FLIGHT MIDWIVES

Left: Karen Ferraccioli in action as a Flight Midwife in Taranaki with rescue pilot Fergus Maclachlan.

FLIGHT MIDWIVES A JOINT COLLEGE OF MIDWIVES AND MERAS PROJECT

In 2018, during the strike by members of midwives’ union MERAS, the district health boards’ list of essential life preserving services included the 24/7 availability of ight midwives as part of the minimum safe stang requirement.

CLAIRE MACDONALD MIDWIFERY ADVISOR

KAREN FERRACCIOLI CHAIR, MERAS NATIONAL REPRESENTATIVE COUNCIL

MERAS and the New Zealand College of Midwives therefore began a project in 2019 to investigate and understand the roles and responsibilities of employed midwives who attend women on ight transfers for clinical care. We asked one MERAS representative in each DHB to complete an online questionnaire. We are grateful to the participants for their assistance in achieving a 100% response rate. is provides a rich understanding of professional midwifery practice, career pathways and how DHBs manage rosters, on-call and stang arrangements to ensure that a maternity ight service can be provided. e next step will be to start collaborative discussions between MERAS, the College, DHBs and other parties about where and how we can achieve some consistency across the country for midwives, as well as recognition of the additional knowledge and skill required for ight transfers of pregnant and postpartum women. We hope to be able to contribute to a cohesive national approach to education and support standards for ight midwives.

BACKGROUND

Flight Midwife: A fully trained* ight midwife attends the women for transfer. e ight midwife is in charge of the ight, including communications with receiving hospital. e ight midwife is a member of the crew. Capital letters for ‘Flight Midwife’ are used in this article to specically denote this denition.

Escort: A midwife attends the woman as an escort. A ight nurse or a paramedic is in charge of the ight. e midwife escort is considered a ‘medical passenger’ and is not a member of the crew.

Transfer: Flight originating from the maternity unit where the woman is located. Sta from that unit accompany the pregnant or postpartum woman or baby. Retrieval: Sta from the receiving facility are sent to pick up a pregnant or postpartum woman or baby from another facility.

Flights are either in xed-wing aircraft (small aeroplanes) or helicopters.

FIG 1. FLIGHT STRESSORS

Hypoxia; Barometric pressure; Fatigue; Dehydration; Noise; Vibration; G-forces; Third spacing

FIG 2. IN-FLIGHT OBSTETRIC COMPLICATIONS

Nausea and vomiting (80%); Tachycardia (up to 15%); Increased contractions (8.8%); Hypertension (1.3%); Hypotension (1.3%; Decreased maternal respiratory drive (1.3%); Infiltrated intravenous line (1.3%); venous thrombosis; Noisy and hurried, adds stress to pregnant women and may trigger labour; In-flight birth <0% to 0.9 % in AU and USA; up to 2.3% in Canada.

INDICATIONS FOR OBSTETRIC FLIGHTS

ere are two main reasons for the aeromedical transfer of pregnant and early postpartum women. • In-utero transfer: the transfer of a pregnant woman so she births in the most appropriate facility to manage fetal or potential neonatal concerns. Transferring a pregnant woman with a known indication improves outcomes and lowers costs compared with transferring the baby after birth.

• Maternal indications including severe obstetric complications or complications arising from pre-existing medical conditions. e rate of transfers in this category is rising internationally in line with the well-recognised increase in medical complexity during pregnancy. Midwives who provide care during ight transfers therefore need to be well equipped with complex care skills and additional knowledge about ight physiology.

WHAT ARE THE ROLES AND RESPONSIBILITIES OF A FLIGHT MIDWIFE?

Communication and coordination of care (both clinical and operational):

• Liaison between origin and receiving service; • Liaison with pilot/crew (aircraft set-up and weights) and ambulance team if needed (stretcher, wheelchair, equipment) • Pre-ight and aircraft safety brieng • In-ight communication: - with pilot/crew if there is a clinical indication to request ight-related actions by the pilot; implications of turbulence, possibility of diversion due to weather - update receiving hospital sta, change in clinical condition, time of arrival, appropriate receiving ward (assessment unit/birthing suite/OT), need for sta/equipment/ wheelchair at the time of landing - with family members if requested by the woman or deterioration occurs.

Preparation of the woman for transport:

• Handover from origin facility; Patient history and assessment

• Consider IV lines, IDC, TEDS, warm clothes, drugs; • Flight bag, drugs, equipment (IV pumps, sonicaid, oxygen). Safety: How to approach the aircraft with the woman; secure restraints, equipment orientation, assess for danger, use of electronic equipment, cell phones, dangerous goods, notify any spillage (body uids and bloods are corrosive to plane ttings), survival training (land and sea).

Patient care: Clinical care/decision-making. Documentation: Pre/in/post-ight records.

Logistics: If return home is not possible due to weather or aircraft issues.

WHAT IS THE MIDWIFE’S ROLE AS A FLIGHT ESCORT? is role is not consistently dened, but generally includes preparation of the woman for the ight, handovers at the origin and receiving hospitals, clinical care and support of the woman during the ight including observations and emergency response, and documentation. In some cases the midwife liaises with the pilot and other crew, in other cases she communicates via the ight nurse or paramedic.

WHAT IS SPECIAL ABOUT PHYSIOLOGY DURING A FLIGHT?

A good understanding of ight physiology and the eects of altitude are essential to provide optimal care in the aviation environment. Although ying is considered safe for well pregnant women, the in-craft environment conditions coupled with the physiologic changes of pregnancy, result in maternal cardiopulmonary and foetal adaptations that increase the potential clinical risks for unwell women. (see Fig 1 and 2.)

SURVEY RESPONSES

Facilities: ere are six tertiary maternity facilities, 18 secondary facilities and 52 primary facilities, which are unevenly distributed among 20 DHBs. Obstetric ights occur to rapidly transfer a woman either to a higher level facility or between tertiary facilities for birth when neonatal units are at capacity.

Transfers and retrievals: Five of the tertiary facilities provide a retrieval service when needed, as some DHBs are too small to maintain ight teams. Most secondary services provide transfers out. Two DHBs never (or very rarely) have maternity-related ights as they have a tertiary facility close enough for road ambulance transport in a neighbouring DHB. e responsibility for ights from primary facilities varies with a mixture of transfers and retrievals. e woman may be accompanied by her LMC midwife or by a DHB core midwife.

Midwifery role: ree DHBs have teams of trained Flight Midwives. For other DHBs, midwives usually accompany women as an escort.

Education, training and experience: Nine DHBs reported that any midwife can y with a woman except a midwife in her rst year of practice. In two DHBs, there was no experience requirement and rst year of practice midwives could accompany women on a ight. While some DHBs did not have a specic policy about the minimum level of experience, they only select experienced midwives who have specic skills in complex care for Flight Midwife training.

e education and training for Flight Midwives varies considerably in content, structure and hours allocated. In a small number of DHBs a dedicated ight midwives course is provided or midwives can

join the ight nurses' study day, which includes the Civil Aviation Authority (CAA) standards test. Midwives may also have the option to attend a ight nurse induction course (three or ve days), where a small midwifery component is provided, and Helicopter Underwater Escape Training (HUET).

Annual study days are required in three DHBs and include a half-day safety update; a ight nurse study day with CAA standards test; and in-service education on obstetric ight transport. Some members of Flight Midwife teams may attend the ight nurses' symposium.

A small number of respondents indicated that their DHB had funded two or three midwives to attend various education courses to become Flight Midwives, however the DHBs did not then prioritise those midwives as the ones to accompany women on ight transfers. In most DHBs, no specic education or training was required or provided for midwives to be eligible to accompany women on ights.

Flight medical checks: For midwives, ight medical checks are only provided in one DHB, and not required or provided by others. A compulsory annual medical check including hearing, vision and weight/BMI is an aviation requirement for other aero-medical transport clinicians, and supports the safety of both crew and patients. For example, poor hearing (either pre-existing or caused by ight stressors) can aect the quality and safety of communication and care delivered.

Aircraft weight limitations are important to maintain the aircraft’s structural integrity, performance and balance. e combined weight of the crew, patient, baggage and any additional gear should be accurate to determine fuel and balance adjustments. e crew’s physical wellness is an important consideration for mobility and patient care, as well as being able to undertake safety procedures in case of evacuation.

Rostering and on-call: None of the DHBs have a continuous on-call roster for Flight Midwives. One DHB indicated they initiate an on-call roster and pay the on-call rate to available midwives on occasions when there is high acuity in clinical areas and the neonatal unit is under pressure.

A midwife is chosen from the oor when necessary in ve DHBs. A phone call or text is made to nd a midwife who is available to provide transfer care when the need arises in six DHBs. One DHB uses whichever of these options works at the time.

Another DHB calls in the midwife who is on-call for the ward in general. One DHB sends one of its own midwives only if absolutely essential as there are only two midwives on shift at any time. Retrievals are usually organised for this DHB. None of the DHBs employ ight midwives with a separate contract. e MECA does not specically include payments for ight transfers but does include provisions for on-call, call-back,

Flight Midwife HUET training in Canterbury.

overtime, late and missed meal breaks. We did not ask about pay rates but free text answers indicated inconsistency where some DHBs pay call-back rates while others do not.

Equipment and support: By denition, attending a woman on a ight will take the midwife out of her region and return transport home is not always immediate and is commonly by road. In many instances, the decision for a midwife to attend a woman on a ight is made only a short time before the ight takes place, so the midwife may not have time to prepare food and clothing for the journey and return. e number of DHBs that routinely provide specic equipment or resources to midwives for ights is indicated in g 3.

Results were also varied in relation to how accommodation is organised if a midwife is required to stay in the receiving hospital region overnight as a result of a ight transfer.

For three DHBs, the midwife has to organise and pay for her own accommodation, and is reimbursed by the DHB. In one case, if the midwife is unable to do this the DHB will arrange

it for her. e midwife’s accommodation is sometimes organised and paid for by a third party, including the duty manager in the DHB of origin, the ight nurse, or the pilot (who pays with a DHB credit card).

e hospital arranges accommodation for the midwife in three DHBs, and another provides on-site hospital accommodation. One DHB relies on a combination of all of the above, according to the situation at the time. ere is no formal arrangement for two DHBs. For two DHBs, ight transfers have never resulted in an overnight stay, and the midwife takes a taxi back home.

is illustrates how stories of midwives who have ended up stuck in the receiving hospital’s region with no spare clothes, money or food have occurred, and how a return journey can be signicantly prolonged, creating logistical issues for the midwife and her family back at home.

Clinical guidance: Only four respondents indicated that their DHB has any written guidelines, protocols or standards to guide practice for obstetric ight transfers.

FIG 3. EQUIPMENT AND SUPPORT FOR MIDWIVES ON FLIGHTS

MW Equipment Bag 14 DHBs

Protective Helmet 2 DHBs

Protective Footwear 1 DHB

Flame/Heat Resistant Suit 2 DHBs

DHB Mobile Phone 3 DHBs

Taxi Chits 10 DHBs

DHB Credit Card 0 DHBs

Bus/Train Vouchers 0 DHBs

Canterbury Flight Midwife team at a training day.

DISCUSSION

e responses to our survey conrmed the individual stories that the College and MERAS have heard over time, that there a wide variation in education, equipment, support, and requirements for midwives to attend women on ights in New Zealand. Only three DHBs have dedicated teams of named, trained Flight Midwives. is contrasts with ight nurses who have recognised education, annual symposia, a dedicated association, on-call rosters, and may be paid on the senior nurse pay scale. We are not aware of any DHBs who apply the senior midwife pay scale for Flight Midwives. In fact, in some cases, not even call-back rates are paid.

While midwives are skilled and adaptable health practitioners by way of their undergraduate education and ongoing practice experience, there are aspects of caring for women during ights where additional knowledge is of benet, particularly when the transfer is for maternal concerns. e aim of an aeromedical ight is to stabilise the woman before transfer and to be able to provide the same level of care during the ight as the woman would receive in an appropriate hospital ward for her condition. e aeromedical environment is challenging, and if Flight Midwives are in the lead clinician role for obstetric transport (clinical, communication and ight management), strategies are necessary to ensure the quality and safety of care in the air, with appropriate training, equipment and recognition. As a comparison, ight nurses are required to have a minimum of two years' postgraduate experience in critical care or emergency, at least six months’ ight experience (as a second operator), successful completion of a ve day annual aeromedical retrieval course, a yearly aircraft familiarisation and emergency procedures certicate, land based survival skills and biennial completion of HUET. ere are a number of complicating factors for DHBs and midwives to consider when planning the management of and personnel for obstetric ights. Chief among these is the comparatively small number of obstetric ight transfers (approximately 5-8% of all aeromedical transfers according to NZ and international data)*. is makes it unfeasible for some DHBs to invest in full ight midwifery education for a large enough group of midwives to ensure that there is always a Flight Midwife available. e Midwifery role in some DHBs is perhaps most appropriately as an escort, with a nurse or paramedic in charge of ight logistics. ese midwives still have responsibility for the clinical care of the women and therefore should have some level of education and orientation to the ight environment, as well as support for overnight stays and return journeys.

Undoubtedly, there is scope for discussion and development of Flight Midwife and escort roles at a national level. As well as challenges, there are a number of enablers that could support this work, including e-learning, networking Flight Midwives, and collaborating with other aeromedical transfer professionals.

e next questions that the College and MERAS will be exploring with DHB midwifery leaders, therefore, are to identify the gold standard for ight midwifery education, and what is an acceptable minimum level of education, experience and support for this important role? As always, member feedback is welcomed.