Can tocolytics be given to a pregnant patient in labor for transfer to a hospital with obstetric (OB) resources if the current facility lacks them?

Tocolytic Use for Transfer of Laboring Patients to Facilities with OB Resources

Tocolytics can be appropriately administered to pregnant patients in labor for the purpose of facilitating transfer to a hospital with obstetric resources when the current facility lacks them, provided the goal is to delay delivery for 48-72 hours and there are no contraindications to tocolytic therapy. 1

Indications for Tocolytic Use During Transfer

When considering tocolytic administration for transfer purposes, the following criteria should be evaluated:

• Gestational age: Most appropriate between 23-34 weeks gestation
• Labor status: Patient must be in preterm labor
• Facility limitations: Current facility lacks appropriate obstetric resources
• Transfer time: Reasonable expectation that transfer can be completed before delivery
• Maternal and fetal status: No contraindications to tocolysis

Evidence Supporting Tocolytic Use for Transfer

The primary rationale for tocolytic therapy in this context is not to stop labor completely but to:

1. Delay delivery long enough for safe maternal transfer 1
2. Allow time for administration of interventions that improve neonatal outcomes (particularly antenatal corticosteroids) 2
3. Ensure delivery occurs in a facility with appropriate maternal and neonatal care capabilities 1

Research demonstrates that tocolysis can effectively delay delivery for 48-72 hours, which is sufficient time to complete maternal transfer and administer a complete course of antenatal corticosteroids 2, 3. In-utero transfer is associated with decreased neonatal morbidity and mortality compared to postnatal transport 2.

Recommended Protocol for Transfer with Tocolysis

Step 1: Assessment

• Confirm preterm labor diagnosis
• Evaluate for contraindications to tocolytic therapy
• Assess fetal status and gestational age
• Determine appropriate receiving facility with OB resources

Step 2: Tocolytic Selection

Based on current evidence, consider:

• First-line options:

  • Nifedipine (calcium channel blocker): Easy to administer with limited side effects 3
  • Atosiban: Best maternal and fetal safety profile, though may not reduce neonatal complications 3, 4
  • Indomethacin: Reasonable for gestations <32 weeks, but avoid prolonged use (>48h) 3

• Alternative options:

  • Magnesium sulfate: Controversial as a tocolytic but provides additional benefit of fetal neuroprotection 1, 3
  • Beta-mimetics: Effective but with significant side effects 3

Step 3: Transfer Coordination

• Contact receiving facility with appropriate OB resources
• Establish clear communication about patient status
• Coordinate timing of transfer based on expected tocolytic efficacy

Important Considerations and Cautions

• Duration of effect: Tocolytics typically delay delivery for only 48-72 hours 5
• Safety profile: No tocolytic is 100% safe; each has potential adverse effects 6
• Magnesium sulfate warning: FDA warns against continuous administration beyond 5-7 days due to risk of fetal harm 7
• Transfer protocols: Hospitals without optimal resources should have established protocols for timely transport 8

Special Circumstances

• Imminent delivery: If delivery appears imminent despite tocolysis, on-site delivery may be necessary 8
• Rural settings: EMS systems in rural areas should have coordinated protocols for management and transport 8
• Severe maternal illness: In cases of maternal instability, neonatal transport after delivery may be required 8

Conclusion

When a pregnant patient in labor presents to a facility without appropriate obstetric resources, tocolytic therapy is an evidence-based intervention to facilitate safe transfer to a higher level of care. The decision to use tocolytics should be based on gestational age, maternal and fetal status, and the availability of appropriate receiving facilities.