Sometimes, the patient’s condition is such that her medical needs are best served through transfer from an isolated area to support center where more complete medical resources are available. This is called a “medical evacuation” or MEDEVAC.

Medical evacuation of a woman with a gynecologic problem is usually straightforward. Transporting of a pregnant woman, however, bears special consideration. The primary issues are:

• Special positioning
• Risk of labor or delivery
• Risk of rapid deterioration of condition

Special Positioning

Non-ambulatory, non-pregnant patients are generally transported on their back. This facilitates safe positioning on the litter and allows easy access to the patient for monitoring and airway control.

In the pregnant patient, lying flat on her back has two effects, both of them bad:

• In this position, uterine blood flow is reduced, sometimes enough to compromise the fetus, and
• The heavy uterus compresses the inferior vena cava, trapping blood in the lower extremities and compromising maternal cardiac output.

To avoid these problems, it is best to transport the pregnant woman (in the second and third trimester) on her side, with both knees flexed, with a small pillow between the knees. Safety straps can be easily attached with her in this position, and monitoring is not compromised. She can be positioned on either her left or right side, but may need to move from one side to the other.

Some pregnant women cannot be transported in this way for other reasons…she may be in a backboard or have casts on her limbs that prohibit this positioning. In such cases, the uterus can still be moved off the inferior vena cava:

With the palm of your hand, or with a fist, push the uterus toward the patient’s right side (push from left to right). This will displace the uterus enough to restore normal blood flow both to the patient’s heart and to the fetus. The drawback to this approach is that although it is effective, it requires an extra pair of hands to constantly keep the uterus off to the patient’s right side.

Place a small pillow, rolled up towel, or blanket under the patient’s left hip. This 4 inch elevation of the left hip will be sufficient to displace the uterus from the inferior vena cava.

Risk of Labor or Delivery

Unexpected labor or delivery while in transit is more difficult to deal with (and more dangerous) than the same problem occurring in a stable environment. When someone is transported who is in labor, a qualified medical attendant needs to accompany her so that delivery, should it unexpectedly occur, will be the safest that can be provided under the circumstances.

Risk of Rapid Deterioration of Condition

One feature of pregnancy is a tendency for women thought to be doing well, to rapidly deteriorate:

• Hemorrhage. Pregnant women who are not bleeding can experience a sudden placental abruption, associated with torrential hemorrhage. Within minutes, they can lose half their blood volume. Women who have just delivered are also subject to such sudden onset of life-threatening bleeding. Pregnant women who have demonstrated any vaginal bleeding should be transported with an IV line in place.
• Shock. The non-pregnant individual who sustains on-going blood loss will usually demonstrate the progressive signs/symptoms of tachycardia, tachypnea, narrowing of the pulse pressure, orthostatic hypotension and anxiety/confusion before experiencing vascular collapse. Not so with many pregnant women. The pregnant woman experiencing the same on-going blood loss will usually compensate fairly well, not demonstrating all the pre-shock signs/symptoms, until vascular collapse suddenly occurs.
• DIC. Disseminated intravascular coagulation is a relatively common occurrence among pregnant women with severe pre-eclampsia, HELLP syndrome, and intrapartum hemorrhage. It’s onset can be both abrupt and is sometimes lethal.
• Eclampsia. Relatively mild elevations of blood pressure in the pregnant woman (pre-eclampsia) can rapidly escalate to severe pre-eclampsia and eclampsia (seizures). Pregnant women being transported who have pre-eclampsia should be closely monitored for worsening blood pressure and supplies to treat eclampsia should be available.

Resources

Operational Medicine 2001: Patient Transport

Medical Evacuation in a Theater of Operations FM 8-10-6 (USA)

Seabee Operational Medical and Dental Guide: Aeromedical Evacuation

GMO Manual: Aeromedical Evacuation

Field Medical Service School Student Handbook: Casualty Evacuation

United States Naval Flight Surgeon Handbook: Aeromedical Evacuation