to diagnose when someone is in labor. This is also why jails should have a low threshold to transport someone who might be in labor.
- Common signs of labor include painful, regular contractions; vaginal bleeding; leaking fluid (water has broken). But sometimes the signs can be more subtle, especially if someone is preterm (<37 weeks). People who have had babies before often have labor that goes more quickly.
WHY
Why is it necessary to transport a pregnant patient to a hospital?
Staff at jails that house pregnant patients, especially those with OUD or other substance use, must know when to transport the patient to the hospital (or call an ambulance) for a higher level of care. It is important to have a low threshold for transporting pregnant patients for maternal and fetal health, and for avoiding liability and possible litigation.
Many signs and symptoms would not be concerning in a non-pregnant patient, but in a pregnant patient could be danger signs; so someone with these signs should be evaluated by a clinician with pregnancy care experience. These are called “urgent maternal warning signs.” If ignored, they can lead to serious harm or even death.
Custody staff and most jail medical staff are not trained in obstetrics, nor should they be! However, they do need to have the basic knowledge to know when a pregnant patient, including one with OUD, appears “unwell,” or if they have urgent maternal warning signs, including labor that need evaluation by someone with special training in pregnancy care.
What factors should be considered when deciding whether to transport a pregnant patient to the hospital?
For pregnant patients with OUD, deciding on who and when to transport depends on several things:
- Patient factors: Use of benzos or alcohol, on top of opioids, can make withdrawal management and MOUD initiation more complicated in pregnancy. So can fentanyl, which is 50 times stronger than heroin. So can xylazine, an animal tranquilizer that is found in some drug supplies. Patients won’t always know or report these substances. Opioid withdrawal in and of itself does not require fetal monitoring, but there may be other things going on (see urgent maternal warning signs!) that do require fetal monitoring, which is done at the hospital. If the patient appears “unwell” outside of your scope of care, no matter what the cause may be, TRANSPORT.
- Jail factors: Does the jail have appropriate staffing with people trained to recognize when a pregnant patient with OUD needs a higher level of care? Can the jail dose buprenorphine and/or methadone onsite? Can the jail initiate MOUD onsite?
- Hospital factors: Does the hospital have the capacity to care for pregnant patients? Is the hospital willing to dose pregnant patients with methadone or buprenorphine?
- MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm
- Urgent Maternal Warning Signs – information from the CDC and ACOG on urgent maternal warning signs to look out for and includes 1-page flyers in 39 languages
- Use the MOMCARE Recognizing Urgent Maternal Warning Signs in Custody 1-pager to educate jail staff on what to look out for
- MOMCARE Labor Signs chart for correctional staff. Jails should have a low threshold to transport pregnant patients if they suspect labor.
- BJA Guidelines for Managing Substance Withdrawal in Jails – Newly developed toolkit on substance withdrawal management instructions and care guidance (including opioids) for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
